A Discussion Regarding California Code of Regulations, Title 8, Sec. 9785.
The latest submission to the DGC website (available also using AskDGC@DGCAttorneys.com), came from a client who asked: “Is there a Labor Code Section to support an adjuster stopping TD benefits based on no recent medical report? When should an adjuster stop TD benefits if there is no medical evidence?”
Our response noted that there is supporting legal authority for an adjuster to halt TD benefits, and shared a few of the more common situations where one should, if appropriate for strategic management of a claim, keeping in mind each claim is unique and managed under various client guidelines.
For instance, in accepted claims where initial eligibility for TD benefits is a pending issue, 8 CCR §9785(d) indicates that the “…primary treating physician shall render opinions on all medical issues necessary to determine the employee’s eligibility for compensation…” Thus, since a medical report is necessary for determination of TD entitlement, then the absence of a report addressing the issue would render entitlement indeterminable by the adjuster.
At any point in the life of a claim, an adjuster can proactively ask the PTP for information necessary to administer the claim (such as disability status and work restrictions), and the PTP has 20 days to respond per 8 CCR §9785(f)(7). If the PTP then fails to respond, TD benefits can indeed be stopped, if appropriate to the claim circumstances.
Moreover, 8 CCR §9785(f)(8) requires the PTP to provide a PR-2 Report (or narrative containing the same information) every 45 days when there is continuing medical treatment, even if there is no change in the claimant’s medical condition. The PR-2 Report format (8 CCR §9785.2) essentially requires the PTP to address TD status every 45 days, including how long the claimant will be off. If the last report is over 45 days old, an adjuster can schedule an appointment with the PTP and send the claimant a request to attend, along with a Notice of Intent to Suspend TD benefits. If the claimant fails to attend, then TD benefits can be suspended, per Labor Code §4053.
Keep in mind that none of the aforementioned applies if there is an Order for continuing TD payments. Also, under Labor Code §4053, for accepted claims, “suspending” TD benefits means those benefits will be withheld, and if the claimant later comes into compliance, those benefits will be payable, along with TD benefits restarting.
California Code of Regulations, Title 8, §9785: Click here
California Labor Code §4053: Click here
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