On behalf of Licatesi Law Group, LLP on Thursday, January 26, 2012.

Ever since the Workers Compensation Guidelines were released, becoming effective on December 1, 2010, providers & their attorneys alike took a deep breath, as they knew exactly what would happen next; arguments with the insurance carriers on the applicability of the guidelines. The Guidelines encompass a set of medical guidelines to be used in the treatment of neck, low back, knee and shoulder injuries, which the Worker’s Compensation Board notes accounts for “40% of injuries and 60% of medical costs.” These are not new fee schedules, but guides to the application of certain modalities in certain situations. Of course as with anything new done by Worker’s Comp Board without specificity as to who /when it doesn’t apply; comes the inevitable question of whether these guidelines apply to no fault and when they apply.

Not surprisingly, I’ve already seen these guidelines being misapplied by peer reviewers and carriers alike. Also not surprising that the carriers would jump on any opportunity to attempt to not pay the reasonable and necessary medical care of their own insured. Since I’ve already heard and seen this argument attempt to be made, I figured it was worth giving the Worker’s Compensation Ground Rules a read. Here is what I came across:

The Worker’s Compensation Ground Rules discuss the application of the new Guidelines in Paragraph 1A of Medicine, Physical Medicine and Chiropractic Sections. The exact language is set forth as follows:

“Treatment of work-related injuries should be in accordance with any applicable medical treatment guidelines adopted by the Chair of the Worker’s Compensation Board.”

So there you have it, the treatment of “work-related injuries.” The guidelines were composed specifically for work related injuries, not treatment for injuries related to a car accident, aka, not applicable to No Fault. Although the language seems clear to me, I can still foresee insurance carriers using the guidelines and creating a whole slew of new arbitration decisions and litigation. We will have to watch closely to see how both judges and arbitrators view this issue.

For more information: Call (516) 478-0237
By: Candice L. Deaner, Esq.