In New Jersey the employer has the right to direct and control medical care. However, there are limited circumstances where an employer can lose that right to control – specifically, when the employer has failed to provide “reasonable and necessary” curative treatment to a claimant. What usually happens is that an authorized treating provicder requests authorization to perform a specific treatment (such as surgery) and authorization is withheld or delayed, often for good reason.
Under such circumstances, the Rules of the Division of Workers’ Compensation allow an injured employee to file a “Motion for Temporary and Medical Benefits” (AKA, “Motion for Med & Temp”) to compel the employer/respondent to provide specific medical treatment or temporary disability wage compensation which was denied.
The respondent has 21 days to file a responsive pleading (or 30 days, if the Motion for Med & Temp is filed at the same time as the Claim Petition). If the respondent wishes to present an IME report in opposition to the Motion for Med & Temp (which is usually the case), the doctor’s examination must be conducted within 30 days of the receipt of the filed motion and the report issued within 35 days.
Disputes about whether specific treatments are “necessary” often require testimony – essentially a “mini-trial” within the litigation. First the claimant testifies, and then the treating doctor (who is seeking to provide some specific treatment to the claimant) testifies, and then the employer’s IME doctor testifies. Litigating a motion for Med & Temp can be more costly then just the litigation expense: if a petitioner prevails in their motion, claimant’s counsel is due a fee (up to 20% of all the treatment provided pursuant to the motion). It goes without saying that the potential for an attorneys’ fee often drives the filing of such motions.
Most of the time such disputes can be resolved informally between the parties. If not, a filed motion will be conferenced in chambers with the presiding judge. If the parties can reach an agreement as to the treatment course, a consent order can be issued resolving the matter.
Sometimes when an agreement can not be reached, the Judge or either party will recommend that a third doctors opinion be obtained – to act as an effective “tie-breaker.”
Recent case: Dispute about the “tie-breaker’s role.”
In a recent case (decided July 27, 2011) the Appellate Panel looked at a very interesting issue: absent the clear consent of the parties to be bound to the opinion of the “tie-breaker”, can a judge of compensation “appoint” a court-selected doctor to decide the medical issue?
In the new case, the judge of compensation selected and appointed a physician to perform a physical examination, review the relevant medical records, and provide an opinion as to whether a specific medical treatment (in this case, surgery) was necessary. In their subsequent appellate briefs one side stated that it was agreed by all counsel in chambers that, in light of the conflicting information regarding causation, the court-appointed physician would serve as the “tie-breaker,” and that his opinion would be dispositive of the issue. The other side took a contrary position, contending that the court-appointed evaluation and report would be “non-binding.”
In other words, on appeal, the parties disputed that they had consented to the appointment of the “tie breaker” doctor and disagreed over whether they were to be bound by the findings of the selected doctor.
The hearing transcript was silent: there was no mention by any counsel or the court of an off-the-record agreement as to the effect of the “tie-breakers’s” evaluation and report.
The appellate panel ruled that the workers’ compensation judge correctly exercised her discretion by basing her ruling on the report of her appointed “tie-breaker” in conjunction with other competent evidence in the record.
Practical Tips for counsel:
Resolving medical disputes in a cost-effective manner is always a goal – but in this case the appointment of the “tie-breaker” without a clear statement on the record as to the effect of that appointment – whether or not the parties would be bound by the opinion of the new physician – should not be allowed. If a consent order is entered, the employer’s counsel should clearly mark the appointment of the new reviewing physician as “without prejudice” on the consent order itself to avoid ambiguity and preserve all defenses.