Georgia court invalidates medical authorization rule

The Georgia Court of Appeals invalidated Rule 205 as it impermissibly shifted the claimant's burden of proof to show that an injury was compensable as work-related.

Case name: Selective HR Solutions, Inc., et al. v. Mulligan, No. A10A008 (Ga. Ct. App. 07/12/10).

Ruling: The Georgia Court of Appeals ruled that Georgia State Board of Workers' Compensation Rule 205 is invalid as it impermissibly shifts the claimant's burden of proof to show that an injury was compensable as work-related. It also held that an employee was not entitled to workers' compensation for a back injury.

Sub-subcontractor's employee not entitled to coverage from contractor (02/25/13)
Cleaner's use of helpers indicates independent contractor status (11/01/12)
Statement made weeks before termination moves claim forward (09/30/11)
Failure to rebut rehab counselor's report boosts driver's claim (04/19/12)
Hospital not subject to penalties for worker's fall in elevator shaft (04/19/12)

What it means: Georgia Rule 205 provides that if an insurer does not respond to a request for advance authorization of treatment within five days, the treatment is deemed to be preapproved. The court ruled that it impermissibly shifts the claimant's burden of proof to show that an injury is compensable as work-related.

Summary: An employee suffered a work-related back injury. After she recovered and returned to work, she reinjured her back in a fall at home. After her doctor determined that another lumbar surgery was necessary, he sent the insurer a form requesting advanced authorization, pursuant to Rule 205. The insurer did not respond for more than a month, then stated that it would not authorize the procedure. The employee asserted that the insurer's failure to respond to her request for treatment demanded a finding that the treatment was expressly authorized under Rule 205. The insurer argued that Rule 205 should not be interpreted as providing that an employer's failure to respond within five days to a request for advance authorization for treatment triggers a right to payment for medical care whether or not the injury is work-related. The Georgia Court of Appeals agreed with the insurer and invalidated Rule 205 as it impermissibly shifted the claimant's burden of proof to show that an injury was compensable as work-related.

The employee argued that her injury was a work-related change of condition for the worse. The court noted that she described her injury to her doctor as a fall at her home, she submitted her medical bills to her husband's private group insurer, and she indicated that the renewed pain in her back began after the fall. No evidence showed that her renewed back pain was work-related, so the court held that the employee did not suffer from a compensable injury.

Read more at the WorkersComp Forum homepage.

September 16, 2010

Newsletter Sign-up