Injured Workers' Pharmacy Employee-Clenon Naron v. Liga
175 So. 3d 475
| La. Ct. App. | 2015Background
- Claimant Clenon Naron injured his back at work in 1999 and received workers’ comp benefits; LIGA later adjusted the claim.
- Naron had a CPS prescription card and filled prescriptions at Fred’s or via CPS mail-order through 2009; on Feb 1, 2010 Fred’s refused to fill because coverage had "expired."
- Naron’s counsel referred him to Injured Workers Pharmacy (IWP), an out-of-state mail-order pharmacy that shipped from Massachusetts; IWP filled prescriptions for Naron 11 times between Feb–Sept 2010.
- LIGA paid IWP’s first invoice but then notified IWP Naron should use his CPS card and later denied payment, asserting IWP had not obtained preauthorization.
- IWP sued LIGA before the Office of Workers’ Compensation; the WCJ ordered LIGA to pay $7,025.92 to IWP, finding LIGA failed to furnish necessary drugs and that preauthorization was unnecessary when benefits were denied.
- The appellate court reversed, holding the WCJ erred by not analyzing whether IWP qualified as a permissible out-of-state provider under La. R.S. 23:1203(A).
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether LIGA must pay IWP for drugs under La. R.S. 23:1203(A) | IWP: LIGA failed to furnish necessary drugs when Fred’s refused and LIGA denied alternate pharmacy; LIGA must pay IWP’s charges | LIGA: Out-of-state provider IWP may not be paid where in-state pharmacies were reasonably available and comparable costs exist | Reversed WCJ; court held WCJ erred by not determining whether IWP fit allowable out-of-state provider criteria under §23:1203(A) |
| Whether IWP is barred or limited by lack of preauthorization (La. R.S. 23:1142) | IWP: Preauthorization not required because LIGA denied benefits; thus no $750 cap applies | LIGA: Recovery (or cap) applies because IWP did not obtain preauthorization; liability should be limited to $750 | Appellate court did not affirm payment; primary error was statutory analysis of out-of-state provider status—WCJ’s preauthorization conclusion was not sustained by the court’s ruling |
| Whether claimant (or employer/payor) controls choice of pharmacy | IWP/Naron: Claimant has right to choose pharmacy when necessary; IWP provided necessary services similar to CPS mail-order | LIGA: Payor may limit pharmacy; where in-state, reasonably available, and cheaper options exist, out-of-state mail-order is not authorized | Court emphasized choice is not boundless; out-of-state providers allowed only when in-state unavailable or costs comparable; WCJ failed to apply that limitation |
| Whether IWP’s charges were comparable to in-state costs and thus permissible | IWP: Billed under state fee schedule and thus reasonable | LIGA: IWP charged far more (e.g., $559.62 vs $39.88 for same drug); IWP dispensed costlier brands—thus not comparable | Court noted evidence IWP was not providing drugs at comparable costs and that services were reasonably available in Louisiana; that undermined WCJ’s order without full §23:1203 analysis |
Key Cases Cited
- Brown v. KTBS, Inc., 974 So.2d 784 (La. App. 2d Cir.) (right to choose vendor for necessary medical device discussed in workers’ comp context)
- Nelson v. Highland Ins. Co., 634 So.2d 941 (La. App. 2d Cir.) (reimbursement for out-of-state treatment rejected where in-state care available)
- Downs v. Chateau Living Ctr., 167 So.3d 875 (La. App. 5th Cir.) (addressing employer/payor control over pharmacy choice)
- Bordelon v. Lafayette Consol. Govt., 149 So.3d 421 (La. App. 3d Cir.) (addressing employer/payor authority to select pharmacy)