Failing to serve the claimant with a copy of a utilization review determination does not violate any provision of the Act.

The claimant filed a penalty petition alleging the employer violated the Act by unilaterally ceasing payment of medical bills for a work injury. The claimant was requesting penalties because the carrier was advising that they would not pay because of a favorable UR which the claimant was unable to locate. At a hearing on the penalty petition, the employer submitted into evidence a UR packet which included a UR request, a UR determination face sheet and a UR report. The UR request properly identified counsel for the claimant. The UR determination face sheet identified the name and address of the claimant, but not the claimant’s counsel. The UR report and face sheet also suggested the claimant had notice of the UR request, since the claimant submitted a statement to the URO regarding the treatment in question.

The Judge denied the penalty petition, concluding that the employer did not violate the Act because there was no evidence of any statutory or regulatory provision requiring an employer or its insurance carrier to serve a copy of a UR determination on a claimant and/or a claimant’s counsel. The Appeal Board affirmed on appeal, and so did the Commonwealth Court. The court held that §127.476 of the Medical Cost Containment Regulations imposes no service requirement on the employer and that the plain language of the section imposes the requirement on the URO to serve the determination on all parties.

Case Law Alerts, 4th Quarter, October 2014