Saturday, March 11, 2017

No credit in temporary award without sufficient foundation of self-funded plan.

Miller v Nieman Foods
March 2, 2017

Claimant alleged a back injury from lifting boxes in January 2013.  The ALJ issued a temporary award and back medical bills of about $62,000 related to a prior surgery.

The Commission rejects the alleged error that the employer should have received offset for payments through a self-funded insurance plan.

"Employer argues that many of the disputed charges have already been satisfied, in part, by payments from employee's group health insurance plan through employer. But (as employer acknowledges in its brief) the record is bereft of evidence to establish the nature of that insurance policy, and whether such was fully funded by the employer or instead involved co-pays, co-insurance, deductibles, or monthly premiums payable by employee. In the absence of such evidence, there is no support for a finding these insurance payments and/or any adjustments referable thereto constituted benefits directly from the employer  for purposes of  287.270."

"Nevertheless, employer asserts it will offer the requisite evidence if and when this matter proceeds to a hearing for a final award, and asks the Commission to impose a "stay" on the Division's award of past medical expenses until the full hearing may be held. We must decline this request, because the relevant statutes do not confer upon the Commission the authority to "stay," in whole or in part, any temporary or partial award by an administrative law judge. Instead, pursuant to 287.250. RSMo.  these proceedings are kept open until a final award can be made"

The employer was entitled to a credit for a prior payment sent to claimant by the carrier.  The Commission indicated the employer could offer additional proof on the issue in a final award which could be an indirect invitation to settle the case.