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Pa. employers needn't notify comp claimants of utilization review: Court


Pennsylvania employers aren’t obligated to notify claimants when seeking utilization reviews of their treatment, the Commonwealth Court of Pennsylvania has ruled.

Richard Marek sustained an occupational injury to his back on July 17, 1995, that was described by his employer, Logistics Express Inc., as a “herniated nucleus pulpous,” entitling him to total disability benefits, court records show.

In the years following, when Mr. Marek returned to work, his total disability benefits were suspended. However, his benefits were reinstated each time he suffered a recurrence of symptoms related to his original injury, according to records.

Mr. Marek’s total disability benefits were most recently suspended in October 2003, and his petition to reinstate his benefits in January 2005 was later denied by a workers compensation judge. The judge said that while Mr. Marek wasn’t entitled to wage loss benefits, Logistics Express was still responsible for his medical expenses for his back injury, records show.

In December 2009, Mr. Marek filed a penalty petition alleging that Logistics Express was refusing to pay his medical bills because it was seeking a utilization review of his treatment, according to records.

Logistics Express said it asked a third-party to conduct the review in February 2008 and received a decision in April 2008 stating that Mr. Marek’s treatment was “reasonable and necessary,” records show.

Despite the utilization review being in Mr. Marek’s favor, he said it was “impossible for him to challenge the validity of the UR determination because neither he nor his counsel received a copy of this determination,” according to records.

However, the report indicated that it was mailed to all parties and the Pennsylvania Bureau of Workers’ Compensation in April 2008, records show. “Both the face sheet and the UR report suggest that (Mr. Marek) did have notice of the UR request, as they indicate that (he) submitted a statement to the (utilization review organization) noting that the treatment at issue allows him to cope with his pain and improves his quality of life,” according to court documents.

Apart from that finding, however, a workers compensation judge dismissed Mr. Marek’s penalty petition in April 2011, stating that there’s “no evidence in the record of any statutory or regulatory provision requiring an employer or its insurance carrier to serve a copy of the UR determination on a claimant and/or a claimant’s counsel.”

The Pennsylvania Workers’ Compensation Appeal Board agreed in October 2013, and on Wednesday a three-judge panel of the Commonwealth Court of Pennsylvania unanimously affirmed the order.

Mr. Marek limited his argument to Logistics Express’ “purported violation of the (Workers’ Compensation) Act for failing to serve him with a copy of the UR determination, which we have concluded is without merit,” the ruling states.

In a footnote, the Commonwealth Court states that, to date, Mr. Marek hasn’t “sought penalties with respect to (Logistics Express’) failure to pay his medical expenses after the URO ruled in his favor.”

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