Fatal Claim in PA Compensable Even if Treatment Not Reasonable or Necessary

One aspect of the Pennsylvania Workers’ Compensation system we (thankfully) do not often address is what is known as a “fatal claim,” where the employee is killed in the work accident. This can, of course, occur in the injury itself, or it can occur as a consequence of the original injury.

The Commonwealth Court of PA recently dealt with this latter issue in J.D. Landscaping v. Workers’ Compensation Appeal Board (Heffernan). Here, the employee injured his low back (specifically, he suffered a herniated disc at L4-5, and a lumbar strain and sprain). As a consequence of the work injury, he was taking copious amounts of medications. Unfortunately, the injured worker died as a result of “multiple drug intoxication.”

What makes this case even more interesting, is that, before the death of the injured worker, a Utilization Review (UR) determined that the ongoing use of medications was neither reasonable nor necessary. The last prescription which was filled was prescribed by a different doctor, though a member of the same practice as the doctor subject to the UR (and, remember, a UR only binds the specific doctor against whom it was filed).

The Workers’ Compensation Judge (WCJ) granted the Fatal Claim Petition, finding that the medications which led to the death of the injured worker were prescribed for the work injury, so the death was related to the work injury. As to the effect of the UR, the WCJ found that the doctor who prescribed the last medications was not the same as the doctor against whom the UR was filed, so the UR was not binding on that new doctor (despite being at the same practice). This decision was affirmed by the Workers’ Compensation Appeal Board (WCAB).

The workers’ comp insurance carrier appealed to the Commonwealth Court of PA, arguing the Fatal Claim Petition was granted in error because the medications leading to the death were found unreasonable and unnecessary by UR. The insurance company argued, though a UR is typically provider-specific, in this case it should not be, because the prescriptions were the same as those of the provider under review and the prescriptions were done with the knowledge and approval of the provider under review.

The Court concluded that the question of whether the doctor writing the last prescription was subject to the UR is irrelevant. By law, a UR may address only whether treatment is reasonable or necessary, not whether it is related to a work injury. In this case, the only question of relevance for the Fatal Claim Petition is whether the prescription was related to the work injury. This fact was not disputed. As such, said The Court, the Fatal Claim Petition was properly granted.