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Appellate Court Holds Employee’s Expenses Related to Work Injury Were Reasonable and Necessary, Louisiana Employer Responsible for Payments

In a recent decision, the Louisiana Third Circuit reviewed a workers’ compensation case in which an employee suffered injuries in the course and scope of his employment, and he received treatment without submitting proper workers’ compensation forms to request authorization for continuing medical care.  The issue was whether the employer was responsible for paying for reasonable and necessary medical treaflatbed trucktment, up to the $750 cap set forth by Louisiana law.  The appellate court also reviewed the award of penalties against the employer and attorney’s fees for the employee and workers’ compensation claimant.

In this case, the employee worked for a trucking company as a driver. He was injured on January 4, 2013, while operating a flatbed truck that had been loaded with pipe. As he was delivering the pipe, a load fell from his trailer and onto him. He suffered severe injuries and underwent multiple surgeries.

The incident took place in Arkansas, and the employee was treated by four physicians in that state.  He then requested that his employer write letters of financial responsibility so that he could continue treatment with these physicians. The employer refused and requested the physicians to abide by the guidelines, submitting a 1010 form. The employee then continued treatment, without completing the form or receiving more authorization from his employer.

The employee then demanded payment for his medical care and eventually filed a 1008 form for disputed compensation. The WCJ received briefs and copies of the medical records and issued a judgment against the employer and in favor of the employee for up to the $750 statutory treatment cap with the employee’s providers.  The employer was penalized $2,000 for failing to pay this cap to each of the physicians, for a total of $8,000. The employee was awarded $8,500.00 in attorney’s fees.  The judgment denied the employee’s request for all medical expenses, but it stated that the employer must pay for ongoing medical treatment according to the Louisiana workers’ compensation statute guidelines and medical fee schedule. Both parties appealed.

First, the court rejected the employer’s contention that the employee did not prove his medical benefits that had been awarded were reasonable and necessary. The court stated the rule that a workers’ compensation judge determines the medical necessity of a claimed treatment as a question of fact. Louisiana law mandates that employers provide all necessary drugs and hospital care on behalf of the injured employee.  A workers’ compensation claimant must prove the treatment was reasonable and necessary when the treatment is for a work-related injury.

Here, the employer argued that it was an error for the WCJ to find that the employee had met his burden of showing the medical treatment by his physicians was actually reasonable and necessary, and it was causally related to his January 4, 2013 accident.  But the court stated that within the medical records from his physicians were opinions recommending treatment for work-related injuries.  There is a specific reference to the employee’s work-related injury as the cause for the employee’s treatment.  The appellate court stated the records were uncontroverted and formed a reasonable basis for the WCJ to find that the employee had met his burden of proof regarding showing the treatment was necessary, reasonable, and causally related to his accident.

Regarding the law that a health care provider cannot incur more than $750 in expenses for nonemergency testing or treatment without the mutual consent of the employee, the court stated that the statute relates to an employer’s financial responsibility.  This is the case regardless of a workers’ compensation claimant’s adherence or lack of adherence to the guidelines. Therefore, it was not premature for the WCJ to conclude that the employee here would be awarded up to $750 for each of the four physicians.

Finally, the court stated that whether the employer should be assessed penalties and the employee awarded attorney’s fees requires a manifest error review standard.  Here, the evidence showed that the employee requested the cap of $750 for medical treatment, and this was reasonable and necessary and was causally related to his July 4, 2013 accident.  The decision by the WCJ to penalize the employer and award attorney’s fees to the employee was supported by the record, and it was not manifestly erroneous.

The court then turned to the employee’s contention that his employer should be responsible for all of the necessary medical expenses.  But the court stated that the employee’s treating physicians did not follow the workers’ compensation regulations. They did not submit the proper 1010 form and did not file a 1009 form to request a medical review of the dispute.  Instead, the employee filed a 1008 form, which brought the matter before a WCJ.  The court also noted that some of the physicians knew that a form 1010 was necessary to begin adjusting a medical claim for workers’ compensation. The appellate court rejected the employee’s contention that all his medical expenses should be paid by the employer. The court upheld the WCJ’s order denying the employee’s request that all of his medical payments made to the physicians be reimbursed.

At Lavis Law, individuals who suffer injuries in the course and scope of their employment can gain a better understanding of their rights under Louisiana workers’ compensation law.  Our law firm helps injured workers and their families seek compensation for work-related injuries. We provide a free consultation and can be reached by phoning 866-855-9151.

More Blog Posts:

Louisiana Appellate Court Affirms Compensable Accident Took Place and Claimant Entitled to Benefits, Employer Must Pay Penalties for Failing to Reasonably Controvert Claim, Louisiana Insurance & Injury Lawyer Blog

Appellate Court Upholds Award of Louisiana Workers’ Compensation Benefits and Penalties Against Employer When Benefits Were Wrongly Discontinued, Louisiana Insurance & Injury Lawyer Blog

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