Poole v. State of Delaware, C.A No. 11A-04-012-JOH (Del. Super., December 4, 2012)
Utilization Review is only available for acknowledged injuries. Contested claims may not submit medical treatment to Utilization Review for determination of Practice Guideline compliance; instead the Board must determine whether the expenses are reasonable and necessary.
In this case Claimant alleged a work-related injury. Employer contested whether an injury had occurred. Further, Employer contended that even if an injury had occurred the Claimant's current symptomology was not related to the alleged work accident.
"The case proceeded to a hearing before the Industrial Accident Board. The Employer reserved a right, consistent with prior Board precedent, to submit the outstanding medical expenses to Utilization Review, in the event that the Board determined that the claim was compensable. The Employer correctly noted that it could not submit the medical expenses to UR to determine practice guideline compliance without waiving its causation defense. Claimant argued that the Board was to determine the reasonableness and necessity of the medical expenses while the issue was before the Board in the first instance. The Board ultimately provided the Employer an option to submit the medical expenses to UR after it found that the claim was compensable. Claimant appealed.
The Superior Court concluded that Utilization Review is available only on "acknowledged" claim, and thus with narrow focus on the specific language of the statute, the Court determined that when an Employer defends a claim on the basis of causation, it is not acknowledging the claim. As such, according to the Superior Court, in that procedural context, the legislative amendments to the worker's compensation statute (Senate Bill 1), do not alter the prior practice of the Board's determination of the reasonableness and necessity of medical expenses.