Workers’ Compensation Fraud: 4 Stories of Those Who Were Caught

Workers’ Compensation Fraud: 4 Stories of Those Who Were Caught

Denver Workers Compensation

Workers’ compensation fraud is a problem, due to propaganda, most think the fraud is perpetuated by the workers; however, employers also commit fraud by intentionally misclassify employees to widespread insurance schemes. These schemes cost the system money and detrimentally impact injured workers who rightfully deserve workers’ comp benefits.

Fortunately, most big money scams are eventually uncovered. Here are some stories of workers’ comp fraud over the years that made headlines when the perpetrators were caught.

Massive Medical Insurance Scam

An alleged California medical insurance scam racked up nearly $100,000 in false workers’ compensation medical claims. The fraudulent money-making scheme involved seven people, and was apparently spearheaded by a chiropractor. Several clinics treated injured workers and submitted inflated bills for exaggerated injuries and more. The businesses brought in more than $12 million in payments with their scam. Penalties for the charges they face can include up to 97 years in prison.  

 

FedEx Delivered Fraud in Multiple States

Well-known package-delivery company FedEx found themselves in hot water last year to the tune of $240 million! This proposed settlement was the result of a common scheme some employers use to avoid paying workers’ compensation and other employee-related costs and benefits. It involved fraudulently classifying employee as independent contractors, and dates back to litigation that began in 2005. The settlement was approved for $227,000 earlier this year. About 12,000 drivers in 19 states will receive payments of various amounts from the total.

 

Fake and Fraudulent Florida Construction Company

 

In this recent case, Leon Jimenez, the owner of a construction company, ran a widescale workers’ compensation scam. The company didn’t even perform any construction work. Instead, Jimenez was selling workers’ compensation certificates to subcontractors for profit. The subcontractors got their bogus certificates and the employees were left exposed to the risk of uncovered work injuries. Jimenez was arrested for workers’ compensation fraud, false documentation, grand theft, and various other charges that may carry up to 30 years in prison.

 

If you’ve been injured on the job and you believe that your employer or his insurer is behaving unfairly or illegally, contact an experienced workers’ compensation attorney like Kaplan Morrell to protect your rights.

SOURCES

 

https://www.thebalance.com/workers-compensation-fraud-examples-4101604

http://www.reuters.com/article/us-fedex-settlement-idUSKCN0Z229Q

http://www.theindianalawyer.com/judge-approves-227m-in-fedex-driver-suit-settlements/PARAMS/article/43610

http://www.businessinsurance.com/article/20170602/NEWS08/912313724/Construction-firm-owner-arrested-workers-comp-fraud-Chuy-Construction-Florida

http://www.desertsun.com/story/news/crime_courts/2016/06/06/seven-riverside-county-charged-98m-medical-fraud/85368290/

Marijuana Use Can Impact Your Workers’ Compensation Benefits

Marijuana Use Can Impact Your Workers’ Compensation Benefits

Denver Workers Compensation

When it comes to marijuana use on-the-job, the best advice is “don’t do it!” Contrary to what you may believe, whether for medical or recreational uses, your right to toke is not protected by law in the work environment. Colorado has legalized both the medical and recreational consumption of marijuana, but our state laws still butt up against federal laws. And this makes for lots of confusion across the board.

Employers on Marijuana Use

Legal marijuana, whether for medical reasons or recreational use, is no mandate for use at work. Employers are well within their legal rights to prohibit consumption at work and to require drug testing to weed out users from their workforce.

Federal law prohibits the possession and consumption of marijuana for any reason. This supports the rights of employers in banning marijuana consumption in their employees. Now that the new Trump administration is in place, federal versus state law on marijuana may become even murkier. Currently, there is no clear-cut answer on whether the federal government will be cracking down on states that allow legal marijuana use.

Statewide Marijuana Use Laws

As of the November 2016 election, more than half of all the states in the union, plus D.C., now have medical and/or recreational marijuana use legislation on their books.

1. California passed legal recreational marijuana use last November.
2. Massachusetts joined the ranks of recreational marijuana use states this past election.
3. Maine will soon be allowing limited recreational marijuana use and on-site consumption in social clubs.
4. Though late to the party, Nevada is now a legal recreational marijuana state.
5. Washington, D.C. voted for nonmedical marijuana use in 2014.
6. Oregon came aboard on recreational use of marijuana in the summer of 2015.
7. Alaska passed recreational marijuana law in 2015.
8. Colorado passed legislation to allow recreational marijuana use in 2012. Recent ballot initiatives support public consumption programs in Denver.
9. Washington joined Colorado in groundbreaking recreational marijuana use in 2012.
10. Florida, Arkansas, North Dakota, Montana, Arizona, New Mexico, Minnesota, Michigan, Illinois, Louisiana, Ohio, Pennsylvania, New York, Vermont, New Hampshire, Connecticut, Rhode Island, New Jersey, Maryland, Delaware have all legalized medical marijuana.

Bottom Line: Colorado Statute on Marijuana and Workers’ Compensation

Regardless of what the future holds for legal marijuana consumption, for now, Colorado Statute, Article 42 of Title 8 limits your financial benefits under the workers’ compensation system if you test positive for a controlled substance. You can lose 50 percent of your income replacement benefits if marijuana use is detected. While you will still receive full medical treatment benefits, your finances will likely suffer greatly from this impact.

Note that the issue with federal vs. state laws on marijuana impact this area of the law as well. §8-42-112.5. C.R.S. excludes medically prescribed drugs from the identified controlled substances, but that’s the problem. Doctors in Colorado cannot prescribe marijuana. They can only advise their patients on its use.

If you have questions about marijuana and the workplace and workers’ compensation benefits, ask a lawyer. Your pot-smoking buddy probably has a lot of opinions and knows quite a bit about the legalities of smoking weed in Colorado. But workers’ compensation is a complicated system wherein state and federal laws often overlap. A Colorado workers’ compensation lawyer is your best source of information on this thorny subject. We’re always here to answer your questions- don’t wait- get a free consultation on your workers’ compensation case now.

 

How Trump May Affect Workers’ Compensation In Colorado

How Trump May Affect Workers’ Compensation In Colorado

Denver Disability Denver Workers Compensation Workers Compensation Blog

The new Trump administration has ushered in some changes that many Americans weren’t quite prepared for, and much of the impact is not yet fully known. After all, he’s only been in office for a little over four months, and many changes are yet to come. With respect to workers’ compensation (work comp) benefits, the potential effect has not been fully realized. However, it appears that the greatest potential impact will come from the repeal of the Affordable Care Act (ACA) and budget cuts.

Healthcare Reform

In Colorado and many other states, the ACA, more popularly called Obamacare, has generated a favorable trend in work comp claims. Claim rates and costs have been dropping, and this movement is very likely due to increased worker access to healthcare. In its 2016 report, the Upjohn Institute for Employment Research identified a strong correlation between the decreased work comp claims and costs and the uptick in health insurance coverage.

Joe Paduda of Health Strategy Associates delves even deeper into the link between Obamacare and work comp claims. He alleges that workers who are hurt on the job have less reason to pursue care through their employer’s work comp insurance if they have their own health insurance.

Further, other health issues that may impact their work injury can be covered by the worker’s insurance, rather than work comp. For example, an employee with high blood pressure would need additional treatment for his hypertension before he could undergo a necessary work-related surgical procedure. However, when the worker has health insurance, his coverage would bear the additional cost, rather than work comp.

The proposed repeal and replacement efforts of Trump and the Republican-led House has thrown millions into uncertainty with respect to healthcare coverage. The most recent version of the new TrumpCare coverage, the AHCA, has the potential to take away health insurance from 14 million Americans by next year, according to the Congressional Budget Office (CBO) estimates. And the number of insured is expected to continue increasing over the next 9 years.

These dire projections could spell big trouble for work comp. Uninsured workers would likely once again turn to work comp for as much medical coverage as possible. These changes would also disproportionally affect older employees, workers in higher risk jobs and many who currently receive coverage through Medicaid. These issues will equate to increased claims and higher costs.

Budget Cuts and Safety Issues

Trump has also proposed budget cuts and safety reform rollbacks that will have adverse effects on the work comp system. While the Obama administration was moving towards establishing minimum workers’ compensation benefit standards on the state level, the Trump administration has expressed no interest in pursuing these reforms.

Repeal of an Obama-era OSHA safety regulation could have a detrimental impact on injured workers, as well. The “Volks” rule requires dangerous industry employers to keep health and safety incident records for five-and-a-half years. But Congress changed that to just six months, and Trump signed off. This minimum record-keeping requirement may prevent identification of frequent and repeated safety issues with many companies, and make it much more difficult for their employees to obtain work comp benefits when injured.

If a disabled worker is receiving both Social Security Disability Insurance (SSDI) and work comp benefits, the total may not exceed 80 percent of the average earnings that the worker was receiving before he became disabled. It they do, the SSDI benefits are reduced to offset the overage. In 15 states, this works in the reverse. Instead, it is the work comp benefits that are offset. On May 23, Trump released information on his most recent budget plan with proposed cuts. The Workers’ Compensation Reverse Offset faces elimination in 15 states, of which Colorado is one. With this change, work comp will need to make up the shortfall that the government has been covering via SSDI, hence, raising costs.

Overall, it appears that the Trump administration will be bad news for work comp in Colorado, and throughout the nation. And that’s only addressing what we know so far. If you have questions about these pending changes, or other workers’ compensation issues, please contact us for answers.

 

 

Sources

Kalin: Obamacare has had an impact on workers’ compensation claims in Colorado

AHCA, CBO, and Workers’ Comp

Four Ways the New Administration Will Influence Workers’ Comp

http://www.safetyandhealthmagazine.com/articles/15517-trump-signs-resolution-to-strike-down-volks-recordkeeping-rule

https://www.bostonglobe.com/news/politics/2017/05/23/here-list-agencies-and-programs-trump-budget-would-defund-entirely/DMRzbdY4lwB0XEGA13Y6PP/story.html

How Does House Bill 1119 Stack Up For Workers’ Compensation In Colorado?

How Does House Bill 1119 Stack Up For Workers’ Compensation In Colorado?

Denver Workers Compensation Greeley Workers Compensation Lawyer Workers Compensation Blog

The Colorado General Assembly has proposed new legislation that would address the issue of worker injuries when their employers have no workers’ compensation insurance. If passed, the proposed law packaged in House Bill 1119 will create the Colorado Uninsured Employer Act.

Colorado’s HB 1119 Overview

This legislation is a show of bipartisanship with support from Democrat Senator Cheri Jahn and Democrat Representative Tracy Kraft-Tharp and Republican Senator Jack Tate and Republican Representative Lang Sias. The Act would create a fund from which eligible injured workers can draw benefits. Employer penalties and fines imposed by the Division of Workers’ Compensation for no insurance coverage will help fund the account. Other financial sources may include grants, donations, and public and private gifts.

The bill also directs the establishment of a governing board to cover a range of duties for the uninsured employer fund. Some of these responsibilities include the setting of criteria for rates, claims adjustments, rules adoption and benefit payments. The Board must establish a plan of operation for fund administration duties and money collection procedures for the fund.

The Plight of the Injured Worker and No Workers’ Compensation Coverage

As a worker, when you are considering employment, you may look at several different factors. While stable work hours, healthcare benefits, paid leave, and retirement plans are frequently considered, whether your potential employer has workers’ compensation coverage rarely comes up.

Because it’s the law, most workers assume their employer has the necessary coverage. They only discover a lapse if they experience a work injury that leads to a Colorado workers’ comp claim. A seriously injured employee who is unable to receive benefits under workers’ comp due to their employer’s negligent insurance oversight is left in a precarious position.

Workers’ comp covers medical treatment for your injury or illness. It also pays a percentage of your wage loss if you are unable to work due to your injury. With no workers’ comp coverage, these and other benefits are no longer available.

Seriously injured workers find themselves struggling to receive desperately needed medical treatment and facing overwhelming unpaid bills due to their lost wages. In the event of a resulting disability, the injured worker is unable to receive the temporary or long-term disability benefits that would otherwise be available to him under the workers’ comp program.

Related: Passage of Amendment 69 Could be Bad News for Colorado Workers’ Compensation

One option in this situation is to sue your employer in civil court for the losses associated with your injury. A big problem with this method of reimbursement is the length of time it typically takes to recover damages in civil court. The process is lengthy, and your medical and financial needs are immediate. The biggest problem is that most employers don’t have the assets to pay the benefits due injured workers. Bankruptcy is declared – or the business stops functioning – and the injured worker is left with an order he or she cannot collect.

The proposed Colorado Uninsured Employer Act is a far more effective solution to the uninsured employer problem. Many other states already have these funds set up for these types of injured workers. Some have temporary disability insurance programs instead.

Uninsured Employers’ Workers’ Compensation Fund Examples

Several states, such as California, New Jersey, and New York, have some form of compensation funding for injured workers whose employers have no coverage. California has two funds, the Uninsured Employers Benefits Trust Fund (UEBTF) and the Subsequent Injuries Benefits Trust Fund (SIBTF).

New Jersey also operates two funds, the Uninsured Employer’s Fund and the Second Injury Fund. In New York, their Uninsured Employers Fund (UEF) assigns direct liability to the employer for compensation payments and medical costs.

HB 1119 was introduced on January 20, 2017 and is currently under consideration. Meanwhile, if you have suffered a work injury and subsequently learned that your employer has no workers’ compensation insurance, contact a seasoned Colorado Workers’ Compensation lawyer like Kaplan Morrell to explore your options.

Need help now? We’re here for you. Contact our Denver Workers’ Compensation Attorneys here, and if you’re out in the “burbs” you can reach our Greeley Workers’ Compensation Attorneys here.  We’re here to help- and we will fight to get you the benefits you are entitled to!

 

 

Social Security Recipients Second Amendment Rights preserved Having a Representative Payee No Longer Prevents You From Owning a Firearm

Social Security Recipients Second Amendment Rights preserved Having a Representative Payee No Longer Prevents You From Owning a Firearm

colorado gun laws Denver Disability Denver Workers Compensation gun laws Social Security Blog Workers Compensation Blog

In February 2017, the House of Representatives voted to “overturn an Obama administration rule” that required the Social Security Administration to “forward the names of all Social Security Disability Insurance . . . benefit recipients who use a representative payee . . . to the National Instant Criminal Background Check System . . ..

Reaction sadly was over-the-top and exaggerated as some gun safety advocates characterized the vote as the House permitting “severely mentally ill” people from getting guns and will make Americans less safe.

WHAT ACTUALLY HAPPENED

The Obama Administration required the Social Security Administration to send the records of Social Security Disability (SSDI) recipients who need a representative payee to the FBI for the National Instant Criminal Background Check System.  This meant these particular SSDI or SSI recipients were deprived of their right to purchase a firearm.

What’s a Representative Payee?

Individuals are required to have a representative payee for mental impairments when a beneficiary is “legally incompetent or mentally incapable of managing benefit payments.”  An injured and disabled worker who has difficulties remembering deadlines, properly doing math, or any other significant inability to spend their SSDI benefit properly may be required to have a representative payee even if his or her disability has nothing to do with a mental impairment.

Having a Representative Payee does not mean that your inability to mange finances is because a disabled worker is violent, or poses a risk to themselves or to others.

Because of the myriad of impairments that could require a representative payee, even the American Civil Liberties Union (“ACLU”) spoke out against the rule, saying “A disability should not constitute grounds for the automatic per se denial of any right or privilege, including gun ownership.”  Republican House Judiciary Chairman, Bob Goodlatte opposed the rule because “it paints all those who suffer from mental disorders with the same broad brush.”

Congress has now revoked that rule.

WHAT HAPPENS NOW?

Because of this vote, if you are awarded Social Security Disability benefits, SSDI or SSI, and have the need for a Representative Payee – the Social Security Administration will no longer automatically report you to the NICS.

Have Questions?

Navigating the Social Security Disability process is not always easy.  Circumstances are always changing, and we are happy to answer questions and help navigate the process.  Email – Tre Eyden, EDPNA, or call 970-356-9898.

Two most common overlooked benefits injured workers in Colorado should get – but don’t.

Two most common overlooked benefits injured workers in Colorado should get – but don’t.

Denver Workers Compensation Greeley Workers Compensation Lawyer Workers Compensation Blog

There are some Denver workers’ compensation benefits that are well known such as medical care and payment of lost wages.  However, there are also some benefits that are not as well known and should not be overlooked.

Some injured workers who are owed disfigurement benefits.  Disfigurement benefits are paid for things like scars from surgery or suffering from a limp.  The workers’ compensation insurance company is not required to automatically pay such a benefit.

Another benefit is mileage reimbursement.  The workers’ compensation insurance company needs to reimburse you for all of your trips to doctors, physical therapy visits and even to pick up your medications at the pharmacy.  Even if someone else provides transportation for you, you can still get reimbursed for that mileage.  If you are unable to get to your medical appointments, the insurance company has to provide you some form of transportation to get you there.  We would welcome the opportunity to explore these little known benefits with you.

As always, how this or any other issue we discuss in this blog would apply to your case depends on many more factors.  We urge you to call us to see if you are entitled to workers’ compensation benefits.  Workers Compensation is difficult, confusing, and very complex.  Kaplan Morrell has helped thousands of injured workers since 1997 get the benefits they deserve.   Contact us here or call us at (866) 356-9898 for your FREE CONSULTATION.

What a Difference An “AND” Makes In Colorado Work Injuries

What a Difference An “AND” Makes In Colorado Work Injuries

Denver Disability Denver Workers Compensation Greeley Workers Compensation Lawyer

THE Industrial Claims Appeals Office (ICAO) HIGHLIGHTS A MAJOR LIMITATION ON MAINTENANCE MEDICAL CARE

Intersection between a law with a later statute creates a major distinction for injured workers’ medical care rights.

Lola Chism injured her left shoulder in July 2009 in an admitted work injury.  Following what was described as “considerable” physical therapy, and two surgical procedures her treating physician placed her at Maximum Medical Improvement(MMI) in January 2011.  The treating physician recommended, and the insurance carrier admitted for, future maintenance medical benefits.

Injured Colorado workers are entitled to medical benefits following an on-the-job injury “to cure and relieve effects of the injury.”  CRS §8-42-101(1)(a).  In 1988 the Colorado Supreme Court interpreted that law as requiring Colorado Workers Compensation Insurance carriers to pay for all medical care “to relieve the worker from the effects of the industrial injury” based upon the rationale that it “is an obvious fact of industrial life, however, that an injured worker can reach maximum medical improvement from an injury and yet require periodic medical care to prevent further deterioration in his or her physical condition.”  Grover v. Industrial Commission, 759 P.2d 705, 710 (Colo. 1988).

However the Colorado Legislature added a formal, statuotry definition of MMI as the “point when any physical impairment is stable and “no further treatment is reasonably expected to improve the condition.” That definition excluded from ‘further treatment’ any “future medical maintenance.”  CRS § 8-40-201 (11.5).

Ms. Chism continued to have ongoing physical therapy for her shoulder after MMI as maintenance care.  In December of 2015 the treating physician referred her to a surgeon who recommended a reverse total arthroplasty   The employer challenged the proposed treatment, however an ALJ ruled that the surgery should be approved, finding it reasonable and necessary to “cure and relieve” the effects of the injury. The employer appealed.

The ICAO determined the obligation to “cure” the effects of the injury ends at MMI because of the later 1991 statutory definition of MMI that declares “no further treatment is reasonably expected to improve” the injured worker’s condition.  Thus, ICAO reasons, only treatment that will relieve but not cure the work injury can qualify as maintenance care.

The ICAO remanded the case back to the Administrative Law Judge for further consideration if the proposed treatment would just “relieve” the injury, noting that there was no “bright line” test to distinguish between those treatments.  Because six years had passed after the injury, Ms. Chism cannot reopen her work injury claim, she is limited to maintenance care.  If this surgery is curative – it has to be denied under the ICAO’s parsing of the statute.

 

CITE:  Chism v. Walmart, WC No. 4-809-103-03, (January 9, 2017).

Appeals Office Shifts the Burden to Injured Workers in Responsible for Termination Claims

Appeals Office Shifts the Burden to Injured Workers in Responsible for Termination Claims

Denver Disability Denver Workers Compensation Greeley Workers Compensation Lawyer

Injured Workers must now be ready to provide evidence explaining that work absences weren’t their fault.

Injured workers who lose their job while treating for a work injury are entitled to lost wage benefits, called Temporary Total Disability.  However the Colorado Legislature changed the law allowing employers to avoid paying lost wages to injured workers when they are “responsible” for their termination.

Until now, the burden to prove this allegation has rested squarely upon the employer.  The employer must not only prove that the injured worker did – or failed to do – something that led to his or her termination – but that that it is was volitional on the part of the injured worker.  For example if a worker is fired for being late to work three times in one week, the employee could show that the absences were caused by circumstances outside his or her control.

Nicholas Coleman worked as a housekeeper and suffered a low back injury in late 2014.  However in February 2015 he was incarcerated for violating his parole and as a result stopped coming to work and was terminated.  After his release in August 2015 he sought lost wage benefits.  The employer denied claiming that Mr. Coleman was responsible for his termination.

At hearing, although the employer did introduce evidence that Mr. Coleman stopped coming to work, and that Mr. Coleman had been incarcerated for violating his parole – there apparently was no evidence why or how Mr. Coleman violated his parole.  Reasoning that the employer had failed to show proof as to whether the parole violation was volitional, the Administrative Law Judge was unwilling to assume that it was and awarded benefits.

The Industrial Claims Appeals Office (ICAO) remanded the case back for a further hearing and testimony.  The ICAO imposed the burden not on the employer, but the injured worker.  “Typically, when an employer introduces evidence that a claimant has failed to show up for work when scheduled, this amounts to a prima facie case satisfying the employer’s burden of demonstrating the claimant was at fault for the job separation. See Lucero v. Industrial Claim Appeals Office, 812 P.2d 1191 (Colo. App. 1991)(employer’s initial burden to show claimant was discharged for disqualifying reasons). The claimant must then introduce exculpatory evidence or evidence showing that his failure to show up for work when scheduled was non-volitional. See Gonzales v. Industrial Commission, supra (disqualification for failure to meet defined standards, unless the claimant is not at fault in the circumstances).”

This burden-shifting is a major departure from traditional litigation when a a party must prove each and every statutory requirement.  Now, employers may simply be able show that a worker was fired in accordance to policy without showing that the worker acted volitionally.  Then if the employee doesn’t provide an explanation, the employer will win.  This case highlights another reason why injured workers need experienced and dedicated attorneys.  Workers Compensation Law Changes weekly and you or your loved one needs an attorney who keeps up with these changes.

 

Source Citation:  Coleman v. Starmark Holdings, WC No. 4-969-560-02, (January 9, 2017)

 

Top Ten Most Costly Work Injuries Of 2016

Top Ten Most Costly Work Injuries Of 2016

Denver Workers Compensation Workers Compensation Blog

The Liberty Mutual Research Institute revealed 2016’s top ten causes of the most costly work injuries.

Here they are:

1. Overexertion involving outside sources. $13.79 Billion (Examples include lifting, pushing, pulling objects.)

2. Falls on the same level. $10.62 Billion (Slip and falls on slippery surfaces)

3. Falls to a lower level.  $5.50 Billion (Scaffold, ladder, stair falls)

4. Struck by Object or Equipment. $4.43 Billion

5. Other Exertions or Bodily Reactions. $6.5 Billion

6. Roadway incidents involving motorized vehicles.  $3.7 Billion

7.  Slip or trip without fall.  $3.8 Billion

8. Caught in/Compressed by Equipment or Objects. $1.95 Billion

9.  Struck against object or equipment.  $1.94 Billion

10. Repetitive Motions involving micro-tasks. $1.81 Billion.

Some work injuries cost more because of the nature of the injury.  Injuries requiring surgery will be more costly, not simply because of the medical care, but also because of the additional lost time during the recovery.  Injuries from lifting, in this study, may be more costly simply because those kinds of injuries are more common and numerous.  The injuries in this study included only those injuries where the employee missed six or more days of work.

When you’ve been injured on the job in Colorado, your primary concern is getting healed and back to your life. For the vast majority of injured workers that happens, but some workers sustain serious injuries that continue to interfere with their lives.  We’re here to help seriously injured works get the medical care and the Colorado Workers’ Comp benefits they deserve.  Don’t wonder, “What are my rights under Colorado Workers Compensation?”  Instead, call us and meet with an experienced Denver Workers’ Compensation attorney for a free consultation. Let us help with filing your Colorado Workers’ Comp claim- we can help get it approved.

 

 

 

Source:  http://imag e.email-libe rtymutual.com/lib/fe541570726d02757312/m/1 /2017+WSI.pdf

Case Update: If The Insurance Carrier Shuts Off My Lost Wage Benefits – Can I Get Penalties?

Case Update: If The Insurance Carrier Shuts Off My Lost Wage Benefits – Can I Get Penalties?

Denver Disability Denver Workers Compensation

MacDougal v. ICAO, Bridgestone Retail Tire Operations

The Court of Appeals put out an (unpublished) opinion affirming the denial of penalties against an adjuster for failing to reinstate lost wage benefits (TTD). On February 6, 2015, a Physician’s Assistant (PA) – not the actual Authorized Treating Physician – placed the injured worker at maximum medical improvement (MMI) and removed all restrictions – effectively clearing the worker for regular duty. However the section for permanent impairment was left blank..

The Insurance Carrier filed a Final Admission admitting to zero impairment that day. However eleven days later, on advice of counsel, the adjuster filed a General Admission of Liability (GAL). The GAL did not reinstate TTD benefits – relying on the PA’s release to regular duty.

On February 23, 2015 the Authorized Treating Physician (ATP) wrote a letter raising concerns about the PA’s medical note and noted that the injured worker would need permanent restrictions and an impairment rating. Because the ATP did not rescind the PA’s release to regular duty – the carrier did not reinstate TTD Benefits. When the ATP saw the injured worker in April, he placed the injured worker at MMI and impairment. (It’s unclear if the ATP provided permanent restrictions.)

The injured worker sought penalties against the carrier’s refusal to reinstate TTD benefits. The Administrative Law Judge determined that while the Final Admission was invalid because there was ambiguity of what, if any, impairment the injured worker had – the release to regular duty was not vague. Further, the ATP’s letter of concern did not expressly impose restrictions or retract the release to regular duty.

Given that confusion, the Court of Appeals agreed that claimant had failed to show that the adjuster acted unreasonably.

Work injury claims in Colorado are complex and fast paced. Don’t make the mistake of thinking you don’t need an experienced fighter in your corner. With everything there is to worry about when you suffer an on-the-job injury – let us make sure you are getting the benefits the law provides you. Get a free consultation on your workers compensation case here.

Case: MacDougal v. ICAO, Bridgestone Retail Tire Operations, 16CA0705 (Colo. App. 2016)