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Insurer must pay for medical treatment, but not at full cost

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The Idaho Supreme Court ruled that an injured worker has to be reimbursed for medical treatments that were later deemed compensable by his employer's workers compensation insurer, but only at the state’s fee schedule rate.

Preston, Idaho resident Thomas C. Millard was injured in an accident in October 2006 while working for Perry, Utah-based Abco Construction Inc. The accident rendered him totally and permanently disabled with back, extremity, neck and shoulder pain, as well as a traumatic brain injury, according to court filings.

Mr. Millard filed for workers comp benefits, and the Workers Compensation Fund of Utah originally handled his claim, court records show. However, once the case entered litigation, Mr. Millard's claim was managed by Boise, Idaho-based third-party administrator Pinnacle Risk Management Service.

He originally settled his claim with a lump sum agreement that left open medical care and related charges, according to court records. 

His ongoing care included epidural injections between October 2012 and October 2014 and physical therapy treatments from late August 2011 through December 2011. However, Mr. Millard's visits were unauthorized by his employer and Pinnacle between October 2012 and October 2013, as they were unaware of the treatments, and they declined to pay for treatments provided during that time.

Mr. Millard argued that he was entitled to workers comp medical payments for that time period, according to court records. He also argued that he should be reimbursed for the full rate he paid for medical services during that time, rather than at the rate of the Idaho workers comp medical fee schedule.

The Idaho Industrial Commission ruled that Mr. Millard had failed to provide reasonable medical care to Mr. Millard from October 2012 and November 2013, and required that Mr. Millard be reimbursed for his medical treatment. The commission also found that Mr. Millard should be reimbursed for the full cost of his epidural injections up until November 2013, but that his physical therapy and epidural injections after that period should be reimbursed at the Idaho fee schedule rate. Mr. Millard appealed.

The Idaho Supreme Court unanimously upheld the commission’s ruling on Wednesday.
Idaho case law says workers comp insurers are "liable for the full invoiced amounts of a worker’s medical bills when ... the surety denies a claim and ... that claim is subsequently deemed compensable."

However, the high court found that not all of Mr. Millard's claims met that two-part test because some of them were not denied, only delayed in payment, and some were not deemed compensable by Abco and its insurer.

The "Commission is affirmed due to the fact that the Commission never deemed the 2011 physical therapy sessions or the 2013 to 2014 injections compensable, and not due to the fact that Surety had paid the bills before the Commission issued its decision," the ruling reads.