Medical maintenance benefits can be terminated, even if from the 1980’s, where respondents prove no longer related to the injury.
A claimant is entitled to seek medical maintenance benefits post maximum medical improvement (MMI) if he or she shows that future medical treatment will be “reasonably necessary to relieve the claimant from the effects of the industrial injury” even though that treatment will not be received until sometime after the award of permanent disability. For maintenance benefits to be “related,” they must have an “inherent connection” to the work injury. Whether the requested continued maintenance care is related, reasonable, and necessary is a question of fact for the administrative law judge (ALJ).
In Schroeder, the Court was tasked with determining whether a Panel of the Industrial Claim Appeals Office (Panel) erred in affirming the ALJ’s denial and dismissal of post-MMI medical maintenance benefits from July 26, 2015 through the date of the hearing, November 15, 2017. In this case, claimant sustained admitted, compensable injuries in a fall at work in 1986. In 1989, a settlement was reached, resolving all issues but post-MMI medical maintenance benefits. The parties agreed that medical maintenance benefits would remain “open and available” to claimant. In 2017, claimant applied for a hearing seeking reasonably necessary benefits. The employer argued that any treatment received no longer related to her 1986 work injury.
To support its argument, the employer highlighted that in October of 2015, claimant was involved in a motor vehicle accident after which she complained of various pains which she associated with the motor vehicle accident. In addition, the employer offered an Independent Medical Examination (IME) report that opined after review of all the records that claimant’s current complaints were not attributable to the work injury of 1986. The ALJ found the IME’s opinions persuasive and credible, and that the “claimant’s present condition and need for medical care and treatment” was not caused by her industrial injury, and ordered that “all claims for post-[MMI] medical maintenance benefits after July 25, 2015 [date of hospitalization for back pain following the motor vehicle accident] are hereby denied and dismissed.” The Panel modified the order, limiting the denial of ongoing medical maintenance to the period from July 26, 2015 to the date of the hearing, November 15, 2017.
The Court of Appeals affirmed the Panel’s order denying medical maintenance benefits. The Court found that the evidence “amply supported” the ALJ’s factual findings and legal conclusions, and that the medical treatment claimant received between the July 26 date and the date of the hearing was unrelated to her 1986 work injury. There was no medical report or opinion connecting the treatment with her work injury, and as a result she was not eligible for medical maintenance benefits for the treatment she received during that time.
Claim Handling Tip: Send a request for updated medical releases and a list of medical providers pursuant to W.C.R.P. 5-4 (c) from time to time in older claims. This could uncover medical records from physicians other than those treating a worker for the work injury, which may provide an avenue to challenge ongoing care, regardless of the age of the claim.
Schroeder v. Indus. Claim Appeals Office, No. 18CA0952 (Colo. Ct. App. June 27, 2019)
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