Agreement to pay benefits for head injury covers traumatic brain injury
Case name: Philip Morris USA, Inc. v. Mease, No. 2224-12-2 (Va. Ct. App. 07/23/13).
Ruling: The Virginia Court of Appeals held that a worker was entitled to six physical therapy sessions per week because the treatment was related to his work-related traumatic brain injury.
What it means: In Virginia, a worker can be awarded attorney's fees if the employer refuses to pay a claim without reasonable grounds.
Summary: A worker fell at work and sustained a compensable injury. The parties signed an agreement providing temporary total wage compensation that identified his injury as "head trauma." The worker was awarded lifetime medical benefits for reasonable, necessary, and authorized medical treatment causally related to his injury. Later, the employer's carrier's claims representative informed the worker that his physical therapy sessions would be reduced because six sessions per week were too expensive. The worker filed a claim requesting that the employer provide physical therapy six times per week. He attached two doctor's notes recommending increased physical therapy and opined that his health problems were related to his traumatic brain injury. The employer asserted that the treatment was not causally related to the compensable injury, was not reasonable or necessary, and was excessive and costly. The Virginia Court of Appeals ordered the employer to provide six physical therapy sessions per week.
The employer asserted that the agreement to pay benefits covered only a "head injury" and that the worker failed to file a claim to add coverage of a traumatic brain injury. The court found that the employer had timely notice that the worker suffered a traumatic brain injury during his industrial accident. The medical reports consistently stated that he had a traumatic brain injury as a result of a fall.
The court concluded that the agreement to pay benefits extended to the worker's traumatic brain injury. The worker displayed cognitive deficits and memory dysfunction immediately after the accident. The employer did not object to paying for other medical treatment associated with the traumatic brain injury.
The court found that the employer's failure to offer medical evidence that the treatment was not causally related to the compensable injury or evidence that the physical therapy sessions were excessive supported an award of attorney's fees for the worker.
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September 9, 2013
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