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Legal Requirements for Medical Care

E. Courtney Gruber

S.C. Code Ann. Section 42-15-60 defines the time period that medical treatment and supplies must be furnished and states that the employer shall provide medical treatment for a period not exceeding ten (10) weeks from the date of injury and for additional time as, in the judgment of the Commission, will tend to lessen the period of disability as evidenced by expert medical evidence stated to a reasonable degree of medical certainty.  The practical application of this statute is that the claimant has to provide medical evidence stated to a reasonable degree of medical certainty that additional medical treatment will tend to lessen the period of disability after ten (10) weeks.

This requirement has been addressed in several decisions, which have been recently and frequently cited by hearing commissioners in favor of both sides depending on the medical evidence presented at the hearing.  Burnett v. City of Greenville, 401 S.C. 417, 737 S.E.2d 200 (Ct. App. 2012), requires medical opinions stated to a reasonable degree of medical certainty to establish medical causation and prohibits the Commission from issuing the equivalent of a medical opinion.  Put simply, if there is a single uncontroverted medical opinion in the record, the hearing commissioner is very likely to issue a ruling supported by the medical opinion.  The practical application of this rule on the defense side is that defendants should have a medical opinion from the treating physician or from an IME to counter any opinion of medical causation presented by the claimant.  Special attention should be given in a case where compensability is denied to avoid putting all of the proverbial eggs in one basket.  If the hearing commissioner finds that compensability has been proven, he or she will have no choice but to follow the medical evidence in the record, even if that medical evidence seems to fly in the face of common sense when compared to the facts.

Hartzel v. Palmetto Collision, 419 S.C. 87, 796 S.E.2d 145 (Ct. App. 2016), states that the Commission cannot order medical treatment ten (10) weeks beyond the injury by accident date without an opinion to a reasonable degree of medical certainty.  The Court held that the statute does require a heightened medical evidence standard to be met in order for the Commission to award medical treatment beyond ten (10) weeks from the date of injury.

Hartzel supports Section 42-15-60 in that the claimant, through his/her attorney, is required to provide a medical opinion stating to a reasonable degree of medical certainty that medical treatment is likely to lessen the period of disability if such medical treatment is sought beyond ten (10) weeks.  As stated earlier, if there is such an opinion in the record, the defense needs to ensure that it is able to provide a contradictory medical opinion if it is seeking to deny additional treatment.

The obvious risk is that a defense IME doctor might provide an opinion that does not support the actual defense, so it is frequently a tactical decision not to ask the questions in the first place.  Every case should be approached differently depending on the facts, but the commissioners are putting greater emphasis on medical evidence and the requirements of Section 42-15-60.  If you have any questions about how the law on medical treatment might affect your claims, feel free to contact us.