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Failure to send notice of claim status allows suit to proceed


A worker may proceed with his claims for additional benefits because the insurer failed to send a notice of claim status, the Idaho Supreme Court held in a 5-0 decision on Monday.

In Austin v. Bio Tech Nutrients, the court affirmed an Idaho Workers Compensation Commission ruling that an injured worker’s complaint for benefits was timely filed, despite being a year after his employer and its insurance company stopped paying workers compensation benefits, because he did not receive a notice with the submission of their final payment.

On Nov. 20, 2008, Brent Austin was injured at work and began receiving temporary total disability benefits. On June 20, 2014, an independent medical evaluator determined he had reached medical maximum improvement, and the following month, he received a notice of claim status informing him his benefits would stop as a result of reaching MMI. However, his permanent partial impairment at 11% of whole person correlated to a payment of about $18,000, and he began receiving bi-weekly payments in August 2014 until it was paid in full. The notice of claim status also included a disclaimer that the impairment rating did “not settle” the claim. He received his last check in June 2015, and a remittance attached to it included the comment of “PPI Final Payment.” However, he received no notice of claim status or other written form of notice about the final payments of his PPI benefits.

In July 2016, Mr. Austin filed a workers compensation complaint seeking medical benefit for chronic pain treatment, another surgery and total temporary disability benefits, and the insurer and employer argued that his complaint was barred by the statute of limitations. The commission concluded that his complaint was timely filed because Idaho code required the insurer/employer to submit a notice of claim status with the last check for PPI payments, and that the failure to do so suspended the one-year statute of limitations based on Idaho law. The defendants appealed.

The Idaho Supreme Court held that the commission properly held that the defendants were required to provide notice to Mr. Austin with the final payment of his benefits. Although they argued that the July 2014 notice was sufficient because it told him about both the “initiation and cessation of the finite award” the court disagreed, deferring to the statute that states an injured worker must receive “written notice within 15 days of any change of status or condition including, but not limited to, the denial, reduction or cessation of medical and/or monetary compensation benefits, which directly or indirectly affects the level of compensation benefits to which he might presently or ultimately be entitled.”

The defendants also argued that the commission wrongly determined that the insurer had “willfully” failed to provide a notice of claims status, but the court held that the commission noted that its “finding of willfulness is implicit in our finding that the plain language of the statute requires a (notice of claim status) NOCS upon the cessation of any class of benefits” and that the insurer’s failure was willful under Idaho code.

Although the insurer and employer argued that they “substantially complied with the notice requirements,” the court disagreed, holding that their failure to provide all of the material information when benefits are stopped cannot allow the court to reach such a conclusion.

Neither of the attorneys in the case immediately responded to requests for comment.




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