Representing Injured and Disabled Workers Columbus Workers' Compensation and Disability Retirement Attorneys

Medical Issues in an Ohio Workers Comp Case

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 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 review" 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-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 condition(s)? 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.

If you have questions about medical treatment or diagnostic study requests in your workers' compensation claim, please call us at (614) 344-6822 for more information.

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