Background
ExamWorks, acting on behalf of State Farm, issued notice of an independent medical examination to a workers’ compensation claimant. On December 9, 2024, the examining physician reported 8% impairment from the compensable injury. The claimant later filed a Failure to Timely Act Petition, asserting that the claim administrator had not timely entered an award based on the report. State Farm issued an order granting an 8% permanent partial disability award on May 7, 2025.
The Workers’ Compensation Board of Review found that the claim administrator’s nearly five-month delay violated West Virginia Code of State Rules § 85-1-10.5.a, which requires a responsible party to act on a qualifying permanent-disability evaluation report within thirty working days after receipt. The Insurance Commissioner adopted the Board’s report and imposed a $1,500 penalty. State Auto, identified in the proceeding as the third-party administrator, appealed.
The Court’s Holding
The Intermediate Court of Appeals affirmed the Commissioner’s order. Although the regulations define “acted upon” broadly enough to include processing, requesting information, medical review, overpayment analysis, interagency checks, and similar administrative steps, State Auto did not establish through record evidence that the claim administrator took any qualifying action on the physician’s impairment recommendation within thirty working days.
The court rejected the contention that a nearly five-month investigation into apportionment satisfied the rule because the record did not substantiate that investigation, and the proposed interpretation would make the thirty-day requirement meaningless. It also found reliance on Logan-Mingo Area Mental Health, Inc. v. Lester misplaced because issues such as prior awards and apportionment could have been investigated before receipt of the impairment report.
The court further held that the Commissioner’s order satisfied the statutory requirement for findings of fact and conclusions of law. By adopting the Board’s detailed report—which addressed the evidence, governing law, and parties’ arguments—the Commissioner adequately supported the conclusion that the claim administrator failed to act promptly and timely.
Key Takeaways
- A claim administrator must take a qualifying, documented action on a permanent-disability evaluation report within thirty working days of receiving it.
- An assertion that the administrator conducted an extended investigation does not establish compliance when the record contains no evidence of timely investigative or administrative steps.
- Potential apportionment and prior-award issues may be investigated before an impairment report arrives and do not excuse an unsupported delay after receipt.
Why It Matters
The decision emphasizes that the regulation’s broad definition of “acted upon” does not eliminate its deadline. Insurers and claim administrators should document processing, investigation, medical review, or other qualifying steps taken within thirty working days rather than relying on a later award or an unsubstantiated assertion of ongoing review.