Physicians: Treating Physician: Who may be the treating physician

MONTANA SUPREME COURT DECISIONS

Wright v. Ace American, 2011 MT 43, 359 Mont. 332, 249 P.3d 485 Physicians licensed or certified in another state may qualify as a treating physician for a claimant residing out of state or upon approval of the insurer.  However, a claimant’s failure to obtain authorization does not automatically absolve an insurer of liability for treatment rendered by unauthorized physicians.  This Court must consider the diagnosis to determine whether the recommended treatment is appropriate.  In this case, the Workers’ Compensation Court correctly considered the opinion of a doctor not licensed in Montana who treated a Montana resident and who was not approved by the insurer, even though the doctor could not be considered the claimant’s treating physician at the time of trial.
Selley v. Liberty Northwest Ins. Corp. 2000 MT 76 After approximately two years of compensating claimant's physician as her treating physician, insurer learned the doctor did not have admitting privileges at any hospital and thus did not qualify as a treating physician under section 39-71-116(30), MCA (1993.) Reversing WCC, Supreme Court held insurer was equitably estopped from refusing prospective compensation of physician as treating physician.
Selley v. Liberty Northwest Ins. Corp. 2000 MT 76 Because insurer was in a better position than claimant to determine whether a particular physician had hospital admitting privileges, the Supreme Court found the insurer should have known the doctor did not have admitting privileges and should not have acquiesced in claimant's treatment by physician without admitting privileges, satisfying elements of equitable estoppel and preventing the insurer from refusing prospective compensation of physician as treating physician even though he did not meet the criteria of section 39-71-116(30), MCA (1993), regarding hospital privileges.
 
 
MONTANA WORKERS' COMPENSATION COURT DECISIONS
Wright v. Ace American Ins. Co. [05/24/10] 2010 MTWCC 11 Under § 39-71-116(36), MCA (2003), a physician who had admitting privileges to practice in a hospital in the community in which he is located, but whose Montana license has apparently expired, cannot be considered a treating physician.
Harrison v. Liberty NW Ins. Corp. and Stillwater Mining Co. [05/12/06] 2006 MTWCC 22 Where Petitioner had two treating physicians from two different claims, both are considered treating physicians for purposes of the Court’s decision.
Anderson v. Albertson's, Inc. [8/12/04] 2004 MTWCC 59 A claimant may have more than one treating physician where his or her industrial injuries require.
Travelers v. Martini, M.D. [6/06/02] 2002 MTWCC 31 Section 39-71-116(36), MCA, defines treating physician as the medical provider "primarily responsible for treatment of a worker's compensable injury." A medical doctor who is primarily responsible for the treatment and maintained supervision and control over the nurse practitioner's services is entitled to reimbursement for the nurse practitioner's services.

Selley v. Liberty Northwest Ins. Corp. [11/16/98] 1998 MTWCC 82. The insurer was not equitably estopped from refusing future payment to claimant's physician, whom it learned did not have hospital admitting privileges and thus did not qualify as a treating physician, where the insurer did not make any representation or concealment of fact and was not shown to have had knowledge that the doctor did not meet statutory criteria for a treating physician. [Note: the WCC was reversed on this point; see Selley v. Liberty Northwest, 2000 MT 76.]