Brad Young of Harris, Dowell, Fisher & Young, LC
March 19, 2024 - The Missouri Labor and Industrial Relations Commission (LIRC) recently reversed a decision by an Administrative Law Judge (ALJ) regarding liability for unpaid medical bills of $114,950 and sanctions against the employer of $59,381 based on the employer/insurer denying medical care and because counsel for the employer/insurer made a settlement offer that was less than the rating provided by the employer's rating doctor. Here’s why:
REVERSAL BY THE COMMISSION
The Commission reversed the award of the ALJ as it pertained to the award of medical care. In Missouri, the employer/insurer must provide authorized medical care or face an award for unauthorized medical care - - as was done in this case.
However, the Commission found that the unauthorized medical care was no different than the care provided by the authorized doctors. As such, it found that the claimant was responsible for payment of $114,950.23 for the unauthorized medical care under §287.140.1, which states: “If the employee desires, he shall have the right to select his own physician, surgeon, or other such requirement at his own expense.”
Regarding the sanctions against the employer/insurer of $59,381.36 awarded by the ALJ, the Commission reversed this as well, stating:
“While employer/insurer’s initial settlement offer of less than its authorized doctor’s rating was aggressive in its response to prior treatment requests, it was reasonable given the subsequent taking of employee’s deposition. We find employer reasonably investigated the claim and relied on the available evidence in initiating settlement negotiations. Additionally, employer/insurer amended the initial offer to conform with Dr. DeGrange’s rating approximately 6 weeks later, absent any communication from employee.”
PRACTICE POINTS
First, regarding the demand for medical care, this case demonstrates the potential harm that an employer/insurer can face if it denies additional medical care. Here, the employer/insurer had to appeal an award of $115k for unauthorized medical care.
As a practice point, when faced with a demand for additional medical care, I recommend the following:
Send the claimant back to the authorized treating physician to obtain an opinion that rules out the need for additional care. That way, we have a defense to the request for payment for unauthorized care and it further demonstrates that any refusal to provide more care is based on the evidence presented by the authorized treating physicians; and,
Have your counsel send a letter to the claimant’s attorney requesting copies of medical records from all unauthorized doctors BEFORE substantive medical care is provided so that those records can be provided to the authorized physician and an opinion to rule out the need for additional care can be obtained from the authorized physician prior to any denial of further medical care.
Even though the employer/insurer in this decision ultimately obtained a reversal of the sanctions and the award of $115k for unauthorized medical care, the award of medical care and sanctions by the ALJ could have been avoided by following the recommendations listed above.
Please let me know if you have any questions or if you wish to discuss how this award might apply to any of your current or potential claims. I’m happy to help at byoung@harrisdowell.com.