Massachusetts Employee Has Standing to Bring Claim for Reimbursement of Benefits Paid by MassHealth and Medicare

The Reviewing Board of the Department of Industrial Accidents recently decided an appeal in a workers’ compensation case, addressing the issue of whether an employee has standing to claim reimbursement of § 13 and § 30 medical benefits from her employer’s insurer for treatment paid by MassHealth and Medicare.  The administrative judge denied the employee’s claim, finding that since the employee would not receive any benefit from a favorable decision, she lacked standing.  On appeal in Dominguez v. Rainbow New England Corporation, the Reviewing Board reversed, finding in favor of the employee.In Dominguez, the employee had settled her workers’ compensation case with her employer’s insurer for a lump sum after a right shoulder injury that occurred in December 2005.  Although all the employee’s medical bills had been paid, and the employee did not personally make any payments for medical treatment, the employee argued that the employer’s insurer had been unjustly enriched because MassHealth and Medicare had paid her medical bills.  The insurer contended that the employee did not have standing to raise her claim, since there was no controversy between the employee and the insurer.

The Reviewing Board cited the holding of Etsey v. Burns International Security, in which it found that the insurer is responsible for paying 100% of the employee’s reasonable, necessary, and causally related medical benefits, and it specifically pointed out MassHealth’s potential lien against the employee’s workers’ compensation case pursuant to G.L. c. 152, § 46A.  In Dominguez, the Reviewing Board likewise found that an outstanding lien and the continued involvement of MassHealth and Medicare would have a direct impact on both the employee’s future medical treatment and a potential third-party claim under § 30 for the reimbursement of other necessary incidental expenses.  In addition, the Reviewing Board reinforced that it has consistently held that the insurer is required to pay all reasonable and related medical expenses.

The Reviewing Board also disagreed with the insurer’s argument that the employee’s lump sum settlement agreement relieves it of any responsibility for any medical treatment for the right shoulder of the employee after her second surgery.  The Board made clear that pursuant to § 48(2), when liability has been accepted by an insurer, as in Dominguez, the agreement cannot alleviate liability for payment of medical benefits with respect to the injury.  The employee therefore retains the right to litigate causal relationship issues regarding the accepted claims.  The Board therefore reversed the administrative judge’s decision and remanded the matter for a consideration of the causal relationship between the surgery claimed by the employee and the accepted injury.

If you have been injured while working on the job, you may be entitled to compensation for your medical expenses and lost earnings.  At the Massachusetts firm of Pulgini & Norton, our personal injury attorneys provide aggressive, trusted legal representation to individuals pursuing workers’ compensation benefits.  To discuss your benefits claim with one of our skilled attorneys, contact our office at (781) 843-2200 or through our website.

More Blog Posts:

Massachusetts Reviewing Board Affirms Award of Workers’ Compensation Benefits, Including Handicapped Housing, Massachusetts Workers’ Compensation Lawyer Blog, published November 2, 2015

Massachusetts Court Finds No Newly Discovered Evidence in Workers’ Compensation Case, Massachusetts Workers’ Compensation Lawyer Blog, published July 15, 2015

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