Case Summaries

January 22, 2014

Utilization Review:

 

Leventakos v WCAB (Spyros Painting), __ A.3d __ (Pa. Cmwlth., No. 2156 C.D. 2012, filed December 5, 2013).

 

A WCJ lacks jurisdiction to hear a UR Petition, where the physician under review fails to provide the required medical records to determine whether the treatment under review is reasonable or necessary.

 

In Leventakos, the employer filed a utilization review request, seeking a review of treatment the claimant received in Greece. In response to a request for medical records, the physician under review submitted a summary, although he had been told that a summary would not be considered in lieu of records. The summary was not sent to the utilization reviewer. The physician participated in a telephone conversation with the reviewer and advised that there were no medical records documenting his treatment of the patient. The utilization reviewer concluded that none of the treatment under review was reasonable or necessary due to the lack of documentation.

 

The WCJ denied the UR Petition filed by the claimant on the basis that she lacked jurisdiction since the physician had failed to submit any medical records to the URO.
The Commonwealth Court agreed, finding that the neither the summary provided by the doctor nor the telephonic conversation constituted a “record.” There was no exception although the physician was a Greece and claimed that it was “foreign convention” that medical records were not maintained.

 

 

Set-Aside Final Receipt/Supplemental Agreement:

 

Kraeuter v. WCAB (Ajax Enterprises, Inc.), __ A.3d __ (Pa. Cmwlth., No. 457 C.D. 2013, filed December 19, 2013).

 

A WCJ may set-aside a Final Receipt after the three year limitations period, where the claimant proves that the final receipt was obtained by fraud, intentional or unintentional deception or other improper action by the employer. Where the insurer gives a final receipt to a claimant known to be receiving ongoing medical care, this constitutes fraud sufficient to set aside a final receipt beyond the three year period of Section 434. Where the insurer also prepares a final receipt, knowing that the claimant is still disabled and the claimant signs it, without knowing the significance of the final receipt, also constitutes fraud sufficient to set aside a final receipt beyond the three year period of Section 434.

 

Where a claimant does not challenge a Notification of Suspension within the 20 day period specified in Section 413(c)(1) of the Act, the Notification has the effect of a supplemental agreement to suspend disability benefits based upon a return to work with no loss of earnings. The first section of Section 413(a) allows a WCJ to set aside an original or supplemental agreement at any time if the agreement is materially incorrect. A WCJ can set aside a supplemental agreement for relevant and significant inaccuracy, even absent a finding of mistake of law or fact, fraud or overreaching. Accordingly, where the employer issues a Notification of Suspension is incorrect and suspends a claimant’s benefits without basis, a WCJ can properly set-aside the Notification of Suspension and reinstate the claimant’s benefits.

 

 

Dismissal of Claim Petition:

 

Wagner v. WCAB (Ty Construction Co. Inc.), __ A.3d __ (Pa. Cmwlth., No. 1202 C.D. 2013, filed January 3, 2014).

 

A Claim Petition cannot be dismissed on the basis that the claimant did not meet certain evidentiary deadlines where there is no showing of prejudice to the employer.

 

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