Employer refusing to pay for medical treatment causally related to work injury, without explanation or requesting UR, subject to penalties imposed at discretion of judge.

The claimant filed a penalty petition alleging the employer violated the Act by failing to pay for numerous Therapeutic Magnetic Resonance (TMR) treatments, from May 2008 through June 2009. The petition was assigned to a workers' compensation judge, who held one hearing and told the parties they had three months to submit their evidence and briefs. The claimant submitted HCFA billing statements sent to the employer, along with medical reports documenting his condition and response to the treatments. Also offered by the claimant were denial letters from the employer. The employer objected to the documents as hearsay, but the workers' compensation judge overruled the objection. The employer presented no evidence in defense of the penalty petition and did not submit a brief.

The workers' compensation judge granted the penalty petition, finding the employer had refused to pay some bills without explanation. The total outstanding balance of unpaid medical bills was $140,876, and the workers' compensation judge assessed a 50% penalty. The judge's decision was affirmed by the Appeal Board.

On appeal, the Commonwealth Court rejected the employer's argument that the penalty petition should have been denied because the claimant's documentary evidence was legally insufficient to prove a violation of the Act. The court cited numerous cases supporting the submission of medical bills and reports where litigation involves medical expenses, making medical reports admissible regardless of the length of disability. The court also rejected the employer's argument that the claimant failed to prove the TMR treatment was reasonable and necessary, or reasonable in cost, and that the claimant failed to prove that the treatment was related to the injury because the claimant did not present medical evidence that the treatment was "generally accepted in the medical community." The court pointed out that the injury was to the claimant's left knee and that the treatment was for the left knee injury. The court also pointed out that the employer did not submit the bills for utilization review. The court also rejected the employer's argument that they were denied due process rights by the workers' compensation judge and that the 50% penalty was excessive. The employer did not meet the deadline for presenting evidence given by the judge, and the judge was empowered to assess a penalty of up to 50% for violations involving "unreasonable or excessive delays."

Case Law Alert - 1st Qtr 2012