Fourth Circuit: Claim for Reimbursement Was Not a New Request for Treatment Subject to Medical Treatment Guidelines

On November 15, 2001, Claimant was shot while in the course and scope of his employment with Whole Food Company, Inc. (“Employer”).  He has been in a permanent vegetative state since that time.  His mother (“Claimant”) filed a disputed claim for compensation in April 2013, requesting an order requiring Employer to pay for food authorized by Claimant’s physicians.  Claimant also sought penalties and attorney fees as a result of Employer arbitrarily stopping a prescribed food for solely financial reasons without any medical input.  Claimant alleged that Employer paid for a particular type of food for many years but recently refused to approve and pay for this food because, in its view, it was too expensive.  Instead, Employer approved a different type of food in a different form which caused difficulties for Claimant.

Employer filed an Exception of Prematurity, arguing that Claimant failed to follow required administrative procedures necessary for a claim for medical treatment.  Employer argued that Claimant first needed to submit a Form 1010 requesting additional medical treatment.  Employer also argued that the claim was premature as penalties and attorney’s fees were prayed for on the same day that the medical treatment was recommended by Claimant’s physician.  Employer’s Exception of Prematurity was granted by an OWC Judge and Claimant’s claim was dismissed with prejudice.

Claimant appealed this decision, arguing that the medical treatment guidelines cited by Employer did not apply retroactively to a 2001 accident.  Further, Claimant argued that these guidelines did not apply as there was no request for new medical treatment. Rather, Claimant merely requested that Employer continue to pay for previously ordered treatment.  On appeal, the Fourth Circuit was guided by two recent Louisiana Supreme Court cases which held that the medical treatment guidelines where procedural in nature, did not affect substantive rights, and applied to all requests for medical treatment and/or all disputes emanating from requests for medical treatment after the effective date of the statute, regardless of the date of the accident or injury.  The Fourth Circuit held that Claimant’s argument against the retroactivity of the medical treatment guidelines was without merit.

The Fourth Circuit next addressed Claimant’s argument that the guidelines did not apply because there was no new request for treatment.  The Court determined that the claim was not a new request for medical treatment but, rather, a claim for reimbursement of sums paid for allegedly necessary medical supplies and for attorney’s fees and penalties for the alleged arbitrary discontinuance of the food that had been provided by Employer since 2002.  The Court determined that the OWC Judge erred in granting the Exception of Prematurity because the disputed claim for compensation fell outside of the medical treatment guidelines.  The judgment of the OWC was reversed and the matter was remanded for further proceedings consistent with the Fourth Circuit’s opinion.

Malord Gales v. Whole Food Co., Inc.