Injured worker + disputed claim + an avalanche of disputed conservative “treatment”….Respondent’s and their insurers are quite familiar with this situation. In a recent case, I&F successfully fought off petitioner’s claim for this type of unreasonable and unnecessary care.
In this case, the petitioner sustained a shoulder injury while stacking pallets. Initial x-rays were negative, as was an MRI scan of the shoulder done shortly after the accident. The examination findings of the petitioner’s first two physicians and the IME physician (all occurring within the first two months after the injury) were unremarkable. Three months after the accident, the petitioner came under the care of an orthopedist who diagnosed an AC joint separation and recommended surgery and physical therapy. Respondent’s IME physician diagnosed a right shoulder contusion and opined that no further treatment was needed.
Following the IME and the initial visit with the orthopedist, the petitioner participated in 150 physical therapy sessions at a notorious local provider of such services, racking up approximately $60,000.00 in disputed medical expenses. The Arbitrator ruled in favor of the respondent on the issue of prospective medical treatment, finding that the petitioner failed to prove that he had a right AC joint separation that required surgery. The Arbitrator also sided with the respondent in finding that a significant amount of the physical therapy treatment was unreasonable. The Arbitrator awarded the petitioner $8,900.00 in medical bills.
On petitioner’s appeal, the Commission reversed the Arbitrator and awarded surgery, noting that it didn’t want to subject such a young person (20) to unnecessary pain. The Commission then took the opportunity to essentially strike Section 12 from the Illinois Workers’ Compensation Act and found that the treating doctor was credible because he saw the petitioner on several occasions as opposed to the IME physician who only saw him once. The Commission awarded the petitioner $60,000.00 in medical expenses, reasoning the high number of therapy visits but finding that the PT was necessary to prevent the petitioner from becoming atrophied and from healing incorrectly prior to surgery.
I&F appealed the IWCC decision to the Circuit Court. The Circuit Court held that the Commission’s award of medical expenses and prospective medical care was against the manifest weight of the evidence. The Circuit Court noted that the treating doctor’s opinion regarding the need for surgical intervention and approximately 150 physical therapy visits was in error as it was contrary to the initial treatment records, the diagnostic studies (x-ray films and MRI films), and the opinions of the respondent’s IME physican.
The Commission reinstated the Arbitrator’s award of $8,900 in medical bills. The petitioner has appealed the Circuit Court decision to the Appellate Court. Congratulations to Attorney Scott McCain for the great result.