Pennsylvania Supreme Court Backs Injured Workers on Prescription Costs
- The Pennsylvania Supreme Court ruled 5-2 on June 16 in 700 Pharmacy v. Bureau of Workers’ Compensation Fee Review Hearing Office that state workers’ comp law that bars doctors from referring patients to services they have a financial interest in does not extend to prescription drugs or pharmacy services.
- The ruling reversed a Commonwealth Court decision that had let an insurer refuse payment for a prescription because the prescribing physician held a financial interest in the dispensing pharmacy, closing a loophole insurers had used to deny or delay pharmacy bill reimbursement.
- The Workers’ Compensation Act’s Anti-Referral Provision remains limited to laboratory, physical therapy, rehabilitation, chiropractic, radiation oncology, psychometric, home infusion therapy and diagnostic imaging services, meaning insurers can no longer cite a physician’s financial stake in a pharmacy alone as grounds to deny prescription payment.
- Lancaster County law firm RG Injury Law, which represents injured workers across Central Pennsylvania in workers’ compensation disputes, says the ruling gives claimants with denied or disputed pharmacy bills new grounds to challenge those denials.
Court Upholds Denial of Worker’s Claim Due to Her Lack of Credibility
- The Commonwealth Court of Pennsylvania upheld the denial of a woman’s workers’ compensation Susquehanna Valley Nursing and Rehabilitation Center, finding that her testimony was “not credible” after a doctor had concluded she had not suffered a workplace injury.
- The woman said she was injured at work in November 2017 when she fell while helping transfer a patient resulting in neck and back pain, blurred vision, headaches and incontinence.
- The workers’ compensation judge credited the opinion of board-certified neurologist Dr. Howard Levin, who concluded she had not suffered a work-related injury, over contrary opinions from other physicians that the WCJ found relied largely on the worker’s own discredited account.
- On appeal, representing herself, the worker argued the WCJ ignored evidence and reached the wrong conclusions, but the court found substantial evidence supported the WCJ’s findings and that credibility and weight-of-evidence determinations are solely within the WCJ’s authority, not subject to reweighing on appeal.
Employer’s Knowledge of Concurrent Employment Key to AWW Calculation: Court
- An Illinois appellate court ruled that an employer’s knowledge a worker holds a second job is sufficient to establish concurrent employment for workers’ compensation average weekly wage calculations, even if the worker is furloughed and not earning wages from that second job at the time of injury.
- The woman injured her wrist in October 2020 while working for J-H Alliance, doing business as The UPS Store. She had also worked for Sunline Services, a company that supplied airport gate and ticket agents, but was on furlough from Sunline due to the COVID-19 pandemic at the time of her injury.
- An arbitrator and the Illinois Workers’ Compensation Commission initially found no concurrent employment, reasoning the employer didn’t know Collins was still a paid Sunline employee. The circuit court reversed, finding the evidence undisputable that the employer knew of her Sunline employment and that she remained available for recall.
- On remand, the Commission found concurrent employment and set Collins’ combined AWW at $757.67 and the appellate court affirmed, holding that a furlough — even one lasting many months — doesn’t sever the employment relationship for purposes of the Workers’ Compensation Act’s concurrent employment provision, so long as the worker remained available and intended to return to that job.