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Massachusetts Appellate Court Upholds Denial of Coverage for Hip Replacement Surgery Following Work Accident

skeleton hip boneAlthough some work injury cases are very straightforward when it comes to diagnosing the nature and scope of the injury, there are other instances in which the medical issues can be complex. At Pulgini & Norton, our seasoned Boston workers’ compensation lawyers have handled a diverse array of work injury cases involving all kinds of accidents. The Massachusetts workers’ compensation rules allow injured workers to offer additional evidence in some instances in which the complexity of the medical issues requires a deeper analysis. Being able to offer this additional evidence to support your claim for compensation can make all of the difference in your ability to recover benefits, as a recent Massachusetts appellate opinion demonstrates.

The facts of the case are as follows. The employee worked at an electric company starting in 1980. On May 31, 2011, the employee suffered an injury when a revolving door struck his left knee. He fell at the time of the blow and suffered an injury to his left side as well. The employee saw two doctors, who treated his left knee and left hip injuries, respectively. The employee required surgery on both of his knees and was awarded weekly indemnity benefits while he recovered.

The employee filed a workers’ compensation claim, which the employer’s insurer rejected. The claim proposed a total left hip replacement surgery, alleging that the surgery stemmed from the May 31, 2011 accident. The employee appealed. As part of the appeal process, the employee saw an impartial physician, who examined the employee.

During a hearing regarding whether the employer should be required to pay for the left hip replacement surgery, the employee filed a motion to offer additional medical testimony regarding what he described as complex medical issues. The employee specifically wanted to offer additional evidence regarding his pre-existing arthritis in his hip. The employee also wanted to offer evidence regarding the disagreements among the many doctors who consulted on the issue. The judge denied this motion and dismissed the employee’s claim seeking compensation for his left hip replacement surgery.

The employee appealed, alleging that the judge erred in finding that the medical issues were not complex and in not allowing the employee to offer additional medical evidence. On review, the appellate court ultimately upheld the lower court’s decision to deny the employee’s motion to offer additional medical testimony and denial of coverage for the left hip replacement surgery. Before reaching this conclusion, however, the appellate court commented on the standard that should be applied when determining whether medical complexity exists.

The appellate court reiterated that a determination regarding medical complexity requires a subjective analysis. Although judges have discretion in deciding whether a medical issue is complex, the concept of complexity is not defined in any statute or regulation. Instead, Massachusetts courts have applied a subjective approach to determining in each case whether an issue of medical complexity exists. Although the lower court judge erred in articulating the standard for determining complexity, defining it as a two-part analysis, the appellate court concluded that the rationale that the judge provided for rejecting the employee’s request for finding the medical issues complex was well-reasoned. Specifically, the judge rejected the employee’s assertion that the disagreement among the physicians who consulted on the case created a matter of complexity warranting additional evidence.

If you experienced an injury on the job, you may be entitled to workers’ compensation benefits. At Pulgini & Norton, we have handled many work injury claims on behalf of Boston residents, including everything from relatively straightforward and minor injuries to catastrophic and complex medical cases. We offer a free consultation to help you understand your legal rights and whether you may be entitled to benefits. To set up your appointment, call us now at 781-843-2200 or contact us online.

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