Employer has legal basis to deny paying for claimant’s narcotic medication on causation grounds because claimant was arrested and charged with illegally selling the medication prescribed for his work injury.

The claimant had sustained a low back injury on July 26, 2011, which was accepted as compensable. He underwent two back surgeries and was receiving narcotic medications. His total disability benefits had been terminated in February 2014, and he was receiving partial disability benefits. In March 2014, the employer stopped approving the claimant’s prescription for Oxycodone because the claimant had been arrested in February 2014 and charged with illegally selling that medication.

At the legal hearing, claimant’s counsel asserted that the treating doctor had indicated that suddenly stopping the claimant’s medication could cause serious medical problems. The employer countered that the medications were being denied as not being necessary, reasonable and related to the accepted injury. The claimant asserted that the employer had no legal basis to stop paying for the medications. However, the Board rejected that argument and stated that, as a general rule, an employer can refuse to pay for medical treatment that it in good faith believes is not necessary, reasonable and causally related to the work injury. In this case, since the claimant had been charged with selling Oxycodone—the very medication the employer was paying for—it was reasonable for the employer to assume that the claimant no longer needed it for his work injury. Thus, the Board found that there was no illegal conduct by the employer in denying payment for the medication.

The Board further addressed the issue of whether the denial of the medication should have been submitted to Utilization Review as not being necessary and reasonable. The Board’s analysis shows that this situation falls into a gray area in which it could be contended that the claimant no longer needs the medication and that it is, therefore, not necessary and reasonable and the dispute should be sent to Utilization Review. On the other hand, the Board also indicated that the employer could contend that, since the claimant no longer needs the medication, the work injury is then no longer causing the need for the medication, and thus, it can be denied on causation grounds. The Board concluded that the employer did not act improperly in characterizing the denial of the medications as being due to causation and, therefore, it was not required to be submitted to Utilization Review. In conclusion, the Board denied the claimant’s motion to compel payment for the medication and indicated that claimant’s counsel would need to file a Petition to Determine Additional Compensation Due to pursue this issue further.

Case Law Alerts, 3rd Quarter, July 2014