AI Generated Opinion Summaries

This summary was computer-generated without any editorial revision. It is not official, has not been checked for accuracy, and is NOT citable.

Facts

• The Worker suffered injuries from a work-related automobile accident and filed a workers' compensation claim in 2011. Following a 2012 order for the Employer/Insurer to pay indemnity benefits, the Worker experienced repeated denials of medical benefits between 2013 and 2015, leading to multiple applications for bad faith and unfair claims processing. In June 2018, a settlement agreement was reached, mandating the Employer/Insurer to approve all care requested by the Worker's authorized healthcare provider within fourteen days. The Worker filed another application for bad faith and unfair claims processing in 2019, alleging non-compliance with the 2018 order by the Employer/Insurer (paras 2-4).

Procedural History

• [Not applicable or not found]

Parties' Submissions

• Worker-Appellant: Argued that the Employer/Insurer violated the terms of the 2018 order by failing to timely authorize medical care and denying care without seeking a requisite order from the Workers’ Compensation Judge (WCJ) (para 4).
• Employer/Insurer-Appellees: Contended that the denied medical care was not causally related to the work injuries and argued that the 2018 order did not require them to file an application when denying a claim on these grounds (para 5).

Legal Issues

• Whether the Employer/Insurer had a reasonable basis to deny the requested medical care without following the procedure set forth in the 2018 order (para 7).
• Whether the WCJ erred in denying an investigation into the attorney fees paid to Employer/Insurer’s counsel (para 14).

Disposition

• The Court of Appeals reversed and remanded for reconsideration of the Worker’s bad faith and unfair claims processing claims, disagreeing with the WCJ's conclusion that Employer/Insurer had a reasonable basis for denying medical care without following the 2018 order's stipulated procedure (para 13).
• The Court affirmed the WCJ’s decision to deny an investigation into Employer/Insurer’s payment of attorney fees (para 15).

Reasons

• The Court, comprising Judges Megan P. Duffy, Zachary A. Ives, and Shammara H. Henderson, found that the 2018 order explicitly required the Employer/Insurer to approve requested care within fourteen days and to file an application with the WCJ, including medical evidence, before denying any requested medical care. The Court disagreed with the Employer/Insurer's interpretation that the order did not apply to denials based on causation, emphasizing that the order's terms necessitated compliance regardless of the denial's basis. The Court also noted that by agreeing to the 2018 order, the parties implicitly acknowledged that the requested care was causally related to the workplace accident. Regarding attorney fees, the Court pointed out that the authority to investigate overpayment lies with the Workers’ Compensation Administration and the enforcement bureau, not the WCJ, and affirmed the WCJ's decision based on the lack of substantial evidence presented by the Worker to support her claim (paras 9-15).