The Unilateral Suspension Of Benefits In Workers’ Compensation – A Refresher On The All-Important Role Of The “Return To Baseline” Opinion From The Authorized Treating Physician


 Dan Cauley

Drew Eckl & Farnham, LLP

Following an employer’s commencement of weekly benefits to a claimant in connection with a “compensable” work injury, the Workers’ Compensation Act describes some of the limited scenarios which permit the employer to subsequently and unilaterally suspend such benefits without a hearing before an Administrative Law Judge. Collectively, O.C.G.A. § 34-9-221, O.C.G.A. § 34-9-240, and Board Rule 221 list the more common justifications for the unilateral suspension of such benefits, which include: (1) an actual return to work, (2) an opinion from the Authorized Treating Physician releasing the claimant to regular duty, or (3) the claimant’s unjustified refusal of suitable, limited duty employment approved by the Authorized Treating Physician under the WC-240 process.

Accordingly, barring the claimant voluntary returning to work after an employer has commenced benefits, the opinion of the designated Authorized Treating Physician as to the claimant’s work status and need for treatment plays a significant role in the longevity of a claim and an employer’s ultimate exposure. All too often, however, we find doctors sometimes forget to confine these opinions solely to the work-related injury for workers’ compensation purposes. For instance, when there is seemingly no objective medical evidence of an ongoing injury resulting from a work accident, an authorized physician may nevertheless continue to prescribe treatment or physical limitations over an exceedingly extended period. These scenarios often arise when a claimant continues to report subjective complaints of pain or limitations due to a mere aggravation of a pre-existing condition, as the physician may continue to prescribe conservative treatment and maintain previously prescribed work restrictions without ever revisiting the issue of causation.

In these scenarios, it is especially important to remind the authorized physician to address whether the need for ongoing treatment or limitations remain related to the work injury versus the natural progression of a pre-existing degenerative condition, as the Georgia Supreme Court recently held in Ocmulgee EMC v. McDuffie, 302 Ga. 640 (2017) that an employer may still be justified in the unilateral suspension of benefits pursuant to an opinion from the authorized physician that the claimant has returned to his pre-existing “baseline condition” from before the accident, i.e., any work-related “aggravation” injury has resolved such that any ongoing symptoms, disability, and need for treatment are no longer causally related to employment. Thus, even if the claimant has not returned to work, nor has the authorized physician has not provided a regular duty work release in an otherwise compensable claim, an employer may still unilaterally suspend benefits.

Ocmulgee EMC v. McDuffie and Impact of “Return to Baseline” Opinion

Pursuant to O.C.G.A. § 34-9-1(4) of the Workers’ Compensation Act, it is well-established that a work-related injury includes an “aggravation” to a pre-existing condition, although the statute explicitly states further, “the pre-existing condition shall no longer meet the criteria when the “aggravation” ceases to be the cause of disability.” Consequently, following an “aggravation” injury to a pre-existing condition, Georgia courts previously suggested that an employer was required to continue paying workers’ compensation benefits up until the pre-existing condition had improved such that the claimant was able to return to work. Nevertheless, the Georgia Supreme Court recently clarified this was not the case.

In Ocmulgee EMC v. McDuffie, the Supreme Court reviewed a lower ruling from the Court of Appeals, which ultimately held an employer improperly suspended an employee’s benefits based on an opinion from the treating physician that the work-related “aggravation” injury to a pre-existing condition had resolved. In doing so, the Court of Appeals essentially determined that, despite the authorized physician’s opinion regarding the resolution of the work injury, the employer was required to prove it had suitable employment available to the employee, otherwise within the non-work-related limitations prescribed by the physician.

On appeal, the Supreme Court reversed the decision and held an employer is not responsible for compensating an employee until the pre-existing condition improves; instead, the court clarified that “as soon as the effects of an on-the-job injury cease, an employer’s responsibility for workers’ compensation also ceases.” Thus, upon noting that deference is given to the authorized treating to determine what is the “baseline condition,” and thereafter whether or not an employee has returned to that state, the Supreme Court clarified that once an employer establishes with sufficient medical evidence that an employee has been restored to his pre-injury baseline condition, so that he is no longer suffering any work-related disability, an employer may carry its burden in justifying the unilateral suspension of benefits prior to a hearing.

Consequently, the Supreme Court seemingly confirmed that when an employer has sufficient medical evidence that a claimant to whom it is paying benefits has fully recovered from the on-the-job injury, such that any ongoing disability is the product of a condition unrelated to employment and no longer causally related to the work injury, the employer may carry its burden to justify the unilateral suspension of benefits.

Practical Application of the “Return to Baseline” Opinion from the Authorized Treating Physician

Ultimately, compensable claims for which an employer continues to pay weekly benefits following a work-related “aggravation” injury, due in part to the authorized treating physician ostensibly continuing to treat a pre-existing degenerative condition while refusing to release him or her back to regular duty, the holding in Ocmulgee EMC v. McDuffie provides an alternative approach to the unilateral suspension of benefits even when the claimant has not returned to work.

In this manner, the Supreme Court has seemingly clarified that, even without an actual return to work or a regular duty release from the authorized treating physician, an employer may still be justified in unilaterally suspending benefits if the authorized physician agrees that the work-related “aggravation” or injury has more likely than not resolved, such that he or she has returned to their “baseline” condition. Consequently, should the authorized treating physician provide such an opinion, Ocmulgee EMC v. McDuffie likely permits the employer to file a notice to controvert further liability, coupled with a notice of suspension of disability benefits (with the 10-day notice) pursuant to same.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

Originally Published At The Mondaq Platform