CHARLESTON – The West Virginia Supreme Court of Appeals issued an opinion ruling that a man doesn't have to repay an overpayment of temporary total disability payments that he received due to a mistake of a claims examiner.
The appeal was regarding overpayment by 156 days of temporary total disability benefits, according to the opinion.
Justice Menis Ketchum authored the June 6 majority opinion. Justice Beth Walker dissented and authored a separate opinion.
According to the opinion, Edward Reed was employed by Excel Logistics as a shuttle driver and was injured on the job in 2013. Reed underwent surgeries and other medical care for a fractured ankle that, despite the care he received, continued to be unstable.
Reed submitted a claim for workers' compensation and received $67.37 per day for temporary total disability. For two-and-a-half years, the opinion states Reed continued to see physical therapists and other physicians for help with his ankle.
The claims examiner halted benefits on Nov. 24, 2015, and entered orders to refuse the approval of further therapies or evaluations. In 2016, the claims examiner retroactively declared that Reed had been improperly paid for 156 days beyond the 104-week limit of temporary total disability.
When Reed received permanent partial disability, the claims examiner refused to provide him the payout and informed Reed the $10,509.72 he was overpaid for in temporary benefits would go toward what was owed for permanent disability.
Reed filed a complaint with the Office of Judges, who reversed the claims examiner's finding, ruling that the claims examiner failed to timely seek the termination of benefits.
The Workers' Compensation Board of Review then reversed the decision of the Office of Judges. Reed then appealed to the Supreme Court.
The court noted that the claims examiner had complete control over the claim and payment process and that it did not know why the examiner failed to end the benefits at the 104-week statutory cap.
"Because the claims examiner did not seek to modify and terminate the temporary total disability benefits at the end of 104 weeks, as required by the clear language of W.Va. Code § 23-4-1c(h), the claims examiner may not seek to recover as overpayments the 156 days of benefits paid beyond that deadline," the opinion states.
The court reversed the Workers' Compensation Board's decision and remanded the case for further proceedings.
In her dissenting opinion, Walker stated that she would have affirmed the Board of Review's decision because there is a clear 104-week cutoff on Reed's claim and he had received 156 days of benefits over that cut-off date.
"As the majority states, we do not know why the claims administrator continued Mr. Reed’s TTD benefits beyond the 104-week cutoff," Walker states. "But, the claims administrator did and Mr. Reed received more TTD benefits than he should have, albeit through no fault of his own."
Walker wrote that the facts of the case do not discount the limitation of benefits and that the overpayments should be repaid.
West Virginia Supreme Court of Appeals case number 17-0864