45-day time limit for appealing Utilization Review Determinations is invalid.

In an important and long-awaited decision, the Delaware Supreme Court, in a 3:2 ruling, holds that the 45-day time limit for appealing an adverse Utilization Review Determination is invalid since it conflicts with the five-year statute of limitations on compensable claims.

This appeal involved three consolidated cases, and in each one, the claimants had suffered compensable injuries and the employers had challenged some of the medical treatment through the Utilization Review process. The Utilization Review Determinations found that portions of the medical treatment at issue were not compensable under the Healthcare Practice Guidelines. The claimants, through their counsel, filed petitions with the Board, and in each instance, those petitions were filed after the 45-day time limit for doing so. Accordingly, the Board dismissed each petition as untimely. On appeal to the Superior Court, it was held that the 45-day time limit was invalid since it conflicts with the five-year statute of limitations contained in §2361.

The Supreme Court discussed §2361 of the Act, which provides that, in open compensable claims, no statute of limitations shall take effect until the expiration of five years from the time of the making of the last payment of compensation. The Court noted that in prior decisions it has emphasized that the statute unambiguously provides that no statute of limitations shall take effect until five years from the last payment of compensation benefits. In contrast, the Court pointed out that the 45-day time limit for appealing Utilization Review Determinations is only a regulation that was adopted by the Department of Labor on the recommendation of the Health Care Advisory Panel. The Court reasoned that the broad language of the statute with the five-year limitation protects claimants from the preclusive effect of a regulation imposing a shorter time limitation. In essence, the Court held that, where, as here, a regulation conflicts with the statute, the statute must prevail. They rejected the argument advanced by the employers that the regulation did not foreclose all claims but only those specific claims dealing with the medical treatment being challenged.

The dissenting opinion pointed out that the majority holding gives a claimant five years to seek review of an adverse Utilization Review decision and contradicts the purpose of the Healthcare Practice Guidelines, which is the "prompt" resolution of claims, and also makes no practical sense in that there is no reasonable likelihood that a claimant's condition or the disputed treatment will remain static for five years. They also reasoned that there is an important difference between the statute of limitations in §2361 and a time limit on appealing a regulatory body's decision, which is what they viewed the 45-day time limit as being.

Case Law Alerts, 3rd Quarter 2103