Perez v. IWCC: Case Law

14.1.2018

Two issues addressed by this decision: (1) the applicable standard of review of a Commission decision related to statutory construction; (2) whether an employer need be a party to a rate agreement to receive the benefit of the agreement.

Claimant sustained a lateral meniscal tear in her left knee in a work-related accident on 6/19/2007. She underwent medical treatment, including physical therapy and surgery. Her medical expenses were either paid by Cigna, her then husband’s medical insurance carrier, or paid out-of-pocket. The employer submitted an exhibit listing medical payments made by Cigna, showing payments of $17,597.96 and copayments of $260.00. On 4/4/11 the parties entered stipulation reflecting fee schedule amounts for the claimant’s medical services totaling $37,767.32, however the employee maintained that it disputed the fee schedule was the appropriate basis for calculating the medical if compensable.

On 4/25/11 the arbitrator issued a decision finding the claimant’s injury was not causally connected to her work accident on 6/19/07. On 1/31/13 the circuit court confirmed the Commission. The claimant appealed to the Appellate Court, which reversed the circuit court’s judgment and found that that injury was work related. On 3/17/15 the Commission issued its decision on remand awarding TTD benefits and ordering the employer to pay claimant’s medical expenses without specifying an amount. On 11/12/15 the circuit court ordered the Commission to determine the amount owed for medical expenses. On 6/6/16 the Commission ordered the employer to pay $17,857.96, reflecting the negotiated amount of medical expenses paid by Cigna and the claimant. On 1/9/17 the circuit court confirmed the Commission’s decision.

The claimant sought review of the Commission’s decision, arguing that under section 8(a) of the Act, the employer pays the negotiated rate only when the rate is negotiated by the employer or its own insurance carrier. The employer argued that under the plain language of the statute, it is only liable for medical expenses paid pursuant to the negotiated rate, regardless of whether the employer or its insurer negotiated the rate.

The court reviewed the plain language the law and determined that the employer must pay the negotiated rate for medical expenses regardless of whether it is negotiated by the employer or the employer’s own insurance carrier. The statute only requires the employer to pay “the negotiated rate”. Section 8(a) is intended to provide relief to injured employees only to the extent reasonably required to cure or relieve claimant from the effects of a workplace injury.

Key Take-Aways:

- Section 8.2 of the Act requires the employer to pay (1) the negotiated rate, if applicable, or (2) the lesser of the health care provider’s actual charges, or (3) the fee schedule rate.

- An employer pays the negotiated rate regardless of which insurance carrier negotiated it.

-By paying, or reimbursing an injured employee, for the actual amount paid to the medical service providers, the statue is satisfied.

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