Massachusetts Appellate Court Reverses Order Requiring Insurer To Pay for Prescription Medications Based on Improper Reliance on Impartial Medical Examiner’s Report

There are many aspects of a workers’ compensation claim when it comes to calculating the amount of benefit payments and reimbursements that you are entitled to receive. Although the workers’ compensation system provides compensation for any medical expenses incurred regarding the accident, many insurance companies attempt to dispute the amount of expenses that you claim, attempting to describe them as either unreasonable or not necessary. As dedicated Massachusetts workers’ compensation lawyers, the attorneys at Pulgini & Norton have assisted many injured workers with ensuring that they receive the full amount of compensation that they need for their medical costs.

A recent Massachusetts court decision discusses this issue. The injured worker in the case experienced a left elbow injury as a result of repetitive motions. She underwent multiple surgeries to address the issue, but they were unsuccessful and left the employee with nerve damage. She then developed complex regional pain syndrome as well as other conditions. The employee accepted a lump sum settlement in 1999 for her injury, which included a provision requiring the insurer to pay reasonable, necessary, and related medical expenses. In 2000, the worker began taking pain medications to help manage her symptoms, including Vicodin and Fentanyl.

The employee obtained a new degree and began working for a different employer in another capacity. In 2009, she suffered injuries in a non-work-related accident and developed a pain issue in the affected leg. She was then prescribed Lyrica in addition to the Vicodin and Fentanyl.

The employee applied for medical expenses reimbursement with her employer. She also joined a claim against the insurance company for her second employer. The judge denied the employee’s claim for medical reimbursement, and she appealed, while also withdrawing the claim against her new employer’s insurer. At the hearing, the primary issues were whether the three pain medications were reasonable and necessary to treat her elbow injury in light of the new non-work-related leg injury. The employee then underwent an independent medical examination. The examining physician produced a report concluding that the three medications were necessary and reasonable in connection with her elbow injury. Based on this opinion, the judge ordered the insurer to compensate the employee for her pain medications and medical treatments. It also denied a request by the insurer to submit additional medical information.

The insurer appealed, claiming that the judge erred in relying on the expert’s medical opinion. The appellate court agreed with the insurer, finding that the lower court erred in denying the insurer’s request to offer more medical information. According to the appellate court, there were issues regarding the consistency of the medical examiner’s opinions and his own testimony, indicating that he was not an expert regarding pain management. Accordingly, the court reversed the order and remanded the case for more proceedings.

If you have suffered permanent disabilities as a result of a work injury, you can receive reimbursement for your reasonable and necessary medical expenses through the Massachusetts workers’ compensation system. At Pulgini & Norton, we proudly serve injured workers throughout the region and assist with all phases of the claims process. This includes helping you gather the appropriate documents and negotiate with insurance companies. To schedule your free consultation, call us now at 781-843-2200 or contact us online.

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