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Uniforce Services and State Workmen's Insurance Fund v. Workers' Compensation Appeal Board11/18/2003
. § 991(d)(i). "If a claimant seeks penalties for an employer's alleged violation of the Act, the burden of producing such evidence and persuading the fact-finder of its credibility is on the claimant. Sanders v. Workers' Compensation Appeal Board (Marriott Corporation), 756 A.2d 129 (Pa.Cmwlth.2000). No penalty may be imposed under section 435 absent proof of a violation of the Act or its regulations ... and a violation of the Act must appear in the record in order for a penalty to be appropriate." Dow v. Workers' Compensation Appeal Board (Household Finance Co.) 768 A.2d 1221, 1226 (Pa.Cmwlth. 2001). After the claimant sustains his burden, the burden of proof shifts to the employer to prove that a violation of the Act has not occurred. Shuster v. Workers' Compensation Appeal Board (Pennsylvania Human Relations Commission), 745 A.2d 1282 (Pa. Cmwlth. 2000).
Employer argues that it is not subject to any penalties because Claimant presented no evidence that Dr. Pelicci complied with Act 44, which requires that medical bills and reports be submitted on specific forms before payment is required. We agree. There is no evidence in the record that the bills at issue were properly presented to Employer for payment. As such, Claimant failed to prove that Employer violated the Act and, therefore, an imposition of penalties is not warranted because " ntil a provider submits bills on one of the forms specified in § 127.201 ... insurers are not required to pay for the treatment billed." 34 Pa. Code § 127.202(a) (emphasis added). See AT&T;v. Workers' Compensation Appeal Board (DiNapoli), 728 A.2d 381, 383-384 (Pa. Cmwlth. 1999). Therefore, the Board erred by reversing the decision of the WCJ.
Because Claimant did not show that these bills were properly presented to Employer for payment, we do not reach the issue of whether the prior WCJ decision bars Claimant from asserting that his medical bills are causally related to his work-related injury . We also note that the proper procedure would be for Claimant's medical provider to submit the bills at issue in this case to Employer on the proper forms. Then, Employer would have to pay these bills within 30 days. 77 P.S. 531(5). If Employer does not believe that these bills are reasonable or necessary, then it must file a petition for utilization review. If Employer believes that these bills are not causally related to the work-related injury, then Claimant can file a Penalty Petition and Employer's non-payment would establish a violation of the Act. Or, Employer could file a petition to review Claimant's medical treatment. See Bloom v. Workmen's Compensation Appeal Board (Keystone Pretzel Bakery), 677 A.2d 1314 (Pa.Cmwlth. 1996), appeal denied, 546 Pa. 657, 684 A.2d 558 (1996) (explaining that a petition to review medical treatment goes to the question of causal connection, whereas utilization review goes to the question of reasonableness and necessity of medical treatment).
If the connection between the medical treatment and the accepted work-related injury is "obvious", then the burden would be on the Employer to prove that there is no causal relationship between the treatment and the work-related injury. Kurtz. If the connection is not "obvious", then the burden would properly be on Claimant to prove the causal connection between the medical bills and the accepted work-related injury. Id.
Accordingly, the order of the Board is reversed.
ORDER
AND NOW, November 18, 2003, the order of the Workers' Compensation Appeal Board docketed at A01-2878 and dated April 4, 2003 is hereby REVERSED.
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