Workers' Compensation Defense

NEWS

Elias Hassinger (Philadelphia, PA) will co-present at the 2023 Philadelphia Bar Association’s Bench-Bar & Annual Conference on September 22, 2023. In “Proper Identification of Pain Generators in Work Injuries/Personal Injuries and Novel Treatment Options,” Eli and the other panelists will explore proper identification of pain generators and novel treatment options and how they may affect the workers' compensation claim.

Michele Punturi (Philadelphia, PA) will co-present “Getting Caught with Your Hand in the Proverbial Cookie Jar” at this year’s ClaimsXchange in Philadelphia. In this presentation, the panel will discuss best strategies for investigating, uncovering, and deterring fraudulent acts while exploring methods to recover monies paid out to fraudulent actors. They will also examine how fraud impacts the claim value and how to counteract its debilitating effects. For more information, visit: https://www.theclaimsx.org/getting-caught-with-your-hand-in-the-proverbial-cookie-jar.  
 

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RESULTS*

Greg Bartley (Roseland, NJ) successfully defended a case involving the cancellation of a workers’ compensation policy. The case involved a company that had failed to pay their insurance premium on its workers’ compensation policy. The carrier notified the insured company that the premium had not been received and that the carrier was taking the necessary steps to cancel the policy. The carrier complied with rules for policy cancellation pursuant to the New jersey Department of Labor. The case involved a worker who was injured on the day after the policy was cancelled. The company, on the day after the worker’s injury, electronically paid the premium. The day following receipt of the policy premium, the carrier issued a new policy covering the company. When given notice of the claim, the carrier denied it based upon the cancellation of the policy. The petitioner filed a claim petition, alleging that the failure to pay the premium should not deny him coverage, as the payment of the premium and subsequent issuance of the new policy amounted to a mere lapse in coverage and the carrier’s acceptance of the premium should result in the coverage being reinstated as of the date of cancellation, not the date of the new policy. After numerous hearings over more than two years and two judges, who supported the position of the petitioner, Greg argued the case with all parties present. The court agreed that the cancellation was legally effective and, therefore, entered an order of dismissal as to the carrier.

Ben Durstein (Wilmington, DE) was successful in having the Delaware Superior Court affirm the Industrial Accident Board’s decision that the employer correctly paid for ketamine infusion treatments. The Board had found that these treatments were properly paid pursuant to the Delaware Workers’ Compensation Fee Schedule. The court rejected the claimant’s argument that Section 2322(b) of the Workers’ Compensation Act required a higher payment for the “reasonable cost” of the treatment.

Adam Huber (Mount Laurel, NJ) successfully obtained orders for dismissal with prejudice on two Medical Provider Applications. Two separate New Jersey medical providers alleged they were entitled to additional money for medical treatment provided in New Jersey to a New Jersey resident. Each provider claimed that, because the injured worker who received the treatment was a current resident of New Jersey and treatment was rendered in New Jersey, that provided sufficient contact for the court to exercise jurisdiction for a Medical Provider Application and bills should be paid at a usual and customary rate, as opposed to New York’s fee schedule. The worker’s compensation claim that resulted in the Medical Provider Applications was a New York claim, with no New Jersey contacts for the parties at the time of the injury. The injured worker only later moved to New Jersey and received medical treatment with New Jersey providers, who were then paid per the New York fee schedule. The providers’ billed amounts were $221,591.55, $6,157.50, and $6.157.50 for three dates of service. The employer made payments in the amount of $55,488, $1,401.83, and $740.42, respectively, per the New York fee schedule. Adam successfully argued to the court that, because it would not have been able to exercise jurisdiction over the underlying worker’s compensation claim, it would not be able to exercise jurisdiction over the two resulting Medical Provider Applications. Therefore, the providers could not seek additional money in New Jersey based on its usual and customary standard, as opposed to New York’s fee schedule. This saved the employer up to $176,276.30 in potential medical payments. Both Medical Provider Applications were dismissed with prejudice.

William Murphy (Roseland, NJ) successfully obtained orders for dismissal with prejudice where two New Jersey medical providers alleged they were entitled to additional monies for medical treatment provided in New Jersey to a New Jersey resident. The underlying accident involved a truck driver who resided in New Jersey, regularly worked in New Jersey, but sustained injuries in Massachusetts. While the injured worker initially filed a New Jersey workers’ compensation claim, he subsequently opted to pursue his claim in Massachusetts, in part, because Massachusetts allowed him to select his own treatment providers (unlike New Jersey, where the employer designates the treatment providers). Each provider claimed that, because the injured worker was a resident of New Jersey, worked in New Jersey and treatment was rendered in New Jersey, there was sufficient contact for the court to exercise jurisdiction for a Medical Provider Application. As such, they claimed their bills should be paid at New Jersey’s standard of a usual and customary rate, as opposed to Massachusetts’s fee schedule. The providers’ billed amounts were $173,927.52 and $128,088.00. The employer made payments in the amount of $13,872.87 and $7,149.01, respectively, per Massachusetts’ fee schedule. William successfully argued to the court that, because the injured worker had opted to pursue a Massachusetts workers’ compensation claim and had selected these medical providers pursuant to said claim (as a New Jersey claim would have required employer-approval), the payment of these medical providers should be governed by Massachusetts’ workers’ compensation system. Therefore, the providers could not seek additional money in New Jersey based on its usual and customary standard, as opposed to Massachusetts’ fee schedule. This saved the employer up to $280,993.64 in potential medical payments. Both Medical Provider Applications were dismissed with prejudice.

Tony Natale (Philadelphia, PA) successfully defended a claimant’s reinstatement and review petitions and prosecuted the employer’s termination petition. The claimant sustained traumatic injuries when the vehicle he was operating was targeted for collision by a mentally disturbed individual trying to commit suicide. The claim was accepted as compensable, and eventually, the claimant was able to return to work full duty. Nine years later, the claimant alleged his right to reinstatement to total disability and payment of medical bills that quizzically were not submitted to the carrier but were paid, in part, by a personal health carrier. The claimant was also pursuing Heart & Lung benefits, and the township’s bargaining agreement allowed the H&L claim to be governed by the ruling in the workers’ compensation claim. Both sides submitted expert evidence on the issues of full recovery and recurrence of disability and factual evidence on the payment of medical bills. The court found in the favor of the employer on all issues. 

Tony Natale (Philadelphia, PA) successfully prosecuted a termination petition involving a knee injury where claimant’s job duties required him to fill a basket with mushrooms, pivot or sidestep and dump the basket into a slicer machine. During his course and scope of employment, it was judicially determined that he sustained injuries in the form of meniscal tears of the knee and the rather vague “injury” of patellar subluxation. On cross examination of claimant’s medical expert, Tony forced him to admit that the meniscal tears had fully recovered. As for the subluxation, Tony exposed the fact that the expert did not diagnose such a condition in the medical treatment notes but, instead, referred to a “chondromalacia” condition that was NOT judicially part of the work injury. The claimant’s medical expert went as far as to indicate on cross examination that the claimant remained totally disabled from his pre-injury job, even though Tony forced him to admit that he had no idea of the claimant’s pre-injury job. 

Robin Romano (Philadelphia, PA) successfully defended the claimant’s petition to review to add a right hip injury. The claimant had already succeeded in having a claim petition granted that acknowledged the left hip and left hip surgery. The Workers’ Compensation Judge carefully considered the testimony of both medical experts. Importantly, the judge rejected the claimant’s surgeon’s testimony, which found a causal relationship between the right hip and the work injury. Robin presented the defense medical expert, who credibly testified that the mechanism of the original injury would not have caused a right hip injury and, also, that an altered gait, suffered by claimant as a result of the accepted left hip surgery, did not lead to a right hip injury or aggravation of what was clearly pre-existing osteoarthritis. 

Michael Sebastian (Scranton, PA) successfully defended a claim petition alleging a specific loss of the right eye from being hit in the eye with the top of a box. The Workers’ Compensation Judge rejected the claimant’s expert’s testimony that the macular scar, which is in the back of the eye, was caused by the work injury and believed the defense expert, who opined there was insufficient force from the top of the box to cause the injury to the back of the eye. The defense expert testified that the claimant’s loss of vision was unrelated to the work event because the claimant did not have any visible damage to the front of the eye at the time of the accident and that there are dystrophies that can cause macular degeneration in one eye. 

*Prior Results Do Not Guarantee a Similar Outcome
 

_{What’s Hot in Workers’ Comp, Vol. 27, No. 9, September 2023, is prepared by Marshall Dennehey to provide information on recent legal developments of interest to our readers. This publication is not intended to provide legal advice for a specific situation or to create an attorney-client relationship. We would be pleased to provide such legal assistance as you require on these and other subjects when called upon. ATTORNEY ADVERTISING pursuant to New York RPC 7.1 Copyright © 2023 Marshall Dennehey, all rights reserved. No part of this publication may be reprinted without the express written permission of our firm. For reprints or inquiries, or if you wish to be removed from this mailing list, contact tamontemuro@mdwcg.com.}