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Case # G0171297
Date of Accident: 07/09/2009
District Office: Peekskill
Employer: Westchester County
Carrier: Westchester, County of
Carrier ID No.: W878755
Carrier Case No.: WC290268
Date of Filing of Decision: 10/02/2013
Claimant's Attorney: Fine, Olin & Anderman P.C.
Panel: Robert E. Beloten

MANDATORY FULL BOARD REVIEW
FULL BOARD MEMORANDUM OF DECISION

The Full Board, at its meeting on September 17, 2013, considered the above captioned case for Mandatory Full Board Review of the Board Panel Memorandum of Decision, duly filed and served on January 30, 2013.

ISSUE

The issue presented for Mandatory Full Board Review is whether the self-insured employer (SIE) must reimburse the claimant in the amount of $2,557.00 for medical and travel expenses, without further audit.

The Workers' Compensation Law Judge (WCLJ) directed the SIE to reimburse the claimant in the amount of $2,557.00 for medical and travel expenses, without further audit.

The Board Panel majority modified the WCLJ's decision to rescind the direction that the SIE reimburse the claimant for medical and travel expenses, without further audit; instructed the claimant to submit a modified request for reimbursement within 10 days of the filing date of the decision; and returned the matter to the hearing calendar for the WCLJ to direct reimbursement upon review of the claimant's modified request for reimbursement.

The dissenting Board Panel member would affirm the WCLJ's decision.

On February 20, 2013, the claimant filed an application for Mandatory Full Board Review, arguing that the SIE waived its right to submit a meaningful audit and that the expenses should be reimbursed to the claimant without further audit.

On March 20, 2013, the carrier filed a rebuttal arguing that the Board Panel's decision should be affirmed.

Upon review, the Full Board votes to adopt the following findings and conclusions.

FACTS

This is an established claim for bronchial asthma and rhinitis, which resulted from the claimant's exposure to mold at work.

The claimant submitted a request for reimbursement of medical and travel expenses in the amount of $1,639.00 and, in a notice of decision filed on March 9, 2011, the WCLJ directed the SIE to audit the claimant's reimbursement request and to pay all causally related items within 30 days of the date of the filing of the decision. The SIE submitted a letter dated September 7, 2011, to the claimant indicating that some expenses were being denied. Specifically, the letter indicated that the carrier was not responsible for reimbursement of copying costs or medical co-pays, and informed the claimant that she had not provided the carrier with sufficient documentation relating the dates of treatment to this compensation case and, therefore, her request for mileage was being denied. The letter did not detail which expenses, if any, were being accepted. No payment was made to the claimant.

Thereafter, on September 23, 2011, the claimant submitted a request for reimbursement of medical and travel expenses in the amount of $918.00. In a notice of decision filed on September 28, 2011 (as amended on October 11, 2011), the WCLJ directed the SIE to audit the claimant's reimbursement request and to pay all causally related items within 30 days of the date of the filing of the decision. The SIE did not audit the reimbursement request and failed to make any payment to the claimant.

During a hearing on February 10, 2012, the WCLJ found that the SIE had failed to audit and pay the claimant's medical and transportation expenses and, in a notice of decision filed on February 15, 2012, the WCLJ directed the SIE to reimburse the claimant in the amount of $2,557.00 for medical and travel expenses, without further audit.

LEGAL ANALYSIS

In the present case, the claimant submitted to the SIE a request for reimbursement of medical and travel expenses and, in a notice of decision dated March 9, 2011, the WCLJ directed the SIE to audit the claimant's reimbursement request and to pay all causally related items within 30 days of the date of the filing of the decision. The SIE did not request an extension of the time frame within which to conduct the audit; the SIE did not provide the claimant with a written explanation of each item being rejected until September 7, 2011, which was almost six months after the filing of the WCLJ's decision; and the SIE did not reimburse the claimant for the expenses which the SIE was not objecting to. In addition, on September 23, 2011, the claimant submitted to the SIE another request for reimbursement of medical and travel expenses and, in a notice of decision dated September 28, 2011, the WCLJ directed the SIE to audit the claimant's reimbursement request and pay all causally related items within 30 days of the date of the filing of the decision. As of the filing of the Board Panel decision on January 30, 2013, the SIE had not requested an extension of the time frame within which to conduct the audit; had not provided the claimant with a written explanation of each item being rejected; or reimbursed the claimant for the expenses which the SIE was not objecting to.

The fact that the SIE submitted a letter to the claimant on September 7, 2011, generally informing her that some of the expenses for which she sought reimbursement were not eligible for reimbursement for various specified reasons, does not negate the fact that the SIE failed to comply with the directives set forth in the March 9, 2011, and September 28, 2011, WCLJ decisions. The SIE was given a set time frame within which to complete an audit of the claimant's requests for reimbursement; to provide the claimant with a written explanation for each rejected expense; and to remit payment to the claimant for all reimbursable expenses. The SIE never requested an extension of the set time frames, yet the SIE failed to comply with the WCLJ's instructions to conduct an audit within the set time frames. As such, the SIE waived its right to conduct a meaningful audit.

CONCLUSION

ACCORDINGLY, the WCLJ decision filed on February 15, 2012, is AFFIRMED. No further action is planned by the Board at this time.