The Legal Doctrines: How Would You Decide?

Here's What Happened: (While this is a case arising out of Pennsylvania, workers' compensation legal doctrines are generally consistent throughout the country.  Use your own experience and knowledge of legal doctrine and Florida law and see if you can predict the Pennsylvania result!)

James Heffernan injured his lower back in July 2002.  After five years of continuous treatment and disability, in 2007 he was found unresponsive in his bed with a box of fentanyl patches in his hand.  A forensic pathologist's report stated that Mr.Heffernan "died from drug intoxication due to an overdose of fentanyl prescribed for his work injury.”

That same year Mr. Heffernan's daughter, Casey Lynn Heffernan, filed a workers comp claim alleging that her father died of multiple drug intoxication.  The employer denied Ms. Heffernan's claim.  Why? 

It seems that Mr. Hefferman's employer had filed a utilization review request in 2006 to investigate the appropriateness of the claimant's treatment.  The doctor who conducted the utilization review opined that all treatment provided to Mr. Heffernan by his treating physician, Dr. George L. Rodriguez, - including multiple prescriptions for Docusate, Fentanyl, Oxycodone, Fentora, Lyrica and Sonata - was neither reasonable nor necessary.

While the utilization review was conducted only as to the treatment by Dr. George Rodriguez, evidence also indicated that Hefferman had also had been treated and prescribed identical drugs by Dr. Rodriguez's sister, Dr. Daisy Rodriguez.

In 2009 a workers comp judge granted the claimant's request for benefits, finding that the claimant's death was causally related to an accidental overdose of pain medications, primarily fentanyl, that were prescribed for the work-related back injury.

The employer, J.D. Landscaping, appealed, arguing that the judge erred in granting the claim because the man died as a result of an accidental overdose of prescription pain medications found by a utilization determination to be neither reasonable nor necessary.

Appellate Courts Render Their Decision: The Workers Compensation Appeal Board affirmed the workers' compensation judge's ruling by finding that the utilization review finding applied only to treatment rendered by Dr. George Rodriguez.  As an aside, the Appeal Board also found that it was the treating doctor's sister, Dr. Daisy Rodriguez, who had prescribed the medications that caused the man's death.

Not taking "No" for an answer, the employer again appealled...this time to Pennsylvania's Commonweath Court, arguing that the utilization review determination should also apply to Dr. Daisy Rodriguez's treatment because it was she who wrote prescriptions identical to those issued by her brother.

The Commonwealth Court disagreed.  It ruled unanimously that the utilization review determination concerned only issues of reasonableness and necessity, and that these issues were irrelevant in determining whether Mr. Heffernan's death was causally related to his work injury.

Florida Work Comp and the Legal Doctrines: Sometimes I wonder who is making the decisions to appeal cases.  Certainly the decisions to appeal in this case must have been made by an "unsophisticated" employer vs. a savvy TPA or traditional carrier.

This is a case that simply follows traditional legal doctrine.  It doesn't matter if the injured employee receives bad or inappropriate treatment, general work comp law holds that the consequences of that treatment will be compensable.  How many bad surgeries by bad doctors have left injured employees totally disabled?  How many times have doctors amputated the wrong leg or foot and we still have to pay for the consequences?  And how many times have injured employees found themselves addicted to drugs and the employer/carrier has to pay for detox or other treatment?  Traditional legal doctrines holds the above case totally compensable, notwithstanding the matter of inappropriate treatment.

Don't get this confused with "unauthorized" treatment.  That's another issue entirely.  The care involved in this case was authorized.  Until the carrier does something to "deauthorize" the treatment, if it's possible, it will be responsible for the consequences.

Yet the importance of this case is not just making the right decision on whether to accept compensability up front and not wasting thousands of dollars in legal expenses and increasing the loss of a deceased employee's dependents through unnecessary litigation...when they are going to win in the end.

What is more important is the unnecessary and inappopriate issuance of narcotic drugs in the first place!  Did Mr. Hefferman's employer take the information it received from the Utilization Review and try to reason with the Drs. Rogriguez?  Did the employer take any action to have the doctors' treatment disallowed?  Misuse, intential or accidental, of prescription drugs has become a leading cause of death in this country, and the workers' compensation line of business is one of the greatest beneficiaries of this fact.

Lesson Learned:  Remember the doctrines.  Imaging how much expense, not to mention that years of angst in Mr. Hefferman's daughter's life would have been avoided if the employer had just done "the right thing" initially.

And one final thing: Take seriously the threat of inappropriate treatment with narcotic medications, and engage doctors and nurses to influence treating physicians to pursue other means of healing an employee's injuries.  It could be a matter of life...or death!

James W. Greer, CPCU
President, AE21 Incorporated & AE21 Online
Executive Director, WCCP