What Do You Do When Your Employer Denies Workers Compensation Benefits?

bedroom-bliss-no-3-1542621-1024x768Workers’ compensation claims can be very stressful for the injured employee. Because of this, the law in Louisiana will help offset the legal costs of workers’ compensation claim denials by employers by awarding penalties and attorney fees ( PA&F) if the employer is found to have improperly denied the employees claims for medical treatment. This was the case for a Calcasieu Parish employee who experienced trouble sleeping due to pain from her injury. So, what do you do when your employer denies your workers compensation benefits?

Stephanie Lemelle Ardoin was injured while working for the Calcasieu Parish School Board at the beginning of 2013. After the injury, she was awarded workers’ compensation benefits and received treatment for her back injury. Ms. Ardoin’s treatment included a laminectomy. She also had a fusion of her L4-5 vertebrae performed by Dr. Chris Gunderson.

Following the surgery, Ms. Ardoin received care from Dr. Gunderson and was also provided with care from Dr. Daniel Hodges to deal with pain. She received care from Dr. Hodges because she was still experiencing pain and was having problems sleeping. Eventually, both doctors gave a prescription for an adjustable mattress to help with the sleeping issues. The adjustable mattress request was sent to WellComp Managed Care Services for review. WellComp denied this request on the grounds that it did not meet the Workers Compensation insurance guidelines. WellComp stated the claim was inadequate because there was no medical rationale to support the need for the adjustable mattress.

Ms. Ardoin then sent a Disputed Claim for Medical Treatment to the Medical Director to appeal WellComp’s denial. The Medical Director upheld the denial and cited the Medical Treatment Guidelines provision which stated that special mattresses are not necessary to maintain function and that no variance was requested for the mattress. Ms. Ardoin responded by filing a Disputed Claim for Compensation, which requested authorization for the treatment as well as fees for the claim denial. Following a trial, the workers’ compensation judge (WJC) ruled against the School Board and ordered the School Board to authorize the prescription for the adjustable mattress. The School Board was also charged with paying Ms. Ardoin’s expert witness fees as well as       ( PA&F) allowed under La. R.S. 23:1201. The School Board then appealed and challenged the expert witness fees as well as the ( PA&F).

The manifest error standard is applied to ( PA&F) determinations. Baullion v. Old Am. Pottery Co., 801 So.2d 567 (La. Ct. App. 2001). This means that the Appellate Court’s job is not to determine whether the WJC was wrong and instead looks toward whether the WCJ ruling was reasonable. Spikes v. Louisiana Commerce & Trade Ass’n, 161 So.3d 755 (La.Ct. App. 2014). Employers in Louisiana are required to furnish injured workers will all necessary medical treatment and any nonmedical treatment that is legal. La. R.S. 23:1203(A). The failure to authorize or pay for the relevant medical treatment is viewed as a failure to furnish benefits and that failure means that an employer may have to pay ( PA&F). Romero v. Garan’s, Inc., 145 So.3d 1120, 1122 (La. Ct. App. 2014). The employer also has a duty to investigate the relevant medical information before denying benefits. George v. Guillory, 776 So.2d 1200, 1209 (La. Ct. App. 2000).

When the Appellate Court looked toward Ms. Ardoin’s claims it found that the School Board did not rely on sufficient medical information to justify the denial of the adjustable mattress. The Appellate Court pointed to repeated claims by Ms. Ardoin that were documented by her doctors that she was having difficulty sleeping due to the pain from her injuries and that the only solution was sleeping in a recliner. The Appellate Court noted that while the School Board was correct in pointing out that the Medical Treatment Guidelines have a general rule that things such as an adjustable mattress are not necessary, the School Board incorrectly denied the claim because they did not use any of Ms. Ardoin’s medical information in the denial. Because the School Board failed to satisfy the duty to investigate and apply factual information before denying the adjustable mattress it was assessed the costs of the expert witness as well as attorney fees for the cost of defending the appeal.

Ms. Ardoin’s case establishes two things. The first is that an employer can be required to provide workers’ compensation benefits that include less traditional things such as an adjustable bed so the injured employee can have reduced pain in order to sleep. The second is that employers have a duty to provide factual and medical details when denying a claim supported by a doctor’s medical recommendation. A failure to provide a legitimate reason why a claim is denied can lead to ( PA&F) awards to the injured employee.

Additional Sources: STEPHANIE LEMELLE ARDOIN V. CALCASIEU PARISH SCHOOL BOARD

Written by Berniard Law Firm Blog Writer: John Trepel

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