Massachusetts Appellate Court Affirms Award of Medical Expenses Reimbursement, Rejects Insurer’s Causation Defense

When you are injured at work, you may receive prescriptions for certain medications to help treat your injuries and to manage the associated pain. The Massachusetts workers’ compensation system provides that employees who are injured in the line of work are eligible not only for weekly benefits to replace their lost wages but reimbursements for related medical expenses as well. Despite this clear provision, many insurers attempt to deny reimbursement for medical treatments and associated medications. At Pulgini & Norton, our Boston work injury lawyers are ready to fight on your behalf to ensure that you are treated fairly.

In a recent claim dispute, the insurer appealed from an order requiring it to pay benefits and reimbursement for reasonable and necessary medical expenses, including prescriptions for ibuprofen and Topamax. The insurer disputed the award on the basis that the presiding judge did not perform an appropriate analysis about the causal link between the injury and the treatment. It also argued that the lower court mischaracterized evidence regarding the worker’s status as obese.

The injury happened when the employee was attending a company cookout. He slipped and suffered an injury to his left knee. He tried to continue working but was unable to do so. He underwent multiple surgeries to his ankle and knee as a result. During the proceedings, the insurer raised a question as to whether the court had properly done an analysis regarding the employee’s obesity as a preexisting condition. The lower court ultimately awarded benefits and medical reimbursement payments and the insurer appealed.

Although the insurer raised the defense, the appellate court concluded that the insurer had failed to provide an appropriate offer of proof to show that a pre-existing condition was a substantial factor in the injury. The lower court also did not adopt any medical evidence or reports stating that the employee’s status as morbidly obese combined with the injury that happened at the picnic caused the ongoing disability or need for treatment. The appellate court rejected the insurer’s insistence that its counsel’s statement at a hearing that the employee’s obesity qualified as a medical condition satisfied the offer of proof requirement. The requirement that a party raising pre-existing conditions as a defense or issue in a case provide an offer of proof requires a more substantive evidentiary showing.

The appellate court noted that the insurer had several opportunities throughout the claim process to obtain information about whether the worker’s obesity was a contributing factor, including a deposition of a medical professional who examined the worker. At no point during the deposition did the insurer ask questions about whether the employee’s obesity was a factor in causing the injury or the prolonged need for treatment. Based on these findings, the appellate court upheld the award.

If you were hurt at work, you should seek counsel from an experienced Boston work injury lawyer. The workers’ compensation claims process may seem straightforward but there are countless procedural and substantive rules that govern the determination of whether you are entitled to benefits. While you are coping with the stress and inconvenience of your injury, we will ensure that you are being treated fairly. Call us today at 781-843-2200 or contact us online to get started.

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