Benefits: Medical Benefits: Liability

Rushford v. Montana Contractor Compensation Fund [05/30/14] 2014 MTWCC 16 Where the Court found Petitioner wholly lacking in credibility, it concluded that Petitioner had not met his burden of proving that any of his respiratory problems are related to his industrial injury.  Therefore, Respondent is not liable for further medical treatment.

Nelson v. Montana Schools Group Ins. Auth. [05/28/14] 2014 MTWCC 15 Where Respondent advised Petitioner in writing that she would need to seek preauthorization under ARM 24.29.1517(5)(d) for all future treatment with her out-of-state surgeon because she had reached MMI, Respondent had good cause to deny the surgeon’s charges when Petitioner failed to seek preauthorization.  While Respondent’s claims adjuster had earlier advised Petitioner that she could not contact Respondent directly after she obtained legal representation, nothing prevented her attorney from doing so on her behalf.

Koch v. Employers Ins. Group [05/19/14] 2014 MTWCC 14 A ruling by this Court that a claim is compensable should not be viewed as a blank check written out to Petitioner’s treating physician.  However, after liability is established, an insurer cannot decide to terminate a treating physician’s diagnostic work-up in the middle of the process for no discernible reason.

Grande v. Montana State Fund [07/22/11] 2011 MTWCC 21 Petitioner’s treating physician opined that Petitioner’s job duties only temporarily aggravated his rheumatoid arthritis and did not offer an opinion as to whether Petitioner’s work was the major contributing cause of his rheumatoid arthritis.  Where the parties set forth no argument as to whether Petitioner would be entitled to medical benefits for his rheumatoid arthritis condition during the time period in which his job duties temporarily aggravated it, the Court concluded that Petitioner did not establish an entitlement to medical benefits for the treatment of the temporary aggravation of his rheumatoid arthritis.

Wright v. Ace American Ins. Co. [05/24/10] 2010 MTWCC 11 Where a doctor's opinion persuaded the Court that the claimant may be suffering from a cervical condition, the Court concluded that the claimant should be allowed to seek further medical treatment. However, the Court will not order the insurer to pay for the claimant to "doctor shop" until he finds a surgeon willing to perform cervical surgery. The claimant may seek the opinions of two qualified orthopedic surgeons at the insurer's expense. If neither agrees to treat the alleged cervical condition, the insurer shall not be liable for further treatment of the alleged condition.
Hart v. Hartford Ins. Co. of the Midwest [04/07/10] 2010 MTWCC 8 Undisputedly necessary medical treatment arising from a work-related injury is compensable irrespective of prior authorization.  Where some medical bills have no corresponding medical records which would allow the court to assess the necessity of medical treatment and Petitioner’s behavior includes drug seeking and misrepresentations to physicians, it is impossible for the Court to decipher what bills remain unpaid that would fall into the category of undisputedly necessary.

Brown v. Hartford Ins. Co. [12/16/09] 2009 MTWCC 38 Where the parties submitted 30 pages of medical bills as a trial exhibit and the Court concluded that the insurer was liable for the claimant’s occupational disease, the Court directed the parties to review the bills and attempt to agree on the specific dollar amount owed.

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.