CVA, Inc. v. Workers' Compensation Appeal Board
29 A.3d 1224
| Pa. Commw. Ct. | 2011Background
- Claimant sustained a work-related left knee injury on October 18, 2007; Employer accepted liability for that injury.
- Claimant filed a penalty petition in March 2009 alleging Employer refused to pay medical bills from Bristol Family Practice and Medical Center.
- Claimant submitted HCFA billing statements and medical reports showing TMR treatments from May 2008 to June 2009, with Employer issuing denials.
- By February 2009, Employer began downcoding and paying lesser amounts for some bills, then refused others without explanation.
- WCJ found the TMR treatments were for the work injury and that Employer delayed payment unreasonably, awarding a 50% penalty and quantum meruit attorney’s fees.
- Board and this Court affirmed, rejecting Employer’s arguments that evidence was hearsay, that utilization review was required, and that penalties were excessive/Holding:**
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether hearsay medical documents sufficed to prove causation and reasonableness | Claimant argues medical reports establish causation; 422(c) allowed reports in medical-benefit context | Employer contends hearsay cannot prove causal relation and reasonableness/necessity | Yes; reports admissible; causation proven for medical benefits |
| Whether utilization review was required to challenge treatment | Claimant need not prove reasonableness; utilization review not performed by Employer | Only utilization review can determine reasonableness/necessity; Employer could have used it | Utilization review governs reasonableness/necessity; failure to seek it supports penalty |
| Whether TMR treatment was causally related and reasonable/necessary | Treatment related to left knee injury; billed as reasonable/necessary | Treatment not generally accepted; cost concerns; no direct medical testimony required in penalty | Causation established; medical-necessity and reasonableness reviewed via penalty process; not required to prove through utilization review in penalty proceeding |
| Whether 50% penalty was improper or excessive | Penalty within statutory range; timing of payment unreasonable/unduly delayed | Penalty constitutes punitive damages; raised too late for Board; excessive | Penalty up to 50% appropriate where delay is unreasonable/excessive; Board's affirmance proper |
Key Cases Cited
- Shuster v. Workers' Compensation Appeal Board (Pennsylvania Human Relations Commission), 745 A.2d 1282 (Pa. Cmwlth. 2000) (burden on claimant to prove violation in penalty petitions)
- Listino v. Workmen's Compensation Appeal Board (INA Life Insurance Company), 659 A.2d 45 (Pa. Cmwlth. 1995) (employer must pay reasonable medical expenses causally related to work injury; 30-day payment rule)
- Hough v. Workers' Compensation Appeal Board (AC & T Companies), 928 A.2d 1173 (Pa. Cmwlth. 2007) (utilization review for reasonableness/necessity of treatment; penalties context)
- Zuver v. Workers' Compensation Appeal Board (Browning Ferris Industries of PA, Inc.), 755 A.2d 112 (Pa. Cmwlth. 2000) (utilization review controls reasonableness/necessity questions)
- Montgomery Tank Lines v. Workers' Compensation Appeal Board (Humphries), 792 A.2d 6 (Pa. Cmwlth. 2002) (admissibility of medical reports in 52 weeks or less disability disputes (Section 422(c)))
- Enterprise Rent-A-Car v. Workers' Compensation Appeal Board (Clabaugh), 934 A.2d 124 (Pa. Cmwlth. 2007) (fee review process governs medical-cost billing/charges)
- City of Philadelphia v. Workers' Compensation Appeal Board (Brown), 830 A.2d 649 (Pa. Cmwlth. 2003) (Board procedures and standard of review; substantial evidence)