When Do Employers Have To Pay Penalties And Attorney Fees For Denying A Workers’ Compensation Claim?

new_zealand_accident_insurance_0-1024x768If you are injured on the job, you might be entitled to compensation through the workers’ compensation system. What happens if your employer denies your claims for treatment recommended by your treating physicians? Can your employer be required to pay you penalties and fees?

Betty Citizen hurt her back while she was trying to move a bike while working at Wal-Mart. Wal-Mart denied her physical therapy that her treating neurosurgeon recommended. She filed a 1009 Form, which the Medical Director denied for being untimely. Citizen then filed a 1008 Form, claiming she was entitled to receive attorney fees and penalties because Wal-Mart had arbitrarily and capriciously handled her claims. 

Once Wal-Mart formally denied her physical therapy, Citizen filed another 1009 Form. The Medical Director denied that request as well, finding there was no required documentation about the results of prior therapy. On the day of the hearing, Wal-Mart approved the recommended physical therapy. Therefore, the only issue was whether Wal-Mart had acted arbitrarily and capriciously in denying Citizen’s physical therapy. 

The Office of Workers’ Compensation held Wal-Mart had acted arbitrarily and capriciously and awarded Citizen penalties, attorney fees, and court costs. Wal-Mart file dan appeal.

La. R.S. 23:1201(F) governs when an employer can be assessed penalties and attorney fees for failure to authorize an injured employee’s medical treatment. In order to overcome a claim, the employer must provide a valid reason for having denied the benefits. To avoid having to pay penalties and attorney fees, the employer must fulfill its duty to investigate and assess factual information before it denies the employer’s requested benefits. See George v. Guillory

On appeal, Wal-Mart claimed it had relied upon medical records it had that showed Citizen had previously gone to physical therapy but had not had any improvements. Wal-Mart claimed it only learned on the morning of the hearing Citizen had not actually completed the previously recommended physical therapy because she had other health issues. She had only been able to attend one session of physical therapy, which one of her doctors testified was insufficient to qualify as a course of physical therapy.

In reviewing the record, the appellate court did not find anything that reasonably controverted Citizen’s claim for the physical therapy that her treating neurosurgeon recommended. Various other doctors, including an orthopedic surgeon, also recommended physical therapy to Citizen.  

The doctors indicated they thought the physical therapy would help Citizen avoid more invasive surgical options. Therefore, the appellate court affirmed the Office of Workers’ Compensation of attorney fees, penalties, and costs against Wal-Mart. It also awarded Citizen additional attorney fees from the appeal. 

If your employer denies your claims for medical treatments recommended by your treating physicians, you might be entitled to receive penalties and attorney fees. As this situation shows, you can be entitled to receive those payments even if your employer eventually decides to approve the recommended treatment. A good attorney can advise you on potential remedies if you have been injured on the job and your employer is denying recommended medical treatment.

Additional Sources: Betty Citizen v. Wal-Mart Stores, Inc.

Article Written By Berniard Law Firm

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