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1. Purpose and Scope. This Chapter establishes the requirements and procedures for submitting medical reports to the DDs, and identifies the screening process for obtaining and evaluating reports by the Claims Examiner(CE)/Claims Examiner Clerk(CEC) in the supervision of care and treatment of injured workers under the LHWCA.
2. Obtaining/Screening Medical Reports. The CE/CEC, given the appropriate medical documentation in a case, can efficiently assist the DD in the supervision of LHWCA medical care and treatment. This medical documentation consists of timely initial and supplemental reports as well as a complete final medical report which addresses the extent of permanent impairment when necessary. The remainder of this Chapter discusses these various reports.
3. Initial Reports. Within ten days following the initial examination or treatment, the physician shall furnish a medical report to the DD, with copies to the EC. The "B" side of Form LS-1 (back of the employer’s "Authorization" form, Exhibit 1, PM 10-200) has been prescribed for this purpose and it should be used.
a. Additional Reports. If the initial medical report is not received within thirty days, a request on Form LS-216 (Exhibit 25, PM 10-200 - Request for Additional Reports) should be sent to the EC. If no response is received within two weeks, a follow-up request shall be made.
b. Case Closure. When the required documentation is received in the DO (e.g. Forms LS-1, LS-202, LS-204, and LS-208), the DD may close the case if there is no probability of permanent partial disability or time loss, since no need exists under these circumstances for additional supplementary medical reports (e.g. periodic or progress reports).
4. Supplementary Reports. When an initial medical report is received, Form LS-216 may be released if further treatment is indicated. This form may be used to request the treating physician to provide periodic reports on Form LS-204 or in narrative reports at approximately thirty day intervals. (See Exhibit 18, PM 10-200, Attending Physician's Supplementary Report; and Exhibit 25, PM 10-200, Request for Additional Reports.) Progress reports should be requested every thirty to sixty days in short-term disability cases. In cases of obvious 2long-term disability, reports at ninety day or longer intervals may be adequate. The frequency with which medical reports are requested should follow the needs of the individual case, as determined by the policy of the DD, or the CE.
5. Final Reports. All extended disability cases must have a final medical report submitted at the time maximum medical improvement is reached. Forms LS-1, LS-204 or a narrative report may be used for this purpose. In providing a report, the examining or treating physician should not be asked to evaluate the employee's disability, but only the employee's physical impairment. In any case where there is potential for permanent partial disability, a medical report should be requested, giving the percentage of permanent partial impairment, in accordance with the AMA Guides to the Evaluation of Permanent Impairment. If a controversy arises as to extent of impairment, section 7(e) or section 14(h) procedures shall be utilized to obtain a medical evaluation of any residual impairment.
6. Failure of Physician to Report Medical Care After Initial Authorization. No claim for medical or surgical treatment shall be valid and enforceable against an EC, unless the treating physician furnishes to the EC and to the DD, within ten days following the first treatment, a narrative report or a report on Form LS-1. The DD may, however, excuse the failure to furnish such report within ten days when he or she determines that it is in the interest of justice to do so. Situations where the delay is excused will vary widely. It may be as simple as a failure on the part of the employer to provide the Form LS-1. Also, case law has held, for example, that in a situation where the employer had not provided any evidence to suggest that the treatment was unnecessary or unrelated to the claimant's work injury, an excusal of delay was in the best interest of justice. These will frequently be instances beyond the control of the claimant in which the physician, for unexplained reasons, is simply tardy in the submission of the report. The DD has wide discretion on this issue. The DD has authority, upon application by a party in interest, to make or deny an award for the reasonable value of such medical or surgical treatment obtained by the employee. (See 20 C.F.R. section 702.422.)
7. CE's Follow-Up of Medical Reports. To ensure the proper implementation of the reporting procedure for medical care, the CE will use the following procedure to guarantee compliance: If a medical report has not been received within sixty days after examination or treatment, send a request to the employer on Form LS-216. If the attending physician fails to comply within a reasonable period or repeatedly fails to submit reports, the CE shall refer the case to the DD, stating the facts in the case, and making a recommendation for further handling. The DD may wish to write or call the physician for the purpose of securing a current report and explaining the requirements with respect to reporting, or may consider a change in physicians (20 C.F.R. section 702.406).
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