Workers' Compensation - Medical Issues

There are two (2) general forms of benefits paid in workers' compensation claims: (1) compensation (also called "indemnity") and (2) medical benefits. At some point in the life of a workers' compensation claim, there will be a dispute over medical benefits. This usually arises when an attending physician files a C-9 request, or when a physician hired by the employer or Bureau of Workers' Compensation opines the injured worker no longer needs any treatment for the allowed conditions in the claim.

Form of Request

Typically, a physician makes a request for treatment on a C-9 form. Authorizations for treatment in state fund claims are made by so-called managed care organizations ("MCO"). The MCO processes requests from the injured worker's attending physicians and medical providers for medical services, such as requests for treatment, diagnostic studies, physical therapy, consultation exams, medical appliances, and other treatment issues.

If the MCO disapproves or modifies the C-9 request, the injured worker and/or the attending physician may appeal. If an appeal is filed, an alternative dispute resolution ("ADR") process begins. This process consists of medical "peer reviews" and additional decision-making by the MCO. Ultimately, if the injured worker is still dissatisfied with the MCO's decision, the BWC reviews the matter and issues an Order, which the parties may appeal to the Industrial Commission of Ohio. Employers may also appeal decisions of the MCO if they disagree with an approval of a C-9 request.

For self-insured denials or modifications of C-9 requests, the injured worker's remedy is to file an administrative motion with the BWC and request the Industrial Commission of Ohio schedule a hearing.

The Miller Criteria

The Supreme Court of Ohio in the case of State ex rel. Miller v. Indus. Comm. (1994), 71 Ohio St.3d 229, set forth a three (3) part test to determine whether a request for treatment, etc., should be authorized in a workers' compensation claim:

1. Are the medical services reasonably related to the industrial injury, i.e. the allowed condition(s) in the claim?
2. Are the services reasonably necessary for treatment of the allowed conditions? and
3. Is the cost of such service medically reasonable?

If the medical evidence supports a "yes" answer to each of these questions, then the treatment request should be approved. Unfortunately, there is often conflicting medical evidence (whether from the BWC or the employer's physician) and a hearing before the Industrial Commission invariably becomes necessary.

Industrial Commission Hearings

If there is a disagreement with the C-9 request by the injured worker, the employer, or the Bureau of Workers' Compensation, and an appeal has been timely filed (or a motion has been filed in a self-insured claim), then the matter will be scheduled for a hearing before the Industrial Commission of Ohio.

Hearings before the Industrial Commission are informal. This simply means the Ohio Rules of Civil Procedure and the Ohio Rules of Evidence do not apply to proceedings before the Industrial Commission. However, the Industrial Commission strictly follows the laws and rules governing workers' compensation claims. In addition, the Industrial Commission has promulgated Resolutions and has adopted a Hearing Officers' Manual to govern hearings and claims procedures.

If your claim is scheduled for a hearing before the Industrial Commission, it is highly recommended you contact an attorney to represent your interests. Often, the employer attends with their attorney. Moreover, the BWC often has an attorney from their Law Department appear. (Interestingly, this author has never had any hearing or claim where the BWC Law Department lawyer appeared and argued in favor of the injured worker). You should be aware, as the injured worker, you may have two (2) parties arguing against you at your hearing.

The above information is intended solely as an overview. It is advisable to contact an attorney to assess the merits of your individual claim. Please call us at 614-221-1300 to discuss the specifics of your case.