Medical Benefits Liability

Gamble v. Sears [01/30/06] 2006 MTWCC 5 Where Respondent did not contend that surgery was not medically necessary, nor that Petitioner’s surgeon was not an appropriate doctor to perform the surgery, and where Respondent’s IME doctor found the surgery to be “very reasonable” and Petitioner’s surgeon did not opine until after the surgery that Petitioner’s injury stemmed from her industrial accident, Petitioner’s failure to receive pre-authorization for the surgery does not absolve Respondent from liability for the medical expenses Petitioner incurred as a result of her condition.

Messitte v. Liberty Mutual Fire Ins. [8/30/01] 2001 MTWCC 51 Claimant suffering from muscle ailment beginning with lifting heavy items during waitressing work ten years prior was entitled to continued medical services from her treating physician, and to prescribed medicines, but not to massage and health club membership. The physician's recommendations for massage and health club membership must be judged under the language of section 39-72-704, MCA (1989), allowing "other treatment approved by the department." ARM 24.29.2003 and .2004 set out the Department's standards in implementation of the statute. Under treating physician's testimony, the massage and exercise would constitute maintenance which is not compensable under the regulations.

Alocco v. CIGNA [12/06/00] 2000 MTWCC 74 An insurer's liability for medical benefits is limited to fee schedules promulgated by the Department of Labor and Industry pursuant to section 39-71-704 (1995). Denial of a claim does not increase its liability.

Alocco v. CIGNA [12/06/00] 2000 MTWCC 74 A claimant's liability to medical providers for medical care related to his industrial injury is limited to the co-payments required by 39-71-704(7). Any amounts paid by a claimant in excess of those co-payments must be refunded by the providers.

Alocco v. CIGNA [12/06/00] 2000 MTWCC 74 Here the insurer denies liability for medical services and claimant pays for those services, in whole or in part, and the insurer is later found liable for the services, the insurer has a duty to assist claimant in seeking repayment from the medical providers.

Pasha v. National Union Fire of Pittsburgh [2/26/97] 1997 MTWCC 5 Insurer is not responsible for treatment relating to claimant's legs and feet where medical records do not support her assertion that pain in those areas emerged at the time of the compensable automobile accident and remained constant. Rather, the records demonstrate claimant's symptoms in those areas have varied and have not been explained by any physician.

Kaiser v. Sears [6/28/96] 1996 MTWC 47 Where an IME panel found claimant's 1995 complaints of pain related to his 1981 electrocution injury, even though likely exacerbated by deconditioning, and recommended three physical therapy sessions, the Court finds treatment by claimant's family practitioner and one month's physical therapy related to the original injury and reasonable medical treatment. Additional physical therapy was found not reasonable where prescribed without examination of claimant or discussion with the physical therapist.