Christiana Care Health Services v. Palomino; Timber Products v. Avila-Hernandez; Berger Brothers v. Munoz, Del. Supr. Nos. 56, 2012; 62, 2012; 63, 2012 (Consolidated) (April 11, 2013).
Delaware Workers' Compensation Administrative Regulation establishing a 45-day appeal time period for Utilization Review Determinations is invalid, the 5-year statute of limitations applies.
The named claimants each suffered compensable injuries. Each claimant received medical treatment that was submitted to Utilization Review by the respective carriers. The Utilization Review determinations all concluded that at least some of the treatment at issue did not comply with the Healthcare Practice Guidelines. Each of the claimants attempted to appeal the Utilization Review determinations after the expiration of the 45-day time limit imposed by Department of Labor Administrative Regulation 5.1.1. In each instance the Board held that the 45-day time limit controlled and dismissed the claimants' appeals.
The claimants appealed their respective cases to the Superior Court, wherein their appeals were consolidated. The Superior Court determined that the administrative regulation establishing the 45-day time limit for the appeal of a Utilization Review determination was invalid. The Court found that the workers' compensation statute (19 Del. C. §2361) expressly and exclusively governed the limitations for claims under the workers' compensation system. The Court ruled that an administrative regulation could not abbreviate a statutory time period.
The Superior Court's decision was appealed and affirmed by the Delaware Supreme Court. The Supreme Court (in a 3-2 ruling) held that the time limitation expressed in §2361 was unambiguous and could not be shortened by an administrative regulation. The Court noted that the workers' compensation amendments (establishing Utilization Review) did not prescribe any time-limitation for Board review of a Utilization Review determination. Accordingly, the Court concluded that the administrative regulation, establishing the 45-day time limitation, circumscribed the rights of claimants by precluding a claim for medical treatment after the expiration of the 45-day time limitation, as opposed to the 5-year statutory limitation prescribed in §2361.
Consequently, the 45-day time limit to appeal a Utilization Review determination is invalid, the five-year limitation of §2361 governs.