Wyatt v. Rescare Home Care, 2013 WL 6097901, --- A.3d --- (Del. Nov. 20, 2013).

The Delaware Supreme Court holds that medical treatment performed by a non-certified medical provider, which is not preauthorized, is not compensable under the Delaware workers' compensation statute. This case overrules the holding of Vanvliet v. D&B Transp., 2012 WL 5964392 (Del. Super.).

SUMMARY

Claimant, Amanda Wyatt, worked as a certified nursing assistant for Rescare. Claimant's job required her to lift a 45-50 pound patient on a regular basis. Claimant had experienced previous low back pain; however, on December 15, 2010, while lifting her patient, she experienced increased low back pain with the accompanying symptoms of leg numbness and the urgency to urinate. These symptoms were reported to Dr. Tatineni (a general surgeon) who urged Claimant to seek care with Dr. Venkataramana immediately.

Dr. Venkataramana is an in-state medical provider who is not certified under the Delaware Health Care Payment System. Dr. Venkataramana examined the Claimant on December 17, 2010. After sending the claimant to get an MRI and blood work, the doctor informed her on December 18, 2010 that she would need spinal surgery, which was performed the next day.

Claimant filed a Petition to Determine Compensation due, seeking acknowledgement that her injury was compensable, payment of her medical bills and total disability benefits. The Board granted the petition and found the injury to be compensable and awarded total disability benefits and payment of medical expenses. Employer filed a motion for reargument, alleging that Dr. Venkataramana's medical expenses were not compensable because he was a non-certified provider and preauthorization was not obtained for the treatment. The Board agreed and held that the "emergency exception" delineated in 19 Del. C. §2322B(8)(b) did not apply.

Both parties appealed to the Superior Court. That Court reversed the Board's initial causation finding, on the basis that there was insufficient evidence to support a causal connection. The Superior Court did not reach the statutory question of whether Dr. Venkataramana's medical treatment was compensable. That decision was then appealed to the Supreme Court.

First, the Supreme Court reversed the Superior Court's ruling regarding causation and concluded that sufficient evidence was presented to support the Board's conclusion that the claimant's injury was caused by a work-related accident.

The Court then analyzed the statutory provisions regarding medical expense compensability and provider certification and concluded that, despite the Claimant's characterization of Dr. Venkataramana's treatment as "urgent care," the emergency exception of 19 Del. C. §2322B(8)(b) was inapplicable to the claimant's situation because the treatment "was not provided in the emergency room of a hospital or other similar facility, nor was it performed in a prehospital setting by ambulance attendants or paramedics." Wyatt, 2013 WL 6097901, at *5.

The Court held that preauthorization was necessary in order for Dr. Venkataramana's treatment (after the first visit) to be compensable. Specifically, the Court explained that because the General Assembly provided that only the first (non-emergency) visit to a non-certified provider was compensable, that statutory provision would be nullified if the Claimant could simply argue, after the fact, that the subsequent care was reasonable and necessary. This holding abrogates the rule established in Vanvliet, where the Superior Court held that treatment from a non-certified provider without preauthorization could be compensable if the claimant proved that the care was reasonable and necessary, but that such care was not entitled to the presumption of reasonableness and necessity.

Consequently, medical care rendered by a non-certified provider will only be compensable if it is preauthorized, the first visit with with that provider, or if it fits within the narrow statutory definition of emergency care.