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In a recent rulling, the Court of Appeals held that the Five-day time lmit for insurers to respond to a WC 205 request from the treating physician cannot be enforced if the insurer defends on the basis that the requested treatment in not related to the on-the-job injury. This unfortunate ruling for employees could result in even longer delays for employees to get much-needed treatment. Under Board rules, A physicain authorized to provide treatment to the employee could send a form called a WC 205 to the insurer requesting authorization to provide certain treatment. The insurer had 5 days to respond, either approving the request or denying it. If the insurer failed to respond, the procedure was considered approved and the insurer was required to pay the doctor for it. Doctors are oftentimes reluctant to proceed with certain treatment, such as surgery or other expensive treatment, without prior approval from the insurer for fear they may not get paid for it. The delays caused by insurers who are slow to respond to the requests for approval, or who fail to respond at all, are one of the biggest difficulties an employee is faced with who is receiving medical treatment for a work injury. Thus, Board Rule 205 was enacted to give the employee and his doctor a better chance to get a faster response when the treatment requested was of a more urgent nature. In the case at bar, the insurer did not reply to the doctor and when the employee requested a hearing, it defended on the basis while it may not have responded within the 5 days, that the procedure requested was not related to the injury so it did not have to. The employee argued that the insurer waived its right to argue in this manner because it had not responded within 5 days to the WC 205. The Court sided with the insurer, essentially ruling that the 5-day requirement did not apply when the insurer did not believe the procedure was related to the injury. The obvious problem this ruling creates for employees is that as long as the insurer makes the argument, whether valid or not, that the procedure is not related to the injury, it will not have to comply with the Rule. It is unknown whether the employee in this case will appeal to the Georgia Supreme Court, but I hope that he will do so.
On another note, be sure to visit my new website, www.romeworkerscomp.com, a site dedicated to my claimants side workers comp practice. If you have questions about your workers comp claim, please contact me. Thanks, and have a great day. BGS
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