Atlanta Injury Attorney Blog

The Georgia State Board of Workers' Compensation promulgated Board Rule 205. This rule states that an authorized medical provider may request advanced authorization for a patient's treatment or testing by completing sections 1 and 2 of Board Form WC-205 and faxing the form to an employer or insurer. Once the employer or insurer receives WC-205, they must complete section 3 of the form and fax it back to the medical provider within five business days. If preauthorization is denied, the employer or insurer must file a second form giving the reason for the denial. If the employer or insurer fails to comply with Rule 205, they are liable for the treatment or test that the preauthorization sought (forfeiture provision).

In Selective HR Solutions Inc. v. Mulligan, 2010 Ga. App. LEXIS 687 (July 12, 2010), the Georgia Court of Appeals considered the legality of Board Rule 205 and the Board's rule-making authority. The defendant, Selective, argued that Rule 205 must be read in conjunction with the requirement that an employee is entitled to medical benefits only when related to an "on the job injury." The Court agreed. The claimant should bear the burden of proving their injury was work-related and thus compensable.

The Court of Appeals stated: "Rule 205, on its face, establishes a rebuttable presumption of compensability in favor of the claimant upon an ATP's request for advance authorization to provide medical care in that the injury is presumed compensable unless the insurer denies authorization and controverts the treatment. With the employer/self-insurer's failure to timely respond, a conclusive presumption of compensability results. In both instances, the effect of Rule 205 is to shift the burden the claimant would otherwise bear to show the injury is compensable as work-related. Commercial Union Assn., 143 Ga. App. at 64 (1). We conclude, therefore, that insofar as that aspect of Rule 205 precluding an employer from contesting the compensability of treatment is in issue, 1 Rule 205 is invalid as substantive rule-making which impermissibly shifts the claimant's burden of proof to show that an injury is work-related and invades the province of the legislature."

For Georgia workers' compensation claimants, the question is whether Board Rule 205 is completely invalid or not.

In our view, if a case is already compensable, there is obviously no need for claimant to carry the burden of establishing compensability. Therefore, Rule 205 could still be used in a compensable case. Therefore, the rule would still require the employer/insurer to make a prompt decision on specific treatment by the authorized treating physician, and places the burden on employer/insurer to controvert that specific treatment within five days.

It will be interesting to see how this plays out.

In June 2006,Yvonne Bolden, an employee at S&B Engineers and Constructors, suffered a compensable injury to her left hand and began receiving temporary total disability in November 2006. On March 26, 2007, a neurologist reported that Bolden could return to work, with limited restrictions on what she could lift or carry. Bolden's case manager, who accompanied her to the appointment, reported the neurologist's statement to the insurer. The insurer subsequently terminated Bolden's weekly benefits without notice on April 24, 2007. Bolden hired an attorney and sought reinstatement of her temporary total disability from April 24, 2007 until May 9, 2008, when she began a new job.

The Georgia code (OGCA § 34-9-221) requires employers to file a form WC-2 with the board and to send a copy to the employee giving them ten days notice of the termination of benefits. Here, the employer and insurer never filed the WC-2 form at all and never explained to Bolden why they were terminating her benefits. The court held that their noncompliance with the code was unreasonable and that Bolden was entitled to benefits from April 24, 2007 until May 9, 2008.

The code is designed to protect the Georgia injured worker and afford them due process. Not only must the employer notify the employee that their benefits are being terminated, but they must inform them of the reason for the termination.

Visit our Georgia Workers' Compensation Law website at www.atlantaworkerscompensationattorney.com and call us at 404-352-3400 for help with your workers' compensation case anywhere in the State of Georgia.

In Keystone Automotive v. Hall (A08A0086), the Georgia Court of Appeals affirmed the superior court's judgment granting death benefits to Holly Hall following her husband's death three weeks after co-workers found him lying unconscious outside of the company's warehouse, near his truck. Holly's claim for workers' compensation benefits was referred to a Workers Compensation Administrative Law Judge (ALJ) for resolution. The ALJ concluded that because the decedent was in a place where he would reasonably be expected to be while on the job and because his death was unexplained, the presumption that his death arose from his employment, as set forth in Zamora v. Coffee General Hospital, was appropriate. The employer, Keystone Automotive, failed to overcome the Zamora presumption because they were unable to affirmatively demonstrate that the death did not arise out of his employment.

The State Workers Compensation appellate division reversed, concluding that Zamora did not control and that the medical evidence indicated Hall died of a naturally occurring event unrelated to his work duties. The superior court reversed the appellate division and distinguished between the "immediate" and "precipitating" cause of death, the event or chain of events leading up to the death. The court found that because no evidence suggested what exactly caused Hall's cardiac arrest; there was no evidence to suggest a non-work-related precipitating cause of death. In Buschel v. Kysor/Warren, this court held the (Zamora) presumption applied when the employee's death is "unexplained." This means the precipitating, rather than the immediate cause of death must be unexplained. Here, there is no evidence pointing to the precipitating cause of Hall's death as physicians were only able to state possible conditions that may have caused Hall's cardiac arrest. Therefore, the precipitating cause of death was unexplained.

In the absence of evidence establishing the precipitating cause of Hall's death, the Zamora presumption applies and the superior court was affirmed. This means that the worker's family could collect workers' compensation benefits.

If a loved one has been tragically killed while on the job anywhere in the State of Georgia, call the Delius Law Firm for help with your Georgia Workers' Compensation death case at 404-352-3400.

In Keystone Automotive v. Hall (A08A0086), the Georgia Court of Appeals affirmed the superior court's judgment granting death benefits to Holly Hall following her husband's death three weeks after co-workers found him lying unconscious outside of the company's warehouse, near his truck. Holly's claim for workers' compensation benefits was referred to a Workers Compensation Administrative Law Judge (ALJ) for resolution.

The ALJ concluded that because the decedent was in a place where he would reasonably be expected to be while on the job and because his death was unexplained, the presumption that his death arose from his employment, as set forth in Zamora v. Coffee General Hospital, was appropriate. The employer, Keystone Automotive, failed to overcome the Zamora presumption because they were unable to affirmatively demonstrate that the death did not arise out of his employment.

The State Board of Workers Compensation appellate division reversed, concluding that Zamora did not control and that the medical evidence indicated Hall died of a naturally occurring event unrelated to his work duties. The superior court reversed the appellate division and distinguished between the "immediate" and "precipitating" cause of death, the event or chain of events leading up to the death. The court found that because no evidence suggested what exactly caused Hall's cardiac arrest; there was no evidence to suggest a non-work-related precipitating cause of death. In Buschel v. Kysor/Warren, this court held the (Zamora) presumption applied when the employee's death is "unexplained." This means the precipitating, rather than the immediate cause of death must be unexplained. Here, there is no evidence pointing to the precipitating cause of Hall's death as physicians were only able to state possible conditions that may have caused Hall's cardiac arrest. Therefore, the precipitating cause of death was unexplained.

In the absence of evidence establishing the precipitating cause of Hall's death, the Zamora presumption applies and the superior court was affirmed.