Failure to preauthorize medical treatment

In McLaughlin vs. Workers Compensation Appeal Board (St. Francis Country Home), the injured work suffered a back injury.  The work injury was recognized and the Employer filed a petition to terminate the injured workers’ benefits.  During the litigation of the termination petition, the Claimant sought to obtain medical treatment.  The medical provider requested preauthorization for the proposed surgery from the workers compensation carrier.  The Claims Adjuster wrote a letter denying coverage for the surgery.  As a result of the workers compensation carrier’s denial, the Claimant was unable to have surgery.  This unfortunately is a common technique of Employers to refuse to preauthorize medical treatment.  The Claimant filed a petition for penalties alleging the Workers’ compensation carriers’ action which prevented the injured work from obtaining medical treatment for the work injury was a violation of the Pennsylvania Workers Compensation Act.

The Commonwealth Court discussed that the Pennsylvania Workers Compensation Act requires an Employer to pay reasonable and necessary medical expenses incurred for the Claimant’s work injury.  Workers Compensation Carriers are not permitted to stop paying medical bills absent an order from a workers compensation Judge, Final receipt or the agreement of the Claimant.  The Court further recognized that the Employer’s refusal to preauthorize effectively prevented Claimant from receiving the recommended treatment in the first place.  The Court concluded that the Judge’s decision to grant a penalty for the Employer’s refusal to preauthorize the surgical treament and order the Employer to pay for the surgery was proper.