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Uniforce Services and State Workmen's Insurance Fund v. Workers' Compensation Appeal Board11/18/2003
yer's] evidence proves that the bills in question were for the herniation or the chronic pain syndrome as opposed to Claimant's work related back injury. [Employer] was required to produce evidence to prove this. Since [Employer] did not offer any evidence to prove that the bills were specifically related to the "herniation" or "chronic pain syndrome" or some other unrelated condition, it failed to satisfy its burden." Accordingly, the Board reversed the decision of the WCJ and remanded this case to the WCJ for the imposition of penalties. Employer's appeal to this Court followed.
On appeal, Employer argues that the Board erred by reversing the decision of the WCJ because: 1) Claimant failed to sustain his burden of proving that Employer violated the Act and 2) the prior WCJ decision established that Claimant's herniated discs and chronic pain syndrome are not work-related. Initially, we note that " isputes regarding the reasonableness or necessity of treatment ... must be resolved through the utilization review process under Section 306(f.1)(6) of the Workers' Compensation Act (Act) ... once it is determined that an employer is liable for an injury under the Act, the employer is required to pay such bills within thirty days of receipt. Topps Chewing Gum v. Workers' Compensation Appeal Board (Wickizer), 710 A.2d 1256 (Pa. Cmwlth. 1998)." Martin v. Workers' Compensation Appeal Board (Red Rose Transit Authority) 783 A.2d 384, 389 -390 (Pa. Cmwlth. 2001). If the employer believes that the bills are not reasonable or necessary, then it must file a petition for utilization review. Id.
Here, however, rather than challenging the reasonableness or necessity of Claimant's medical treatment, Employer is challenging whether there is a causal relationship between the accepted work-related injury of "twisted back" and Claimant's medical treatments for disc herniations and chronic myofascial spasm and pain. As such, although it is generally true that an employer may not cease paying a claimant's medical bills in the absence of a final receipt signed by the claimant or an order of a WCJ terminating or suspending benefits, "an employer may, however, unilaterally refuse to pay disputed medical benefits without first filing a petition with the referee where the employer challenges the causal relationship of medical treatment to an earlier work-related injury. See also Listino v. Workmen's Compensation Appeal Board (INA Life Ins. Co.), 659 A.2d 45 (Pa.Cmwlth.1995). Assuming the ultimately finds that the injury for which payment is sought is not causally connected to the prior work-related accident, the employer owes nothing further. See Buchanan; Listino." Green v. Workmen's Compensation Appeal Board (Association for Retarded Citizens) 670 A.2d 1216, 1221 -1222 (Pa.Cmwlth. 1996). (emphasis in original).
Furthermore, in Kurtz v. Workers' Compensation Appeal Board (Waynesburg College), 794 A.2d 443 (Pa. Cmwlth. 2002), this Court stated that:
If ... a claimant receives medical treatment for new symptoms that allegedly arise from the compensated injury, and the employer refuses to pay the associated bills, the burden of establishing that the symptoms and treatments are related to the compensable injury turns on whether the connection is obvious. An "obvious" connection "involves a nexus that is so clear that an untrained lay person would not have a problem in making the connection between" the new symptoms and the compensated injury; the new symptoms would be a "natural and probable" result of the injury. If the new symptoms and the compensable injury are obviously related, and benefits have not been terminated, then the claimant will benefit from the presumption that the new symptoms are r
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