A Virginia employer cannot assert that an injury is unrelated to a workplace accident while also arguing that the medical care for that injury is unauthorized; instead the employer must choose one or the other position, the Virginia Workers’ Compensation Commission (VWCC) recently ruled.
The ruling blocked an employer and its insurer in their attempt to deny workers’ compensation coverage for psychological treatments sought by a physically-injured employee.
“If the employer wishes to challenge causation, that defense renders moot a question of authorization of treatment. Conversely, if the employer wishes to contest authorization, this necessarily admits causation exists between accident and injury,” is how the VWCC described the situation.
The case involved an employee who received medical and disability benefits for a back injury sustained in a work-related auto accident but was later denied coverage for psychological treatment related to the injury. A deputy workers’ compensation commissioner allowed the man’s claim for psychological care and the three-member VWCC panel has now upheld that ruling on an appeal by the employer and insurer.
The employer, an investment firm, and its insurer, Hanover American, first maintained that the psychological injuries were not causally related to the back injury and denied the claim. They also argued that the treatment from the particular psychologist who saw the worker was unauthorized.
After the deputy commissioner advised them that they could not argue that the psychological problems were causally unrelated to the accident and concurrently contend that the doctor’s treatment was unauthorized, the employer withdrew the causation defense and proceeded by contending the claimant sought unauthorized medical care.
The employer disputed responsibility for the cost of the psychologist’s treatment, citing the worker’s failure to obtain a referral for psychological care from the physician who was treating him for the back injury. The worker admitted that he did not discuss his anxiety or other psychological problems with the physician treating his orthopedic injuries because mental health was not that doctor’s specialty.
Under Virginia law, when a claimant sustains a compensable injury, the employer is required to “furnish or cause to be furnished, free of charge to the injured employee, a physician chosen by the injured employee from a panel of at least three physicians selected by the employer and such other necessary medical attention.” The worker maintained, and the deputy commissioner agreed, that because the employer offered no panel, the worker could select his own mental health provider, and the defendants were responsible for payment.
The VWCC agreed, finding there is no rule that a claimant must obtain a referral from an authorized treating physician to obtain treatment for an injury for which the employer denies responsibility. “Failing to offer a panel is equivalent to a refusal to provide medical treatment” and “where an insurer denies liability and refuses to pay compensation, the claimant is entitled to choose his own physician,” the commission decided.
On appeal, the employer and insurer argued the deputy commissioner erred by not allowing them to plead as alternative defenses an absence of causation between the psychological treatment and the accident and that the psychological treatment was unauthorized. They maintained that by compelling them to elect between causation and authorization of treatment, the deputy commissioner “improperly struck a legitimate contest to their obligation to pay for the disputed care.”
The VWCC disagreed. “An employer’s challenge to an injury’s causal relationship to a compensable accident is manifestly a denial of responsibility for the cost of treatment for that injury. Allowing the employer to concurrently deny causation while insisting the claimant receive care from an authorized physician would sanction the employer’s refusal to pay while enabling the employer to dictate where the claimant secures medical treatment. Consequently, an employer is justly compelled to make the election between the two defenses,” the VWCC stated in upholding the deputy’s ruling and the worker’s claim.
Although the deputy commissioner did not rule on causation, the VWCC found that the evidence established that the psychological injuries were related to the industrial accident. The medical records state the worker was experiencing significant distress due to the work-related automobile collision. He testified that he began experiencing anxiety and flashbacks relating to the accident, which led him to seek psychological treatment. The employer did not submit any evidence disputing that the accident caused his current psychological problems.
Topics Auto Workers' Compensation Talent Personal Auto Virginia
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