Case Law » Workers' Compensation Law
Medical Expenses and Travel Expenses
First State Orthopaedics v. Sedgwick, IAB Hearing No. 1362536 (June 9, 2011) (Order)
First State Orthopaedics filed a motion to compel against Sedgwick seeking full payment of various medical bills that had been partially paid by Sedgwick. First State argued that because the bills were partially paid, there could be no legal defense to its claim that the remainder must be paid in accordance with Delaware's Health Care Payment System, 19 Del. C. ยงยง 2322B and 2322F. Sedgwick argued that it may have a good faith defense based on a preferred provider agreement that allowed it to pay less than the full charges. Further, Sedgwick asserted that First State needed to proceed by filing a formal petition for compensation rather than requesting a legal hearing before the Board. The Board initially postponed the matter for two weeks to allow Sedgwick additional time to investigate the claims. However, when the Board reconvened, Sedgwick was unable to produce a copy of the alleged preferred provider agreement.
The Board held that First State Orthopaedics did not need to file a formal petition for payment of the medical expenses because having made partial payments, Sedgwick accepted the reasonableness, necessity and causal relationship of the treatment. It noted that there was no dispute as to the amount of the charges as that is controlled by the fee schedule established by the Health Care Payment System. Further, Sedgwick had not produced a copy of the alleged preferred provider agreement or otherwise alleged a claim of improper billing, which could have given rise to an actual factual dispute. Accordingly, the Board ordered Sedgwick to pay the remainder of the partially paid medical bills in accordance with the fee schedule; interest on the unpaid invoices at the rate of 1% per month; a fine in the amount of $1,000 for each of the four partially paid bills; and an attorney's fee in the amount of $2,000.
Mason v. State of Delaware, IAB Hearing No. 1198102 (January 15, 2010)
Claimant filed a Petition to Determine Additional Compensation Due, seeking payment of medical and mileage expenses, including expenses for massage therapy. Employer objected to the massage therapy expenses on the ground that the therapist was not certified and did not obtain pre-authorization for the treatment. Alternatively, Employer argued that the massage therapy was not reasonable and necessary treatment and/or was outside the Health Care Practice Guidelines applicable to Claimant's injury. The massage therapist, a Delaware provider, did not obtain certification until two weeks prior to the hearing. Further, the certification was obtained approximately two months after the last date of service for the massage therapy expenses at issue under the Petition.
The Board held that the massage therapy treatment at issue was not compensable. Citing its prior decision in Bertha Polk v. Green Acres Pavilion, IAB Hearing No, 1253843 (Dec. 4, 2009), it noted that Section 2322C(6) of the Workers' Compensation Act seems to suggest that non-certified providers, without pre-authorization, may seek payment for medical services if they can establish that the treatment is reasonable and necessary at a hearing before the Board. However, after reviewing the legislative history for Section 2322D, the Board concluded that when treatment is provided by a Delaware medical provider, the provider must be certified or obtain pre-authorization from the employer or insurer to seek payment for services through the Delaware workers' compensation system. The Board distinguished the Polk case, noting that it involved treatment provided by an out-of-state provider over which the State of Delaware lacked jurisdiction. Further, it noted that the Claimant in Polk could not reasonably be expected to continue treating with a Delaware medical provider after relocating to North Carolina. Finally, the Board held that, even if the massage therapist had been duly certified, the treatment she rendered was not reasonable and necessary in this case.
Bolden v. Kraft General Foods, IAB Hearing No. 915912 (December 22, 2008)
This case involved a Claimant who injured both knees due to the cumulative detrimental effect of her work at Kraft. Claimant underwent multiple surgeries including bilateral knee replacement. Thereafter she filed a petition seeking payment of bills outstanding for two stair lifts, a chair power lift and travel expenses for a family member who came to take care of her after surgery. Dr. Rowe testified on behalf of the Claimant that the stair lifts would be needed for Claimant to go up and down stairs. The "lift chair" was also needed to assist Claimant to go from a seated to a standing position. Dr. Rowe did not prescribe home health care or the medical devices. Dr. Sopa testified on behalf of Kraft opining that the chair lifts were not a medical necessity. He also indicated that having an aunt come to help is not the standard of care, rather a visiting nurse should have been arranged. The Board denied the petition noting that Dr. Rowe did not prescribe the lifts, Claimant's areas for activities of daily living are all on one floor, Claimant did not live alone so assistance was available to move about, and Claimant's nursing and therapy were taken care of by a visiting nurse, not her aunt.
