006 Medical Benefits

MEDICAL BENEFITS UNDER

THE ACT

General Concepts...

Employer’s obligation to provide medical treatment to Claimant following his injury is defined by Section 7(a): “[t]he employer shall furnish medical, surgical, and other attendance or treatment for such period as the nature of the injury or the process of recovery may require"

An injured employee has a "free choice" of physician he or she treats with.

• When the employee cannot choose due to the injury the employer can make the initial choice
• When able to do so, the employee may later exercise free choice.

DIGGING DEEPER

What is the impact of

extended treatment with...

... the Employer Chosen Physician?

Once the employee exercises free choice, he may not change medical providers unless he or she requires the attention of a specialist.

Under the regs, medical providers must provide a medical report within ten days following the first treatment.

Medical charges should be priced under the appropriate fee schedule. A copy of the OWCP medical fee schedule is available on the Department of Labor’s website.

A claim for medical benefits is never time-barred. Employer has a continuing obligation to pay an injured employee's medical expenses.

The obligation to pay medical expenses is independent of awards for, or denial of, Section 8 compensation or Section 9 death benefits

It is the claimant's burden to establish the necessity of treatment rendered for his work-related injury.

In order for a medical expense to be assessed against the employer, the expense must be both reasonable and necessary.

Medical care must be appropriate for the injury.

A claimant has established a prima facie case for compensable medical treatment where a qualified physician indicates treatment was necessary for a work-related condition.

The claimant must establish that the medical expenses are related to the compensable injury.

The employer is liable for all medical expenses which are the natural and unavoidable result of the work injury, and not due to an intervening cause.

The employer is liable for medical services for all legitimate consequences of the compensable injury, including the chosen physician's unskillfulness or errors of judgment.

Modifications to a claimant's home necessitated by his work injury are covered under Section 7 of the LHWCA, because (1) the modifications qualified as "apparatus" and (2) they also constituted "medical ... and other attendance or treatment" within the meaning of Section 7.

Section 7 does not require that an injury be economically disabling in order for a claimant to be entitled to medical expenses, but only that the injury be work-related.

Jeff consults Mother Theresa regarding

payment of LHWCA medical benefits

The 1984 Amendments require the Secretary to list of physicians and health care providers in each compensation district not authorized to render medical care or services.

The term "physician" includes doctors of medicine, surgeons, podiatrists, dentists, clinical psychologists, optometrists, osteopaths, and chiropractors, within the scope of their practice, as defined by state law.

Subsection 7(k) provides that the LHWCA does not prevent an employee whose injury or disability has been established thereunder from relying in good faith on treatment solely by prayer or spiritual means, by an accredited practitioner of a recognized church or religious denomination, or on nursing services rendered in accordance with its tenets and practice, without suffering loss or diminution of the compensation or benefits under the LHWCA.

DIGGING DEEPER

When does

"unreasonable refusal to treat"

occur?

Section 7(d)(4) provides for suspension of all further compensation to an employee during any period in which he unreasonably refuses to submit to medical or surgical treatment, or to an examination by the employer's chosen physician, unless the circumstances justified the refusal.

The Board has held that this is a two-prong test.

The refusal must be both

"unreasonable" and not

"justified" by the circumstances.

The Secretary has discretion to suspend

compensation or not, even if the employee

fails both prongs

The Burden of Proof is on the Employer

An employee who refuses medical or surgical services solely because he relies on prayer or spiritual means alone for healing, in adherence to the tenets and practice of a recognized church or religious denomination, has not "unreasonably refused" medical or surgical treatment under subsection (d). 33 U.S.C. § 907(k)(2).

Fee Schedule

http://www.dol.gov/owcp/regs/feeschedule/fee.htm

Concepts of MMI

• Is it a medical concept, or legal?
• Who says when MMI is reached?
• When its good and when its bad

Jeff Ceterko, an adjustor with

Avizent in New Jersey, has

"star-photo-itis".. We will follow

Jeff's condition through the discussion

of Medical Treatment... (Meryl Streep)

Free-Choice Physician

George Clooney, from ER

David Letterman poses

with his favorite new intern

R.I.P. Gary Coleman

A pastoral counselor must document his credentials to show whether he is a

physician within the meaning of the regulation or qualified to perform "other"

compensable treatment.

Johnny Depp studies Jeff for his upcoming role as a swashbuckling Longshore Act adjustor

Jeff looks pretty darn happy to

have snapped a pic with Matt Damon

Tom Cruise played a longshoreman working at

American Stevedoring in Brooklyn in War of the Worlds

I'm not sure Jeff..

let me have the Secretary

of Labor check that for you

Will the new healthcare measures

affect Section 7 benefits under the

Act?

Patch Adams has not been debarred yet

Hungry Yet???

Bored?