Thursday, June 13, 2013

"Medical Only" NCP and Extent of Medical Expense Liability

"Medical Only" Work Injury Claims.
A work injury which requires medical care, but does not result in work absence and wage loss, can be documented as a "Medical Only" claim via the filing of a LIBC-495 form, the Notice of Compensation Payable. Since 2004 this LIBC form was revised to include a "check-box" to designate the work injury was a "Medical Only" claim.

As an alternative procedure, a "Medical Only" injury claim can be documented via the filing of a LIBC- 496 form, the Notice of Workers Compensation Denial. See: Armstrong v. WCAB Haines & Kibblehouse, Inc. (Pa. Cmwlth 2007), where a Denial was filed after a Notice of Temporary Compensation was revoked.

What is the extent of Employer responsibility and liability for payment of medical expenses after the filing of the "Medical Only" document?

In Kussie v. WCAB (Yoder Brothers, Inc.) v. No. 1700 C.D. 2012, an unreported memorandum opinion of a panel of the Commonwealth Court, authored by Judge Leadbetter on June 11, 2013, reviewed this issue for an unrepresented Claimant.

The General Rules regarding medical expense liability.

l. The Employer is responsible for medical treatments which are reasonable and necessary as a result of the work injury.

ll. Where an injured employee receives medical treatment for new symptoms that allegedly arise from the work injury and the Employer refuses to pay those medical expenses, the burden of proof to establish the work-related symptoms and medical treatments are related, depends on whether the connection between them is "obvious".

lll. An "obvious" causal connection is one involving a "nexus that is so clear that an untrained layperson would not have a problem" in concluding the new symptoms are related to the work injury.
See: Tobias v. WCAB (Nature's Way Nursery, Inc.) (Pa. Cmwlth. 1991).

If the connection is not "obvious", the burden of proof is on the Employee to establish the connection through unequivocal medical testimony. Tobias.

If the new symptoms and the work injury are obviously related, then Employee has the benefit of a presumption that the new symptoms are related to the work injury and the Employer has the burden to establish they are not related. See: Kurtz v. WCAB (Waynesburg College) (Pa. Cmwlth. 2002).

Factual and Procedural Background in Kussie
The unrepresented employee pursued an appeal from a denial of her claim, reinstatement and penalty petitions. Her September 2004 work injury occurred when she was cleaning a knife at work and splashed bleach into her eyes. The Employer accepted liability for this injury in October 2004 by issuing a Medical-Only Notice of Compensation Payable for the left eye (only).

More than three (3) years after the injury, Employee filed the claim, reinstatement and penalty petitions, essentially seeking payment of medical bills for treatment of additional eye symptoms.

Employee legal counsel withdrew prior to the first hearing, employee litigated the case without legal counsel. The petitions were denied. The WCAB remanded. The petitions were denied on remand.
On appeal, Employee alleged a variety of legal issues. For purposes of this discussion, we will focus only upon the medical expense issues.

Interaction of a Utilization Review, Medical Only NCP and New medical care.

Employee argued that a prior Utilization Review Determination filed by Employer, concluded medical care after on and after January 5, 2007 was reasonable and necessary treatment for her eye conditions.

Employee argued the UR gave her the right to future medical treatment.

Commonwealth Court explained the UR determination only addressed issues of "reasonableness and Necessity" of certain medical treatments.

The Workers' Compensation Judge, not the UR, must decide issues of disability and work-relationship of medical treatments.
See: Corcoran v. WCAB (Capital Cities ) (Pa. Cmwlth. 1999).

Employee's initial symptoms in 2004 were of burning, redness and light-sensitivity of her eyes.
Her current symptoms included complaints of difficulty seeing at night, irritation from dusty work conditions and severe headaches. Her medical report letters did not explain, what were her current eye problems and whether these symptoms were related to her work injury.

As there was no obvious causal relationship of employee's current symptoms to the acknowledged work injury, she had the burden of proving these symptoms and medical treatments were causally related to the work injury. She failed to meet her burden of proof via competent and credible medical evidence, to establish her symptoms were related to the mild chemical burn she received more than three (3) years earlier.

Practice Pointers:
1. It is important to note that the past favorable Utilization Review Determination did not give claimant an "open checkbook" to receive reimbursement for all future medical treatments.

2. The past favorable Utilization Review Determination did not preclude the WCJ from deciding if the current medical treatments were related to the work injury. The physicians could conclude that the treatments were "reasonable and necessary" for claimant's current medical condition, but that condition may not be related to the original work injury. The WCJ must decide if it is related care.

3. Caution, take care in the drafting of the description of the "accepted" work injury, as this description will have an impact upon the Employer's liability for future medical expense treatments. The scope and extent of medical expense liability will rest upon the description of injury. Be Precise!

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