eNotes: Workers’ Compensation – June 2023 – Pennsylvania

SIGNIFICANT CASE SUMMARIES

Pennsylvania Case Summaries

Elite Care, RX, LLC v. Premier Comp Solutions
Superior Court of Pennsylvania
No. 1144 WDA 2020

Decided: May 23, 2023

Non-providers that allege wrongfully denied medical bills may pursue an action against the workers’ compensation insurance carrier in the Court of Common Pleas.

Background

Elite Care was a billing agent of various health care providers. As a separate entity, it was responsible for collecting on accounts receivable. Elite Care originally pursued fee review in the Bureau of Workers’ Compensation Fee Review Section for denied medical bills, but its applications were dismissed by the Fee Review Officer on the basis that the billing agency was not a “provider” under the Workers’ Compensation Act and therefore lacked standing to invoke the fee review process. Elite Care sued the insurance companies denying payment in the Court of Common Pleas. The insurance companies filed preliminary objections to the complaint, asserting that the trial court lacked jurisdiction because the dispute was governed by the Workers’ Compensation Act. The court overruled the insurers’ objections, and the insurers appealed to the Superior Court.

Holding

In a published en banc opinion with one dissenting judge, the Superior Court affirmed. The court acknowledged that the Armour Pharmacy case held that there was no direct statutory remedy for putative providers and billing agents, and that the Fee Review Hearing Officer had jurisdiction to determine whether an entity had standing as a “provider” to pursue fee review. However, the court declined to follow Armour Pharmacy. The court criticized Armour Pharmacy as “legislating from the bench,” creating jurisdiction in the Fee Review Section to decide whether an entity is a “provider” when the legislature had not. The court held that the Workers’ Compensation act does not divest the Court of Common Pleas from jurisdiction over causes of action where the parties to the lawsuit are an employer’s insurance carrier and a provider’s billing agent.

Takeaway

Given that the Superior Court and Commonwealth Court now disagree on the issue of whether the Fee Review Section has jurisdiction to decide whether an entity is a “provider” under the Act, as well as whether disputes over workers’ compensation bills are exclusively under the jurisdiction of the Bureau of Workers’ Compensation, there is a good chance that the Supreme Court of Pennsylvania will be asked to weigh in on the issue soon. This case may prompt entities whose fee reviews were dismissed based on their status as a non-provider to pursue a remedy in the Court of Common Pleas.

Questions about this case can be directed to John T. Morgan, Esquire, at (267) 861-7580 or jmorgan@tthlaw.com.

Gonzalez v. Guizzetti Farms, Inc.
Commonwealth Court of Pennsylvania
144 CD 2022

Decided: April 18, 2023

Act 111 grants employers a credit for previous payments of partial disability, whether made before or after Protz. Said payments are not erased by a reinstatement of benefits.

Background

Here, before Protz, the Claimant’s benefits were modified per the result of a September 5, 2008 IRE. Because Protz rendered the IRE unconstitutional, the Claimant filed a reinstatement petition that the WCJ granted. Following the enactment of Act 111, on October 24, 2018, the employer sent the Claimant for a second IRE on December 17, 2019, which resulted in an impairment rating of under 35%. The Claimant’s benefits were thus modified from total to partial effective December 17, 2019. On appeal, the Claimant argued that Act 111 does not apply retroactively with respect to the calculation of Claimant’s weeks of total and partial disability. The employer argued that the WCJ erred in merely modifying Claimant’s disability benefits from total to partial. Rather, since the 500 weeks of partial disability benefits started on September 5, 2008 and expired on April 6, 2018, the judge should have suspended benefits as of April 6, 2018.

Holding

The Court found that the plain language of Section 3 in addition to the interpreting case law establish that Act 111 is undoubtedly retroactive. In other words, employers are entitled to a credit for partial and total disability payments paid prior to the enactment of Act 111 on October 24, 2018. Pursuant to Section 306(a.3) of the Act, employers are entitled to a credit for partial disability payments made before or after Protz in the accrual of the 500 weeks.

The Court held that employers are entitled to credit for past partial disability payments. The decision reinstating benefits did not re-set the 500 week clock. Here, however, since the evidence of record did not substantiate the employer’s assertion that 500 weeks expired on April 6, 2018, the Court remanded the case to the WCJ to make a finding of fact regarding the same.

Takeaway

Employers are entitled to a credit for past partial disability payments paid. If seeking suspension of benefits based upon the expiration of 500 weeks of partial disability payments, it is imperative to submit evidence to the record to prove that the partial payments were made.

Questions about this case can be directed to Cailey Farinaro, Esquire at (610) 332-7008, or cfarinaro@tthlaw.com.

Davies v. All My Children (WCAB)
Commonwealth Court of Pennsylvania
1244 C.D. 2021

Decided April 3, 2023

Commonwealth Court reaffirms that while modifications to a home are appropriate, the Act does not authorize the purchase of a new home.

Background

Following a significant work injury the claimant became a paraplegic with bowel and bladder issues. Prior to the work injury, the claimant had always lived with his parents. Following the injury, the original home that the Claimant resided with his parents was unable to be modified to accommodate the Claimant’s needs. Consequently, the parents purchased a new home for $220,000.00 and put in $35,000.00 of modifications to accommodate the Claimant. The Claimant filed a Review Petition seeking reimbursement for both the cost of the home and the renovations made to the home. The Workers’ Compensation Judge awarded the costs of the renovations in the amount of $35,000.00 but disallowed the purchase price of the new home. The Workers’ Compensation Appeal Board affirmed. The Claimant appealed to the Commonwealth Court.

Holding

While the employer can be required to pay for modifications necessary to a home, no precedent exists to hold an employer or carrier responsible for an entire house. In dealing with a claim for the purchase of a new home as a result of a work-related injury, the employer is only required to pay for the modifications to the home and not a new home.

Takeaway

Keep in mind that the particular circumstances of the claimant must be considered in determining the precise obligation of the employer to pay for these modifications. As such, each case must be viewed on its own set of facts.

Questions about this case can be directed to Sean B. Epstein, Esquire at (412) 926-1451 or sepstein@tthlaw.com.