Controversion of claim unreasonable when doctors link condition, accident
Case name: Janneck v. Louisiana Workers' Compensation Corp., No. 2012-CA-0316 (La. Ct. App. 10/17/12).
Ruling: The Louisiana Court of Appeal held that a worker was entitled to attorney's fees because his employer acted arbitrarily and capriciously in controverting his claim.
What it means: In Louisiana, an employer's controversion of a claim is unreasonable when it is aware of numerous medical opinions that find a direct connection between the worker's condition and the work accident.
Summary: A worker for an electric company was injured while in the course and scope of his employment. As a result, he experienced the exacerbation of a preexisting mental condition, which caused the onset of a delusional disorder. He sought benefits, and his claim was denied. Many psychologists related the worker's mental conditions or their aggravation to the injuries from the accident. The worker's treating physician also opined that the accident and injuries were the direct cause of his mental problems. The worker's wage benefits were reinstated, but the workers' compensation corporation and the company refused to authorize and pay for psychological treatment. The worker sought attorney's fees. The Louisiana Court of Appeal held that he was entitled to attorney's fees.
The court pointed out that an employer must adequately investigate a claim and have an articulable and objective reason for denying or discounting benefits. The court found that the company failed to adequately investigate the claim. If the company interviewed those close to the worker, it would have discovered that he had not been treated in the past for psychological issues and his symptoms did not manifest until the work-related accident. The court found that the company did not have an objective reason for denying treatment.
The court pointed out that the company was aware of numerous doctors who directly related the worker's mental illness to his work accident. The court found the company's controversion of the claim was unreasonable. Therefore, the company acted arbitrarily, capriciously, and without probable cause when it disallowed payments for his treatment.
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January 28, 2013
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