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Defense Wins by Chesapeake Employers at the Workers’ Comp Commission

August 2017

Chesapeake Employers’ thorough case preparation, investigation and defense help to keep premium costs fair by limiting unnecessary and excessive awards or claim payments. Here are a few cases in which the Commission ruled in our favor.

The Case of No Cause for Surgery          

Chesapeake’s Claims and Legal specialists teamed up to defend against this request for payment of temporary total disability benefits and medical expenses relating to a claimant’s lumbar surgery. The claimant alleged back pain developed as a result of an altercation with a patient at work. Our claim adjuster denied the request for authorization of lumbar surgery, noting that four doctors who previously saw the claimant opined there was no need for surgery. At the hearing, the claimant acknowledged not telling the doctor who performed the surgery about the workplace accident, saying the intent was to have the surgery paid for by private insurance. Our attorney argued that the claimant did not have a legally sufficient causal relationship. The commission agreed and issued an order denying the temporary total disability benefits and finding that the lumbar surgery was not causally related to the accidental injury.

The Case of the Prior Settled Claim         

Claims and Legal worked together again to prevail over this case involving alleged causal relationship of the claimant’s back as well as the request for temporary total disability benefits and payment of back surgery. The adjuster reviewed the claim and found it was initially filed as a “report only” claim and the claimant did not seek treatment relating to the back for almost one year after the accident. The adjuster also identified a prior settled workers’ compensation claim in which back surgery had been recommended and the settlement included a Medicare Set-Aside to pay for costs of the anticipated surgery. At a lengthy hearing before the Commission, the claimant acknowledged having only about half of the Medicare Set-Aside from the prior claim remaining, despite having undergone minimal treatment. The attorney further noted the recommendation for surgery in the prior claim and argued it involved the same region of the spine as the recent back surgery in dispute. The Commission found that the disability to the claimant’s back was not causally related to the accidental injury and denied the request for temporary total disability benefits as well as medical bills associated with the back surgery.

The Case of Close But Not Close Enough    

We were successful in defeating this claim in which the claimant sustained a slip and fall injury on the way to work. The policyholder advised us that the claimant had not fallen on their premises, but rather on a public sidewalk in front of an adjacent building. To investigate this claim, we met with the policyholder at their facility and obtained a blueprint of the property, detailing the layout of the facility including all sidewalks and parking lots. Our adjuster took numerous photographs of the area where the claimant fell, showing its location relative to the policyholder’s premises. At the hearing, the claimant testified to falling very close to the sidewalk leading to up the work building with fewer than 20 feet to the door. On cross-examination, the attorney used the photographs to get the claimant to admit that the fall occurred on a public sidewalk in front of a building adjacent to the work building. The Commission found that the claimant did not sustain an accidental injury arising out of and in the course of employment and disallowed the claim.


 

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Chesapeake Employers' Insurance Company •  Formerly the Injured Workers' Insurance Fund • 8722 Loch Raven Blvd. • Towson, MD 21286   410-494-2000  1-800-264-4943   Privacy Policy and Data Security