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

• A worker was injured at work when a forty-pound box fell on her neck and shoulder. She reported the injury to her supervisor, who directed her to seek medical care from a specific provider, which the employer regularly used. The worker received treatment and was released with restrictions. The employer's third-party administrator sent a letter to the worker, stating that the employer had decided to allow the worker to choose the initial health care provider (HCP). The worker continued treatment with the initially directed provider and was later referred to another doctor for further evaluation. The employer then attempted to change the worker's HCP, claiming the right to the second HCP selection under the Workers’ Compensation Act. The worker objected, arguing that the employer had made the initial selection by directing her to the first medical provider on the day of the accident and contended that the notice allowing her to choose an HCP was untimely and improperly sent by an administrator (paras 2-4).

Procedural History

• Workers’ Compensation Judge, June 6, 2017: The judge determined that the third-party administrator could notify the worker of the employer's decision regarding the initial HCP selection. However, the notice given was not valid as it did not accurately reflect the employer's initial direction to the worker to seek care from a specific provider. The judge held that the employer had elected to initially direct the worker's medical care but concluded that the period prior to the hearing was not a selection by either party (para 5).

Parties' Submissions

• Worker: Argued that the employer had made the initial selection of HCP by directing her to a specific medical provider on the day of the accident. Contended that the notice was legally insufficient because it was untimely and sent by an administrator, not the employer directly (para 4).
• Employer: Argued that the notice given to the worker was valid and timely, and that the employer maintained the right to investigate the worker’s claim before making a decision on the HCP selection (paras 16-21).

Legal Issues

• Whether a third party may provide written notice on behalf of an employer regarding the initial selection of a health care provider under New Mexico’s Workers’ Compensation Act.
• Whether the employer’s notice was timely pursuant to Section 52-1-49(B) of the Act.
• Whether, in the absence of timely written notice, the employer is deemed to have made the initial HCP selection under Section 52-1-49(B) (para 11).

Disposition

• The court held that notice is valid when sent by a third-party administrator on behalf of an employer.
• The notice in this case was deemed untimely.
• As a result, the health care provider providing the initial, non-emergency care is considered the employer’s initial HCP selection under Section 52-1-49(B).
• The Workers’ Compensation Judge’s order to the contrary was reversed, and the case was remanded for further proceedings (para 1).

Reasons

• The Court, per Judge Duffy, with Judges Attrep and Zamora concurring, reasoned that:
  Insurers and administrators may send written notice of an employer’s decision regarding the initial selection of HCP. The regulation allows for such notice by any method reasonably calculated to notify workers, including through third-party administrators (paras 12-15).
  The employer’s decision regarding the initial selection of HCP was not made within a reasonable time. The court found that a twenty-seven-day delay was not reasonable, especially given the employer's prompt actions in other aspects of the worker's claim. The employer did not provide a factual basis for the delay (paras 16-21).
  Employer is deemed to have made the initial selection of HCP under Section 52-1-49(B) because it failed to provide written notice of its decision within a reasonable time. Consequently, the first non-emergency HCP must be considered the initial HCP, attributed to the employer's selection (paras 22-26).