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Massachusetts Appellate Court Upholds Denial of Reimbursement for Pain Medication Based on “Major Cause” Doctrine

cervical spine xrayIn addition to receiving compensation for your lost wages, the Massachusetts workers’ compensation system provides injured workers with reimbursement for the medical expenses they incur as a result of the injury. Although this sounds straightforward, many claims become protracted when an insurance company denies payment for all or some of the medical bills that an injured employee submits. At Pulgini & Norton, our seasoned Massachusetts workers’ compensation lawyers have handled numerous claims involving disputed medical bill reimbursements.

A recent appellate opinion discusses the issue of whether an insurer must pay for certain aspects of an injured employee’s medical care. The employee suffered a neck injury during the course and scope of her employment as a cleaner and transporter. She applied for workers’ compensation benefits, and her claim was accepted. To treat her injury, the plaintiff underwent a spinal fusion procedure, which was ultimately unsuccessful. Her treating physician recommended another cervical fusion, which she accepted. A few days after her second procedure, the employee settled her workers’ compensation claim by opting to receive a lump sum settlement in lieu of weekly benefit payments.

The following year, the employee’s doctor performed a procedure on her lower back that was not related to the work injury. Roughly two years later, the employee filed a request for reimbursement of medical expenses for a pain patch that her physician prescribed to manage the pain associated with her neck injury. The employer’s insurance carrier had been paying for half the cost of the patch up until the hearing. During the hearing, the judge denied the employee’s claim for payment of her outstanding medical bills but concluded that the employer should continue paying for half of the pain patch. Both the employee and the insurance carrier appealed.

On appeal, the employee argued that she was entitled to over $24,000 in medical expenses associated with the patch, in addition to future compensation for medication related to her neck injury. The insurance carrier denied that it was required to compensate her for the patch-related expenses and stated that her work-related neck injury was not the main reason that the doctor prescribed the pain patch. Instead, the insurer argued that her pre-existing lower back condition was the main factor leading to the pain patch prescription.

The parties were allowed to submit additional medical evidence and took the deposition of the plaintiff’s treating physician, who had cared for the plaintiff for nearly 20 years. Based on the information submitted, the lower court concluded that there was insufficient evidence to support the employee’s claim for $24,000 in relation to the pain patch. The plaintiff appealed.

On review, the appellate court agreed with the lower court that the employee failed to offer enough proof to show that the pain patch was a direct result of her neck injury and not primarily prescribed to treat her pre-existing lower back pain. The additional medical evidence and the employee’s medical records failed to indicate whether the work-related injury was the major cause of the plaintiff’s need for a pain patch.

If you were hurt while at work, you may be entitled to receive a weekly benefit payment as well as compensation for your medical bills. At Pulgini & Norton, our dedicated team of Massachusetts workers’ compensation lawyers knows just how daunting and confusing the claims process can seem. We will walk you through every step and ensure that you receive the fair and prompt treatment that you deserve. To schedule your free consultation, call us now at 781-843-2200 or contact us online.

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