Roof bolter not required to obtain prior authorization for psych evaluation

In West Virginia, an injured worker is not required to obtain prior authorization from a claims administrator before seeking an initial psychiatric consultation.

Case name: Hale v. West Virginia Office of the Insurance Commissioner, No. 101028 (W.Va. 03/22/12).

Ruling: The West Virginia Supreme Court of Appeals held that a roof bolter was entitled to a psychiatric consultation.

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What it means: In West Virginia, an injured worker is not required to obtain prior authorization from a claims administrator before seeking an initial psychiatric consultation.

Summary: A roof bolter injured his back while lifting a wooden pallet. His back injury was held compensable. Later, he sought psychiatric treatment and was assessed with major depressive disorder. A physician assistant noted that the roof bolter's depression intensified due to his back pain from his work-related injury. His treating physician submitted a diagnosis update form to the claims administrator requesting that depression be added as a compensable injury. The claims administrator denied the request, stating that the initial psychiatric consultation and treatment were not authorized by the employer. The West Virginia Supreme Court of Appeals held that the roof bolter was entitled to a psychiatric evaluation without the employer's consent.

The court pointed out that two regulations conflicted as to whether a worker was required to obtain authorization before seeking an initial psychiatric evaluation. The court concluded that the rule requiring authorization was not "reasonable" because it required the claims administrator to make a psychiatric treatment decision without having medical opinions on which to base the treatment decision. Also, the rule did not fulfill the legislature's goal of compensating injured workers.

The court concluded that a three-step process exists for workers claiming psychiatric injuries. First, the treating physician refers the worker to a psychiatrist. Next, the psychiatrist examines the worker and makes a detailed report. Third, the claims administrator reviews the psychiatrist's report and determines whether the psychiatric condition should be added as a compensable injury to the claim. This process promotes expedited treatment for a worker experiencing psychiatric problems. Here, the three-step process was not followed.

Read more at the WorkersComp Forum homepage.

May 10, 2012

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