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Thread Title: Denial
Created On Monday October 13, 2008 2:38 PM

friday
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Monday October 13, 2008 2:38 PM

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I have an accepted wrist and forearm inj. (mo conversion) case is now litigated a/a filed and app adding sleepless and sexual dysfunction. Can I deny these new allegations using "no medical evidence to substantiate alleged conditions" ?

steve appell
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Monday October 13, 2008 2:57 PM

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Hi Friday, and initially, welcome to the forum!

If there is no new DOI, you continue to have an admitted injury with nature and extent at issue. Therefore, a subsequent denial of newly claimed body parts has no effect on the AOE COE issue. If however A/A is claiming a new DOI, then your denial would be appropriate.

Good Luck !

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Steve

A government which robs Peter to pay Paul can always depend on the support of Paul.
- George Bernard Shaw

friday
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Monday October 13, 2008 8:25 PM

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Thank you Steve...

postscript2
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Tuesday October 14, 2008 3:50 PM

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What if same scenario and AA files a second CT adding those body parts??? Does not the 90 day discovery rule apply?

--AND if so and no investigation or denial, are the body parts/conditions automatically accepted???

Thanks,

LCS

steve appell
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Wednesday October 15, 2008 8:10 AM

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Hi Post !
If a 2nd CT is pled, the denial must be issued within 90 days of filing, or the claim is presumed compensable. However, nature & extent may still be at issue, and no evidence discoverable within that 90 day period may be used to challenge AOE/COE.

-------------------------
Steve

A government which robs Peter to pay Paul can always depend on the support of Paul.
- George Bernard Shaw

Edited: Wednesday October 15, 2008 at 8:10 AM by steve appell

postscript2
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Wednesday October 15, 2008 1:48 PM

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Thanks Steve,

For confirming this misconception over the years by many of my supervisors!!! I've routinely been told in the past to deny each and every additional body part/condition each time an app was amended. I finally quit signing them and told the supervisor to sign it themselves if they felt so compelled to do so.

This was especially true with psyche add-ons when the I/W was employed less than 6 months. What is your take on that situation?

LCS

gaiassoul1@yahoo.com
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Tuesday October 28, 2008 10:36 PM

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its a preemptive strike and a courtesy notice to all parties as to the status of each body part, this is why supervisors insist on it, so the paper trail stays clear and no one can say "we were never on notice the body part was disputed"

There is no law against denying body parts, but you assume no liability under LC 5402 if at least one body part is accepted.

postscript2
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Wednesday October 29, 2008 1:20 PM

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In my hypo re psyche, I can see a "denial" due to less than 6 months with ER, but what reason would one use to deny any other body part absent the presence of medical evidence, which would then call for the med legal process, right???

LCS

gaiassoul1@yahoo.com
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Wednesday October 29, 2008 3:45 PM

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other reasons would include witness statements as to how the person used that body part, what was reported at the time and what was reported years later, factual situations such as subsequent injuries where the body part was injured in another trauma, etc. etc. etc.

postscript2
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Wednesday October 29, 2008 9:52 PM

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--agreed, but once the 90 days has passed, then it's not appropriate to just outright "deny" subsequent body parts-yet at the same time a "delay" is also inappropriate under the LC, UNLESS, "Honeywell" applies and there is no DWC-1 on file...

And would the amended App allow for the taking of additional statements, depositions, etc., that could not have been achieved during the first 90 days; i.e. an additional "discovery" window? I would think so, however this has always been a "shadowed" area of comp, IMHO...

LCS

Jpod
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Thursday October 30, 2008 8:53 AM

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I think the point is while you are correct that issuing a denial in such a situation does not have the legal effect of a denial AOE/COE, it is nonetheless helpful for a host reasons already mentioned.

One I would add is that the patient, with denial of body part in hand, can now use other insurance to seek treatment. It also is usefull to put all the docs on the notice of the insurer's position.

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