A Trek Through Medical Treatment Options

In terms of exposure in a claim, nothing holds a candle to the kind that is generated by a claimant’s medical treatment. Indeed, maintaining control over the claimant’s medical treatment is one of the primary keys to mitigating exposure. In Georgia, for instance, at the outset of a claim, the main elements of maintaining control over a claimant’s medical treatment are ensuring that you have a valid posted panel of physicians, have posted the panel in prominent places on your business premises, and have taken measures to ensure your employees understand the purpose and function of the panel.

Although the above requirements may differ in your jurisdiction, by ensuring your panel of physicians is up to date and conforms with all applicable laws, you can be more confident from the outset of a claim that the claimant’s medical treatment will be less likely to spiral out of control. Of course, in many of our claims, issues may not arise until the claimant’s treatment begins to progress. Indeed, on many occasions, while the claimant’s treatment is underway, the authorized treating physician may issue a referral to another physician. With the referral in hand, what should you do? For the answer to this question, and more, let us explore the issue through the scenario of how the venerable Captain Jean-Luc Picard from “Star Trek: The Next Generation,” might handle such a situation.

Injury, Physician Selection, and Non-Panel Physician Referral

During an away-team mission on the Planet Janus VI, Commander Will Riker is struck in the head and neck by a large rock. Once the away team beams back to the U.S.S. Enterprise, Riker reports his injury to his supervisor, Captain Picard, and requests medical treatment.

Fortunately, Captain Picard is well-versed in Starfleet regulations regarding the procedures for handling a reported on-the-job injury. Captain Picard takes Riker to his Ready Room, where he provides Riker with a copy of Starfleet’s posted panel of physicians for that sector. From the panel, Riker chooses to treat with Dr. Beverly Crusher, which is fortunate since Dr. Crusher has an office on the ship. Following Riker’s selection, Captain Picard notifies the Starfleet claims adjuster who arranges for Riker’s initial appointment with Dr. Crusher as the initial authorized treating physician for Riker’s claim.

Upon examining Riker, Dr. Crusher notes that he has sustained a large laceration to the back of his head and is complaining of headaches. Further, Riker is reporting neck pain, asserting that the rock hit his head and neck. While Dr. Crusher is more than qualified to treat Riker’s alleged neck pain, she feels he may benefit from being examined by a different physician for his headaches and issues a referral to an unspecified neurologist for examination and treatment of Riker’s headaches.

As is often the case in our claims, now that Dr. Crusher has issued a referral to an unspecified neurologist, what should the Starfleet claims adjuster do? More often than not, Riker would be provided a copy of the posted panel of physicians again and asked to select a neurologist from there. However, most panels generally do not include a neurologist. Indeed, a close inspection of the Starfleet panel reveals that there are, in fact, no neurologists listed. So, what now? Is all hope lost at this point with Riker being entitled to treat with a neurologist of his choosing? Does the lack of a neurologist on the panel invalidate the posted panel of physicians as a whole? Are we now forced to try and reach a compromise with Riker and/or his attorney? Fortunately, if your laws resemble those in Georgia, for instance, the answers to these questions are a resounding “no.”

Maintaining Control of Medical Treatment After Referral

Using Georgia law, O.C.G.A. § 34-9-201, as an example, the purpose of the posted panel of physicians is to allow the claimant to select the initial authorized treating physician. Once the authorized treating physician is selected, that physician “… may arrange for any consultation, referral, and extraordinary or other specialized medical services as the nature of the injury shall require….” Thus, Captain Picard and the Starfleet claims adjuster are arguably bound to honor the referral.

However, because Dr. Crusher did not refer Riker to a specific provider, Captain Picard and the claims adjuster are arguably free to schedule Riker with a neurologist of their choosing without regard to Riker’s wishes. If the laws of your jurisdiction resemble those of Georgia, there is no statutory requirement that Riker be provided a copy of the panel of physicians and be allowed to select the referral physician. Indeed, under Georgia law, and possibly the law of your jurisdiction, the only times a claimant should be presented with a copy of the posted panel of physicians are immediately following an accident and when the claimant requests a change of physician.

The Final Frontier

The next time you run into a situation wherein your claimant’s treating physician has issued a referral, remember that you are still in control, even if there is no listed physician within the specialty to which the claimant has been referred. Instead, check to ensure the law of your jurisdiction allows it, and simply select a referral physician of your choosing.