Medical Benefits in Boston Workers’ Compensation Claims

In a Boston workers’ compensation claim, there are various types of benefits available to claimants, depending on the facts of the case. These benefits can include money for lost wages and they can also include an award of medical benefits for past and future medical treatment and the cost of rehabilitation.  Rehabilitation will typically include payment for occupational therapy or physical therapy, and possibly mental health counseling.

Boston Workers' Compensation Claims In some workers’ compensation cases, an employer and its workers’ compensation insurance company will do the right thing and not fight valid claims for reasonable medical expenses and lost wages.  However, in other cases, a workers’ compensation insurance company will have claimant go to repeated evaluations at their own doctors, will fight to deny payment for certain treatment and will even delay payments they are already supposed to pay via a settlement or court order. A Recent Example of a Medial Dispute in a Worker’s Compensation Case

In Gaasch v. St. Paul Fire & Marine Ins. Co., a civil lawsuit was filed against an employer’s workers’ compensation policy on various grounds, including wrongful death, after claimant died following a workplace accident. In this case, employee was morbidly obese and decided to undergo weight-loss surgery, which involved having a gastric bypass performed.

Following his weight-loss surgery, he was suffering from malnutrition, which is a common side effect or secondary condition as it is often called, to bariatric surgery. He required treatment for this condition prior to being injured at work.  Following his workplace accident, he required being admitted to hospital and had to have various surgeries over the course of two years.  In addition to these work-related problems, he was also still suffering from the nutrition issues pertaining to the weight loss surgery, and this complicated patient’s prognoses.

Pre-Existing Conditions Aggravated by Boston Workplace Accidents

Claimant requested nutrition services be provided since the work-related accident was a factor that aggravated the pre-existing condition.  Employer denied payment for nutrition services by arguing this was a pre-existing condition, which was not in any affected by the workplace accident and therefore they were not responsible for compensating plaintiff for associated medical expenses.

As our Boston workers’ compensation attorneys can explain, if this case occurred in Massachusetts, a condition which already exists will be covered by workers’ compensation if the workplace injury or work-related illness was a major cause of claimants injuries. This is codified in Section 1(7A) of Chapter 152 of the Massachusetts General Laws (M.G.L.), which is our state’s workers’ compensation act.

In this case, there was a hearing on workers’ compensation issues and employer was ordered to pay for medical costs, but allegedly did not make timely payments to treat claimant’s malabsorbtion syndrome following gastric bypass and his workplace accident.  When claimant did not have money to pay for nutritional treatment via workers’ compensation medical benefits, claimant died and the personal representative of his estate filed a lawsuit against employer’s workers’ compensation act.

The claim was defendant breached their contractual obligations.Defendant filed a motion for summary judgement, asking the case be dismissed on grounds workers’ compensation is an exclusive remedy.

This means a claimant must file a workers’ compensation claim and exhaust all remedies in the workers’ compensation claim, and is precluded from filing a personal injury claim against employer.  This was part of the workers’ compensation compromise, which set up a no-fault system.  This is a benefit to employees and their families as without any need to prove fault, workers’ compensation claimants should be able to get benefits paid much sooner than if there was a need to file a personal injury claim and possibly take the case to trial.  The other end of this compromise means there is no way for a claimant to file a personal injury lawsuit against an employer in many cases. Employers wanted fixed costs for workers’ compensation insurance premiums and did not want to be subject to civil lawsuits at any given time following a workplace accident.

In Gaash, this lawsuit was a contracts claim that also included a wrongful death component,instead of a personal injury case as would typically be filed. Defendant argued this was an attempt to usurp the workers’ compensation system and the trial court agreed and granted defendant’s motion for summary judgement, dismissing the claim. Following the dismissal, claimant appealed to the intermediary appeal and the court reversed the dismissal.  At this point, defendant appealed to the state supreme court.  In this final appeal, the court concluded trial judge had not erred as a matter of law in that it really was a workers’ compensation issue and the court lacked jurisdiction to hear a case involving a workplace accident. For this reason, initial granting of defendant’s motion for summary judgment was affirmed and the case was dismissed. This would require claimant to go through the entire workers’ compensation appeals process and then file a case if necessary.

This resolution is not what claimant had requested as it creates an obvious issue.  The medical benefits were not going to do any good once claimant had already died and there is no way to get pain and suffering damages in a workers’ compensation claim like there would be with a personal injury claim.  It might be possible to file a claim against employer or employer’s insurance company for some type of bad-faith dealing if the allegations were true. But claimant, and his estate, would first have to exhaust all workers’ compensation claims with the workers’ compensation commission.

In a workers’ compensation claim, there is a possibility a civil lawsuit could also be filed, but it would require a case in which claimant’s injuries were caused by a negligent third-party defendant.  In cases such as this, claimant would still be required to file a workers’ compensation claim with employer’s workers’ compensation insurance  and then file a civil case against the at-fault third party defendant. The most common example of a case like this is when defendant was hit by a car driven by a negligent third party.

If you or someone you love has been injured in a Massachusetts work accident, call for a free and confidential appointment at (617) 777-7777.

Additional Resources:

Gaasch v. St. Paul Fire & Marine Ins. Co., February, 2, 2018, Supreme Court of Oklahoma

More Blog Entries:
Report: Three Workers Burned in Natural Gas Explosion, Feb. 18, 2017, Boston Workers’ Compensation Lawyer Blog

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