Case Study: When Workers Comp Insurance Stops Paying for Medical Care
Updated: Dec 8, 2019
Souligny v. PB&J, Inc - State of Vermont
In many workers compensation cases, chiropractic treatment is recommended. Because of the nature of chiropractic care, however, workers comp insurance companies can try to get out of covering the costs of the treatment, particularly after several years have gone by. This issue was addressed in a recent case here in Vermont, Souligny v. PB&J. (You can read the decision here.)
This case was about whether the Vermont workers compensation insurance company had to continue to pay the medical bills for chiropractic palliative care. In this case, the insurance company had filed a Form 2 denial refusing to pay for ongoing chiropractic treatment for a back condition. The insurance company had paid for chiropractic treatment, but after several years of treatment argued that chiropractic care was no longer “reasonable” treatment for a chronic back condition.
When Does Workers Comp Insurance Have to Pay the Bills?
The workers compensation insurance company only has to pay for medical benefits that are “reasonable and necessary” and “related to the injury.” In determining what is “reasonable” treatment, the decisive factor is not what the claimant desires or what he or she believes to be the most helpful. Rather, it is what is shown by competent expert evidence to be reasonable to relieve the claimant's symptoms and maintain his or her functional abilities
What is Palliative Medical Care?
There are different types of medical care, including diagnostic, curative, and palliative. Palliative care is care that relieves pain and helps the patient remain functional. Palliative care is the care given after a patient reaches a medical end point [link to explanation of medical end on the temporary benefits page]. Palliative care does not include medical care rendered to diagnose, heal or permanently alleviate a medical condition. Common types of palliative care are prescription medication and physical therapy. Chiropractic treatment can qualify as compensable palliative care if it alleviates the patient's pain symptoms.
In this case, the claimant had been receiving treatment from a chiropractor for several years. The workers comp insurance company had the claimant evaluated by two IME doctors. The first IME doctor, Dr. Nancy Binter, concluded that ongoing chiropractic care was not an appropriate treatment for chronic back pain because there aren’t medical studies supporting it, and because the treatment is passive and results in decreasing muscle strength. The other IME doctor, Dr. Rudolf, concluded that long-term chiropractic care was not in Claimant's "best interests."
Was the Chiropractic Treatment “Reasonable and Necessary?”
The Vermont Department of Labor (“DOL”) rejected Dr. Binter’s opinion because there was only one study showing that chiropractic care was ineffective, and because she never considered whether the chiropractic care decreased claimant’s pain or increased claimant’s functional ability. The DOL rejected Dr. Rudolf’s opinion because he failed to describe in what way it was detrimental to claimant, and did not explain why the short-term pain relief Claimant derived from chiropractic care was any appropriate than the short-term relief provided by pain medications or a TENS unit, which are accepted palliative treatments. The DOL accepted the testimony of the claimant, and her primary care physician and chiropractor that long-term chiropractic treatment helped reduce pain and keep claimant functional.
This case ruled that where the chiropractic treatment provided sufficient pain relief to allow claimant to maintain current level of function as to activities of daily living (claimant was not working), the palliative benefits justify its continuation. Testimony of the chiropractic doctor overcame the contrary testimony of two expert back surgeons who testified there wasn’t scientific support for ongoing chiropractic treatment.
THE BOTTOM LINE: What Does This Case Mean for You as an Injured Worker?
When it comes to palliative care (medical treatment after reaching medical end), if you and your doctor can show that the care helps reduce your pain and maintain or improve your functional ability, then the insurance company should keep paying for it.
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