Insurer's refusal to authorize out-of-state treatment leads to liability
Case name: Ham v. Anchor Glass Container Corp., No. A-1797-09T3 (N.J. Super. Ct. App. Div. 01/20/11, unpublished).
Ruling: In an unpublished decision, the New Jersey Superior Court, Appellate Division held that an employer and its insurer were liable for the costs of a worker's second surgery because the insurer's refusal to authorize out-of-state medical treatment was a cause of her deteriorating medical condition requiring the surgery.
What it means: In New Jersey, an employer can be required to authorize out-of-state medical treatment for a worker.
A worker slipped and fell while working. She complained of pain in her shoulder and wrist, which worsened and required surgery. Within two days of the surgery, the worker left for another state to aid her husband in addressing a serious family emergency. The worker's attorney notified the employer and its insurer. As a result of her travel, the worker missed follow-up visits with her surgeon and physical therapy that were necessary to rehabilitate her shoulder and arm. The worker sought authorization for physical therapy and other medical treatment while in the other state, which the insurer denied. Consequently, the worker received no post-surgery treatment for the 40 days she was in the other state. By the time she visited her surgeon, she had developed a "frozen shoulder." The worker was required to undergo a second surgery. The insurer denied coverage for the second surgery. The New Jersey Superior Court, Appellate Division held that the employer and insurer were liable for the costs of the second surgery.
The court said that no geographical limitations exist for medical treatments, and the insurer had no justification for its refusal to authorize treatment for the worker. Medical experts testified that the worker's lack of physical therapy after the first surgery contributed to the onset of her frozen shoulder. The court concluded that the condition she developed was caused by the insurer's refusal to authorize treatment.
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March 3, 2011
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