On 2003, a complainant man obtained a back injurywhile he was employed. Shortly thereafter, his employer accepted his injury’s compensability and commenced the payments of both medical and indemnity benefits. An Nassau authorized orthopedist initially diagnosed the complainant man with disc herniation with chronic low back pain. After that, a surgical procedure was performed and the orthopedist’s explained that the surgery revealed spinal stenosis with no evidence of disc herniation. The orthopedist also informed the attorney of the man’s employer that one hundred percent of the complainant’s need for medical treatment was caused by pre-existing degenerative changes due to his personal condition. The complainant then filed an appeal for benefits requesting authorization of a neurologist and compensability of the claim, which the carrier timely controverted because of the opinion of the complainant’s treating orthopedist.
After the trial, the judges of compensation claim accepted the opinion of the treating orthopedist that the complainant’s injury was wholly attributable to his preexisting condition and therefore found that his current condition is not compensable as it did not arise out of the course and scope of his employment and no further treatment is awarded.
The Suffolk judges of compensation claim further concluded that there was nothing in the record that would have reasonably placed the employer on notice of the complainant’s personal condition being the major contributing cause of the injury until the conference between its attorney and the orthopedist was done. As a result, the employer denied the medical treatment within 120 days from the notification it had then received and the compensability of the injury was considered timely denied. With that, the judges of compensation claim refused both the claims for compensability of the complainant’s back condition and authorization of a neurologist.
Based on records, the carrier had such information through the condition of the orthopedist’s notes. In fact, the court’s case law interprets the ruling language pertaining to the commencement of the running of the 120-day period from the initial condition of benefits to mean the date the employee’s first visits to the authorized physician, which could produce the first available information useful to the employer and carrier to determine whether the injury is compensable.
Consequently, the court considered that the issue of the complainant’s entitlement to the authorization of a neurologist is controlled by the rule and the court’s earlier decision with other previous court case. In the case cited by the court, the carrier authorized medical treatment for the worsening of the employee’s disc condition during the complainant’s employment, and treatment for same continued for more than 120 days. Thereafter, the authorized physician recommended a laminectomy for the back condition, for which the complainant sought approval, and the carrier timely denied.
In affirming the judges of compensation claim’s denial of the claim, the court noted that the recommended surgery was not intended to address the exacerbation, but to resolve the entire disc herniation, which medical evidence revealed had occurred before the work-related accident happened. The court also concluded that the provisions applied only to the compensability of the exacerbation of the condition and not to a major surgical procedure which involved a condition that had pre-existed the work-related accident.
As a result, the court decided that under such circumstances, the provisions relating to the carrier’s obligations in responding to an appeal for benefits and on its timely denial on the specifically requested surgery just after it had been claimed, it could not be considered to have waived its right to contest. The court finds that the employer timely denied the appeal seeking the authorization of a neurologist within 14 days after the receipt of the appeal.
Acquiring a severe disease or injury is one of the hardest situations a man could have. It could be painful physically and emotionally but it could be more if he cannot return to his work. If you need legal guidance with your contentions, you can have the NY Personal Injury Attorney or New York City Injury Lawyer. But, if you prefer to have the NYC Spine Injury Lawyer for your lawsuit, you can request them at Stephen Bilkis and Associates office.