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Massachusetts Appeals Court Upholds Reimbursement Award to Injured Employee

Injured employees may receive compensation beyond the emergency room bill and calculated wages under the Workers’ Compensation Act. They may also receive payments for prescriptions and therapies for persistent medical conditions. In Magraf’s Case (16-P-364), the appellate court reviewed an award of prescription drug coverage and reimbursement for medical appointments under G. L. c. 152, §§ 13(1) and 30 following a lump sum settlement for an injury. Prescription PillsThe insurer raised an affirmative defense that the employee had a pre-existing condition, but the Administrative Law Judge chose to order payment anyway, citing the opinions provided by the Independent Medical Examiner (IME). The Reviewing Board upheld the ALJ’s determination, and the following appeal ensued.

The existence of a pre-existing condition does not prevent compensation for a work injury. Massachusetts’ General Laws allow for the compensation of an injury as long as the work injury was a major cause of the disability. It does not have to be the predominant cause of the disability. An employer or insurer may raise a pre-existing condition as an affirmative defense to the payment of benefits, but they bear the burden of showing the pre-existing condition is not covered. When assessing the Reviewing Board’s decision, the Appeals Court looks at whether or not the decision was supported by substantial evidence, whether or not the Board made an error of law, or whether the Board issued a decision that was arbitrary and capricious.

The insurer argued that the ALJ failed to make findings regarding the nature of the injured worker’s pre-existing condition. The ALJ felt the issue of causation had been fully litigated and satisfied by the lump sum agreement. To avoid re-litigating causation, the court ruled the insurer must meet a new burden of production. The Board agreed with the judge’s assessment, determining that the judge rightfully adopted the IME’s opinion that the work injury was still a major cause of the injured worker’s disability and need for treatment.

The appellate court backed both the Board and the ALJ, finding there was no error in the ALJ’s credit of the IME’s testimony. The appellate court felt the IME’s opinion was supported by the requisite finding of the ALJ and met the injured worker’s heightened standard to show the work injury was a major cause of the disability. The Board and the ALJ’s rulings ordering the payment of benefits to the injured worker were affirmed.

The Massachusetts workers’ compensation attorneys at Karsner & Meehan can help you through the benefits process. Whether prescriptions, mental health, or physical therapy, you deserve the help to pay for the treatment you need.  Our attorneys and staff will tirelessly work to maximize any available awards. Call our office today at 508.822.6600 to schedule a free, confidential consultation.

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