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Employees Can Recover Benefits for Treatment Not Indicated Under Massachusetts Workers’ Compensation Guidelines

If you are injured while performing the duties of your job, you are most likely entitled to workers’ compensation benefits. Under Massachusetts workers’ compensation law, you are only entitled to benefits that are reasonable and related to your injury. There are guidelines set forth as to what treatment is considered reasonable, and any deviation from the guidelines is presumed to be both unreasonable and inappropriate. In Thibeault’s Case, however, the Court of Appeals of Massachusetts held the presumption of unreasonableness can be overcome if the facts of the case indicate other treatment is acceptable.Legal News Gavel

In Thibeault, the employee was a heavy equipment operator, who injured his lower back moving a steel plate while working for his employer. He was diagnosed with discogenic back pain and a tear and disc bulge in the lumbar region. The employee underwent treatment for his back injury but declined to undergo surgery. He filed a workers’ compensation claim and received a lump sum settlement. The employee continued to get treatment from his primary care physician for his back injuries after he received the settlement. Part of the employee’s treatment included prescriptions for narcotic pain medication.

Subsequently, eight years after the employee received his lump sum settlement, he filed a post lump sum claim for medical benefits, which was denied. He then underwent an independent medical examination, after which the examining doctor issued a report and was deposed. The doctor stated, in part, that the employee suffered from chronic low back pain, which the employee was treating with medication. The doctor further stated that, although there did not seem to be any steps taken to reduce the dosage or wean the employee off the medication, continuing to treat with medication was reasonable, and the treatment was causally related to the employee’s workplace injury.

A hearing was held on the employee’s claim for post lump sum benefits, after which the administrative judge ruled in favor of the employee. The judge noted that while treating with medication was not the preferred protocol under the treatment guidelines, the doctor who performed the employee’s medical exam found the treatment to be reasonable and related to the original injury. The insurer appealed to the Department of Industrial Accidents reviewing board, which affirmed the administrative judge’s ruling. The insurer then appealed to the Appeals Court of Massachusetts.

On appeal, the insurer argued the administrative judge violated workers’ compensation laws by failing to consider the presumption of reasonableness of the treatment guidelines set forth by the Department of Industrial Accidents. As a result, the insurer argued the judge’s decision lacked factual support and was therefore arbitrary and capricious and should be dismissed. The Appeals Court disagreed and affirmed the decision of the reviewing board.

The court noted that the judge referenced the guidelines set forth by the Department of Industrial Accidents and acknowledged the fact that the employee’s treatment was not entirely consistent with the guidelines, but it adopted the examining doctor’s opinion that the employee’s treatment was nonetheless reasonable. The court stated that while a departure from the guidelines is presumed to be unreasonable, the presumption could be disproven if the facts of the case show a treatment that deviates from the guidelines is reasonable. The court found that even if there was a significant departure from the guidelines, the judge considered the testimony of both the employee and the examining doctor in finding the departure reasonable. As a result, the court held the judge’s decision was not arbitrary or capricious but indicated a reasoned decision based on factual support.

If you were injured at work, you may be entitled to workers’ compensation benefits. You should seek the assistance of an experienced workers’ compensation attorney in filing your claim. The workers’ compensation attorneys at Karsner & Meehan are skilled in assisting injured workers in recovering the benefits they are rightfully owed.  For a free, confidential consultation, contact our office at 508-822-6600.

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