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Hiett v. Montana Schools Group Insurance Authority9/6/2001
them pursuant to the settlement agreement. Second, she contends that the medications are "necessary for medical stability" and therefore not within the "secondary medical services" exclusion. Third, she argues that MSGIA either waived its right to contest her entitlement to the benefits or is estopped from doing so. I will address the arguments in order.
I. Settlement Agreement
The settlement agreement provides, "Further medical and hospital benefits are reserved by the claimant." Medical and hospital benefits are governed by section 39-71-704, MCA (1995), as set forth above. The language in the settlement agreement does nothing less or more than reserve to claimant the benefits to which she is statutorily entitled. There is nothing in the language to suggest that the parties intended to expand benefits beyond those provided in the Workers' Compensation Act, and there is nothing ambiguous in the reference to the benefits. The claimant's first argument is without merit.
II. Medical Stability
The claimant argues that her medications are necessary for her to maintain "medical stability," hence they are not excluded secondary medical services. She relies upon the definition of secondary medical services as "those medical services or appliances that are considered not medically necessary for medical stability." § 39-71-116(a), MCA (1995) (emphasis added). Essentially, she argues that her medications are medically necessary for her to maintain medical stability, and therefore do not fall under the secondary medical services limitation.
Unfortunately, the statutes regarding medical services are poorly written and raise extremely difficult questions of statutory interpretation. I will outline the difficulties in interpreting the statutes.
Initially, section 39-71-704(1)(a), MCA (1995), requires payment for all "primary medical services." "Primary medical services" are defined as "treatment . . . necessary for achieving medical stability." § 39-71-116(25), MCA (1995). "Medical stability," of course, is the same thing as "maximum medical improvement" and "maximum medical healing," meaning the "point in the healing process when further material improvement would not be reasonably expected from primary medical treatment." § 39-71-116(17), MCA (1995). MSGIA's argument appears straightforward: Since claimant "achieved" medical stability, the primary services provision does not apply, and the authorization in section 39-71-704(2), MCA (1995), for secondary services also does not apply because the services authorized by that section are limited to services for which there is "a clear demonstration of cost-effectiveness of the services in returning the injured worker to actual employment" and claimant has offered no evidence to support that conclusion.
The medical stability definition is circular insofar it defines medical stability as a point where "further material improvement would not be reasonably necessary from primary medical treatment." "Primary medical treatment" is defined as "treatment . . . necessary for achieving medical stability." Plugging that definition into the medial stability definition yields a definition of medical stability as "a point in the healing process when further material improvement would not be reasonably expected from treatment necessary for achieving medical stability." I must therefore read the provision simply meaning that "any further medical treatment" would not materially improve a claimant's condition.
Even though a claimant may have reached medical stability, her condition may deteriorate and require further treatment to again reach stability. For example, a worker may suffer
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