West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-70 - Injured Employee's Responsibilities Concerning Medical Examination and Treatment. (Effective Date: - February 1, 2005

Current through Register Vol. XLI, No. 28, July 12, 2024
70.1. Examination and treatment.
The Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, may order an injured employee
				  to report for examination and may further order him to undergo such treatment
				  or hospitalization as is indicated in the particular case. It shall be the duty
				  of the injured employee to comply fully and promptly with any such order issued
				  by the Commission, Insurance Commissioner, private carrier or self-insured
				  employer, whichever is applicable.
70.2. Violation of rule.
a. If violation of any provision of this
				rule, or refusal to comply with any order of the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, issued as provided herein, should result in an increase in the
				duration of temporary disability or in the degree of permanent disability, such
				violation or refusal will be considered in determining the compensation, if
				any, to be awarded and no compensation will be awarded for extension or
				increase of disability caused thereby.
b. The Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, may suspend
				benefits being paid to a claimant if the claimant refuses, without good cause,
				to undergo or fully participate in the examinations or needed treatments
				provided for in W. Va. Code §
										23-4-7a.
				Good cause shall consist of the following:
1.
				Compelling evidence that the examination or treatment would have little, if
				any, positive effect on the claimant's injury;
2. Compelling evidence that no ordinarily
				prudent and reasonable person would have submitted to the examination or needed
				treatment;
3. Compelling evidence
				that the examination or treatment would pose a danger to the life or health of
				the claimant or require extraordinary suffering;
4. A consensus of medical opinions
				establishing that the examination or treatment would not effect a cure or would
				not at least improve the likelihood that the claimant could return to gainful
				employment; and
5. Compelling
				evidence that the prognosis for success and recovery were unreasonably
				low.
c. Failure to
				attend a single scheduled examination or treatment shall not be grounds to
				suspend benefits. However, failure to attend two (2) or more consecutively
				scheduled examinations or treatments without clear justification, regardless if
				the examinations or treatments were scheduled for a related purpose, may, in
				the Commission's, Insurance Commissioner's, private carrier's or self-insured
				employer's, whichever is applicable, sole discretion, constitute grounds to
				suspend benefits. Also, a pattern of failing to attend scheduled examinations
				or treatments shall constitute grounds for the suspension of
				benefits.
d. A claimant whose
				benefits are suspended under this rule shall not be entitled to benefits from
				the date the relevant examination or treatment was not undergone until such
				time as the examination or treatment is undergone and notice of such is
				provided to the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable. If benefits are re-instated,
				any overpayment will be deducted from the re-instated benefits at a reasonable
				rate until the overpayment is recouped. The unpaid balance of the overpayment,
				if any, will be recovered from any future award to the claimant.
e. The Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, shall enter
				a protestable order notifying the claimant of the suspension of benefits and
				shall serve the order on all of the parties to the claim.