Downs v. Chateau Living Center
167 So. 3d 875
| La. Ct. App. | 2015Background
- Downs, an employee of Chateau, injured her back on Sept. 20, 2011; Chateau accepted the claim and paid medical and prescription benefits through its TPA (ERMS).
- ERMS selected Carlisle Medical as the authorized pharmacy and issued Downs a Carlisle prescription card (retail or mail-order available); Downs used Carlisle for several retail fills through mid-2012.
- Beginning August 2012 Downs switched to mail-order pharmacy Injured Worker’s Pharmacy (IWP) without ERMS approval; ERMS repeatedly told IWP it was not authorized and refused to approve IWP invoices.
- IWP continued filling prescriptions and submitted pre-authorization requests after dispensing; Downs filed a disputed claim seeking payment for IWP prescriptions on Aug. 21, 2013.
- The WCJ awarded reimbursement to IWP (amount not specified) and assessed $5,000 each in penalties and attorney’s fees against Chateau; Chateau appealed.
- The court reversed: held Chateau entitled to select Carlisle as the authorized pharmacy, limited IWP’s recovery to $750 under La. R.S. 23:1142(B)(1)(a), and reversed penalties/fees against Chateau.
Issues
| Issue | Plaintiff's Argument (Downs/IWP) | Defendant's Argument (Chateau) | Held |
|---|---|---|---|
| Whether employer can designate the pharmacy | Downs: employer’s change violated duty to furnish necessary drugs and she was entitled to use IWP | Chateau: ERMS validly designated Carlisle; employee must use authorized pharmacy absent timely failures | Held: Employer entitled to select Carlisle; no record Carlisle failed to timely provide drugs |
| Whether IWP can recover > $750 for nonemergency care without payor consent | IWP: furnished medications and is owed full reimbursement | Chateau: IWP knowingly incurred >$750 without payor consent and after written refusal | Held: IWP recovery limited to $750 under La. R.S. 23:1142(B)(1)(a) |
| Whether IWP’s statutory noncompliance (La. R.S. 23:1142) precludes recovery | IWP: statutory cap not applicable to prescription fills or facts warrant full payment | Chateau: statutory cap applies to nonemergency pharmacy charges incurred without consent | Held: Court applied statutory cap to IWP and limited recovery to $750 |
| Whether penalties and attorney’s fees should be assessed against employer | Downs: Chateau unreasonably controverted claim, so penalties/fees warranted | Chateau: reasonably controverted IWP’s claim by designating Carlisle and giving repeated written notice to IWP | Held: WCJ erred awarding penalties/fees; Chateau reasonably controverted claim |
Key Cases Cited
- Sigler v. Rand, 896 So.2d 189 (La. Ct. App. 2004) (employer may choose pharmacy so long as chosen provider timely furnishes necessary drugs)
- Bordelon v. Lafayette Consol. Gov’t, 149 So.3d 421 (La. Ct. App. 2014) (upheld employer’s pharmacy selection; limited IWP recovery under La. R.S. 23:1142 where provider knowingly exceeded $750 after notice)
- Rebel Distributors Corp. v. LUBA Workers’ Comp., 137 So.3d 91 (La. Ct. App. 2014) (applied La. R.S. 23:1142 cap to pharmacy-related claims)