FACTS
An employee suffered a work-related ankle injury in 2002 and was diagnosed with Complex Regional Pain Syndrome (“CRPS”) formerly known as RSD. The employer and insurer accepted liability for the injury and paid for medical treatment. Since 2005, the employees medical treatment has consisted solely of prescription medication, including narcotics. In 2016, the employer and insurer had the employee undergo a fourth independent medical examination (“IME”) with a new doctor. The new IME, for the first time, disputed the CRPS diagnosis. The insurer then sent a letter to the employee's treating physician. The letter notified the doctor that the CRPS diagnosis was no longer accepted. The letter also advised the doctor to bring the treatment plan into compliance with the treatment parameters. The employee’s doctor did not comply with this request.
After the employees doctor refused to follow the parameters, the insurer began to deny all of the bills submitted by that clinic. In turn, the employee filed a Medical Request. In their Medical Response, the employer and insurer asserted the defenses that the employee no longer suffered from CRPS, that the treatment expenses were not reasonable and necessary for the cure and relief of the injury and that the treatment failed to confirm with the treatment parameters.
PROCEDURAL HISTORY
After an evidentiary hearing, the compensation judge found that the employee continued to suffer from CRPS. The judge also rejected the defense arguments with respect to the treatment parameters.
WCCA DECISION
On appeal, the employer and insurer argued that they continued to accept responsibility for the injury and therefore the treatment parameters were not barred. The WCCA however, affirmed the compensation judge.
SUPREME COURT DECISION
The Supreme Court held that treatment parameters are inapplicable when the employer and insurer deny liability for an injury. In this case, the Court found that the employer and insurer were NOT denying ongoing liability for the injury.
The employee, however, argued that by denying the CRPS the employer and insurer were essentially denying the injury because the CRPS was the only ongoing diagnosis that the employee had at the time of this dispute. The Supreme Court however said that the Judge found that the employee had work-related CRPS and the employer and insurer did not challenge that decision on appeal. In a footnote the Court did state that this MIGHT be a different situation if the employer and insurer argued that the employee no longer suffered from any symptoms causally related to the work injury. The Supreme Court then remanded the case for a determination on whether the requested medication violated the treatment parameters.
LOOKING FORWARD
In cases where primary liability has been admitted, but the disability or treatment becomes disputed, it will be important to consider treatment parameters in determining whether to approve requested medical treatment. This decision also seems to leave open the door on whether treatment parameters might even apply in cases where primary liability was accepted at one point but the work injury is now considered to be entirely resolved.
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