Employer’s claim denial opened door to out-of-network costs

A teacher who injured her back at work and who had surgery out of state and out of her employer’s network is due compensation for her surgery because the school district had originally denied her claim, the Supreme Court of South Dakota unanimously ruled Wednesday.   

In reversing an earlier Circuit Court decision, the state’s highest court said that the Rapid City School District’s original position that Melissa Dittman’s claim from a 2017 back injury was not compensable opened the door for her to seek care that happened to be outside of their network, in this case by a doctor in Vail, Colorado, to whom her doctor referred her, according to Melissa Dittman v. Rapid City School District and Dakota Truck Underwriters, filed in Pierre.  

State law had made the district and its workers compensation insurer potentially liable for the expense of an out-of-network provider if compensability had been denied, according to the court. A judge in the previous ruling stated the regulation didn’t apply because the school district and insurer didn’t deny compensability in their amended letter decision to Ms. Dittman’s lawsuit. 

Yet the state Supreme Court held the original decision to deny the claim to task: “The initial answer can only be read as a denial by Employer/Insurer that Dittman’s injury was compensable… Long after Employer/Insurer denied compensability and the referral occurred, the (South Dakota Department of Labor and Regulation) allowed Employer/Insurer to amend their answer and accepted their assertion that they had never denied compensability.”