DENIED CLAIMS AND SELF-PROCURED MEDICAL TREATMENT
By Richard J Boggan JD
Summary of Denied Cases
Initially cases are denied and then the medical legal dance takes place. The case in chief is then resolved in
the majority of cases with a “Thomas Finding”, which states in the settlement documents in legally sufficient
grounds that if the case was to be tried on the merits of the case that the applicant would take nothing, in other
words he or she would lose the case..
Now it does not mean that the statement of the “Thomas Finding” is true nor that the evidence exists, it is just a
statement that if proven true then the applicant would take nothing on the case.
The defense may state a “Post Termination Defense” but it is shown that the applicant quit instead of being
terminated then the “Thomas Finding” would be invalid and the medical provider gets paid his usual and
customary fees or if the injury was reported before termination (look at the medical report as it will give a brief
history of how the injury happened.)
The defense may state that they have a witness who will state that the applicant told them that the injury
happened outside of work, but the defense may be unable to produce the witness at trial or the witness may be
misinformed, or the statement is misstated then the medical provider gets paid his or her usual and customary
fees.
The defense may state that the applicant failed to report the accident, then it is discovered he was treated by the
defense doctor on the date of accident (which is a real case) then the medical provider gets paid his usual and
customary fees.
There are many more examples where a “Thomas Finding” is stated in the settlement documents where the
provider gets paid his or her usual and customary fees, a large majority of the time.
What happens when a case is denied than the Case in Chief is resolved with a “Thomas Finding”? What
normally happens is the Insurance Company offers the medical provider 10 cents on the dollar claiming it was a
denied case and it settled with a “Thomas Finding”, normally the provider will take such an amount. However,
there are several different ways a case can settle with a “Thomas Finding”, that would not effect the providers
right to full reimbursement, of which the defense would not offer such information, therefore knowing and
understanding a “Thomas Finding” is essential.
Denied to cumulative and admitted as to specific injury, the defense will state that the injury was denied and
settled with a “Thomas Finding”, but will not tell you that the specific was admitted of which the provider probably
treated for.
Denied for specific body part but admitted for other body parts, but defense will just state that the case settled
with a “Thomas Finding” even though the treatment the provider rendered was on the admitted body part. It is
important to know that for a body part that is connected to a another body that was industrial injury but cannot be
treated without treating the non-industrial injury, the treatment for the non-industrial injury is compensable
regardless of the “Thomas Finding,”
Post Termination
Preexisting injury
And more
The above list is only a few of the reasons cases are settled with a “Thomas Finding”, and still entitles the
providers to full payment of their medical bills, therefore, before you settle your medical bills get a copy of the
settlement documents and found out the bases for the “Thomas Finding”.
The “Thomas Finding”, was initially decided with the injured worker in mind to prevent the worker from signing
away rehabilitation benefits for a settlement fee and then being without a marketable trade or skill once the
settlement, money was gone. The case held that in order for an injured worker to sign away his or her
rehabilitation benefits , that the defense had to state in legally sufficient grounds if the case went to court the
case would be decided against the
injured worker and he or she would have a take nothing order. The problem is that the case said nothing at all
about medical providers or lien claimants, and as such a great confusion for medical providers as to its
applicability to the payment of their medical bills existed when the case was decided. This is where legal logic
and applicability of a case law comes into play making mandatory to understanding how to apply case law.
The defense attorneys who saw the case starting thinking well if the injured worker would take nothing then it
stands to reason that the injury did not occur or did not occur at the place of employments and thus we should
not be liable for any medical bills, which is correct in the truest sense of the law. However, the only time it
should actually apply to the medical provider is if the injury never occurred and fraud or misrepresentation by the
injured work has transpired with
sufficient proof to sustain of such a finding.
GANADO V. WORKMEN’S COMP. APP. BD. (1968) 69 Cal. 2d 399, 404 [71 Cal. Rptr. 678, 445 P.2d 294]; states
as follows:
“There can be no doubt that medical expense is not apportionable. Neither section 4600 nor any of the
succeeding sections in the article of the code dealing with medical and hospital treatment state or even suggest
that the employer may pay part of the expense. So long as the treatment is reasonably required to cure or relieve
from the effects of the industrial injury, the employer is required to provide the treatment, and treatment for
nonindustrial conditions may be required of the employer where it becomes essential in curing or relieving
from the effects of the industrial injury itself. Medical treatment unrelated to the industrial injury need not be
furnished by the employer. If medical expenses reasonably necessary to relieve from the industrial injury were
apportionable, a workingman, who is disabled, may not be able to pay his share of the expenses and thus
forego treatment. Moreover, the uncertainties attendant to the determination of the proper apportionment might
cause employers to refuse to pay their share until there has been a hearing and a decision on the question of
apportionment, and such delay in payment may compel the injured workingman to forego the prompt treatment
to which he is entitled.”
THOMAS V. SPORTS CHALET, INC. (1977) 42 Cal.Comp.Cases 625, decided in bank (Thomas), the Board held
that exempt cases "are those . . . in which there is a good faith issue which if resolved against the applicant
would defeat the applicant's claim for all benefits. Examples of cases exempted are those involving a legitimate
issue of injury, employment, initial physical aggressor, statute of limitations, and any other defense of this
nature." The Board noted that section 5100.6 prohibits compromises of benefits to which an "employee is
entitled under rehabilitation" (italics added) and therefore it is not "necessary to interpret Section 5100.6 to
prohibit complete settlement in this [good faith issue] type of case." (42 Cal.Comp.Cases at p. 633.) "By the
manner in which it has qualified the term employee in Section 5100.6 the Legislature has made it clear that
where the employee is injured and has an enforceable right to workers' compensation benefits, the Board
should not allow a release of either present or future rights to rehabilitation." By "future rights to rehabilitation,"
the Board meant that "an employee not initially in need of vocational rehabilitation may, through changes in
circumstances, become in need." (Ibid.)
Cases are settled or resolved in the following ways;
• Settlement: A workers' compensation case may be settled in one of two ways, by a Compromise and
Release (C&R) or by a Stipulation with Request for Award (Stip). A C&R usually settles all outstanding issues in
a claim for a single lump sum payment. A Stipulation may leave certain issues open, such as future medical
treatment and/or vocational rehabilitation.
• Findings & Award (F&A): A Workers' Compensation Administrative Law Judge's decision finding that an
applicant is entitled to disability benefit payments, future medical treatment, or both.
• Findings & Order (F&O): A Workers' Compensation Administrative Law Judge's decision in which no
disability payments or future medical treatment is awarded.
• Stipulation with Request for Award (Stip): A settlement where the parties agree on the terms of an award. It
may include any future medical treatment. Payment takes place over time.
CURE AND RELIEVE" AND "CURE OR RELIEVE" ARE INTERCHANGEABLE.The Board held that an applicant is
entitled to such medical treatment as is reasonably required to "relieve" from the effects of an industrial injury,
even if such treatment will not "cure" that injury. Thus, THE PHRASES "CURE AND RELIEVE" AND "CURE OR
RELIEVE" ARE INTERCHANGEABLE. Kenneth Grom vs. Shasta Wood 69 Cal.Comp.Cases 1567 December 8,
2004
Medical Treatment--WCAB, in significant panel decision, held that applicant was entitled to such medical
treatment as is reasonably required to ''relieve'' from effects of industrial injury, even if such treatment will not
''cure'' that injury, when WCAB found that Labor Code § 4604.5(c) phrase ''cure and relieve'' is identical to, and
interchangeable with, Labor Code § § 4600 and 4604.5(a) phrase ''cure or relieve.
By Richard J Boggan JD
Summary of Denied Cases
Initially cases are denied and then the medical legal dance takes place. The case in chief is then resolved in
the majority of cases with a “Thomas Finding”, which states in the settlement documents in legally sufficient
grounds that if the case was to be tried on the merits of the case that the applicant would take nothing, in other
words he or she would lose the case..
Now it does not mean that the statement of the “Thomas Finding” is true nor that the evidence exists, it is just a
statement that if proven true then the applicant would take nothing on the case.
The defense may state a “Post Termination Defense” but it is shown that the applicant quit instead of being
terminated then the “Thomas Finding” would be invalid and the medical provider gets paid his usual and
customary fees or if the injury was reported before termination (look at the medical report as it will give a brief
history of how the injury happened.)
The defense may state that they have a witness who will state that the applicant told them that the injury
happened outside of work, but the defense may be unable to produce the witness at trial or the witness may be
misinformed, or the statement is misstated then the medical provider gets paid his or her usual and customary
fees.
The defense may state that the applicant failed to report the accident, then it is discovered he was treated by the
defense doctor on the date of accident (which is a real case) then the medical provider gets paid his usual and
customary fees.
There are many more examples where a “Thomas Finding” is stated in the settlement documents where the
provider gets paid his or her usual and customary fees, a large majority of the time.
What happens when a case is denied than the Case in Chief is resolved with a “Thomas Finding”? What
normally happens is the Insurance Company offers the medical provider 10 cents on the dollar claiming it was a
denied case and it settled with a “Thomas Finding”, normally the provider will take such an amount. However,
there are several different ways a case can settle with a “Thomas Finding”, that would not effect the providers
right to full reimbursement, of which the defense would not offer such information, therefore knowing and
understanding a “Thomas Finding” is essential.
Denied to cumulative and admitted as to specific injury, the defense will state that the injury was denied and
settled with a “Thomas Finding”, but will not tell you that the specific was admitted of which the provider probably
treated for.
Denied for specific body part but admitted for other body parts, but defense will just state that the case settled
with a “Thomas Finding” even though the treatment the provider rendered was on the admitted body part. It is
important to know that for a body part that is connected to a another body that was industrial injury but cannot be
treated without treating the non-industrial injury, the treatment for the non-industrial injury is compensable
regardless of the “Thomas Finding,”
Post Termination
Preexisting injury
And more
The above list is only a few of the reasons cases are settled with a “Thomas Finding”, and still entitles the
providers to full payment of their medical bills, therefore, before you settle your medical bills get a copy of the
settlement documents and found out the bases for the “Thomas Finding”.
The “Thomas Finding”, was initially decided with the injured worker in mind to prevent the worker from signing
away rehabilitation benefits for a settlement fee and then being without a marketable trade or skill once the
settlement, money was gone. The case held that in order for an injured worker to sign away his or her
rehabilitation benefits , that the defense had to state in legally sufficient grounds if the case went to court the
case would be decided against the
injured worker and he or she would have a take nothing order. The problem is that the case said nothing at all
about medical providers or lien claimants, and as such a great confusion for medical providers as to its
applicability to the payment of their medical bills existed when the case was decided. This is where legal logic
and applicability of a case law comes into play making mandatory to understanding how to apply case law.
The defense attorneys who saw the case starting thinking well if the injured worker would take nothing then it
stands to reason that the injury did not occur or did not occur at the place of employments and thus we should
not be liable for any medical bills, which is correct in the truest sense of the law. However, the only time it
should actually apply to the medical provider is if the injury never occurred and fraud or misrepresentation by the
injured work has transpired with
sufficient proof to sustain of such a finding.
GANADO V. WORKMEN’S COMP. APP. BD. (1968) 69 Cal. 2d 399, 404 [71 Cal. Rptr. 678, 445 P.2d 294]; states
as follows:
“There can be no doubt that medical expense is not apportionable. Neither section 4600 nor any of the
succeeding sections in the article of the code dealing with medical and hospital treatment state or even suggest
that the employer may pay part of the expense. So long as the treatment is reasonably required to cure or relieve
from the effects of the industrial injury, the employer is required to provide the treatment, and treatment for
nonindustrial conditions may be required of the employer where it becomes essential in curing or relieving
from the effects of the industrial injury itself. Medical treatment unrelated to the industrial injury need not be
furnished by the employer. If medical expenses reasonably necessary to relieve from the industrial injury were
apportionable, a workingman, who is disabled, may not be able to pay his share of the expenses and thus
forego treatment. Moreover, the uncertainties attendant to the determination of the proper apportionment might
cause employers to refuse to pay their share until there has been a hearing and a decision on the question of
apportionment, and such delay in payment may compel the injured workingman to forego the prompt treatment
to which he is entitled.”
THOMAS V. SPORTS CHALET, INC. (1977) 42 Cal.Comp.Cases 625, decided in bank (Thomas), the Board held
that exempt cases "are those . . . in which there is a good faith issue which if resolved against the applicant
would defeat the applicant's claim for all benefits. Examples of cases exempted are those involving a legitimate
issue of injury, employment, initial physical aggressor, statute of limitations, and any other defense of this
nature." The Board noted that section 5100.6 prohibits compromises of benefits to which an "employee is
entitled under rehabilitation" (italics added) and therefore it is not "necessary to interpret Section 5100.6 to
prohibit complete settlement in this [good faith issue] type of case." (42 Cal.Comp.Cases at p. 633.) "By the
manner in which it has qualified the term employee in Section 5100.6 the Legislature has made it clear that
where the employee is injured and has an enforceable right to workers' compensation benefits, the Board
should not allow a release of either present or future rights to rehabilitation." By "future rights to rehabilitation,"
the Board meant that "an employee not initially in need of vocational rehabilitation may, through changes in
circumstances, become in need." (Ibid.)
Cases are settled or resolved in the following ways;
• Settlement: A workers' compensation case may be settled in one of two ways, by a Compromise and
Release (C&R) or by a Stipulation with Request for Award (Stip). A C&R usually settles all outstanding issues in
a claim for a single lump sum payment. A Stipulation may leave certain issues open, such as future medical
treatment and/or vocational rehabilitation.
• Findings & Award (F&A): A Workers' Compensation Administrative Law Judge's decision finding that an
applicant is entitled to disability benefit payments, future medical treatment, or both.
• Findings & Order (F&O): A Workers' Compensation Administrative Law Judge's decision in which no
disability payments or future medical treatment is awarded.
• Stipulation with Request for Award (Stip): A settlement where the parties agree on the terms of an award. It
may include any future medical treatment. Payment takes place over time.
CURE AND RELIEVE" AND "CURE OR RELIEVE" ARE INTERCHANGEABLE.The Board held that an applicant is
entitled to such medical treatment as is reasonably required to "relieve" from the effects of an industrial injury,
even if such treatment will not "cure" that injury. Thus, THE PHRASES "CURE AND RELIEVE" AND "CURE OR
RELIEVE" ARE INTERCHANGEABLE. Kenneth Grom vs. Shasta Wood 69 Cal.Comp.Cases 1567 December 8,
2004
Medical Treatment--WCAB, in significant panel decision, held that applicant was entitled to such medical
treatment as is reasonably required to ''relieve'' from effects of industrial injury, even if such treatment will not
''cure'' that injury, when WCAB found that Labor Code § 4604.5(c) phrase ''cure and relieve'' is identical to, and
interchangeable with, Labor Code § § 4600 and 4604.5(a) phrase ''cure or relieve.
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