Insurance Dispute Lawyer Blog
In a victory for injured workers in Louisiana, the Court of Appeal for the Fourth Circuit recently upheld a decision granting Lorae Burnett the right to shoulder surgery following a work-related motor vehicle accident. The case, Burnett v. Full Force Staffing, LLC, & LUBA Casualty Insurance Company, centered on interpreting the state’s Medical Treatment Guidelines and whether the recommended surgery was medically necessary and appropriate.
Background of the Case:
Mr. Burnett, an employee of Full Force Staffing, was injured in a motor vehicle accident while on the job. He sought workers’ compensation benefits for various injuries, including significant pain in his right shoulder. After receiving conservative treatment that failed to alleviate his pain, Mr. Burnett’s orthopedic shoulder specialist, Dr. Savoie, recommended surgery.
Dispute Over Surgery:
LUBA Casualty Insurance Company, the Full Force Staffing insurer, denied the surgery request. They claimed the surgery was not pre-authorized, and there was no prior indication that Dr. Savoie was Mr. Burnett’s chosen physician.
Mr. Burnett challenged this denial, filing a Disputed Claim for Medical Treatment with the Office of Workers’ Compensation’s (OWC) Medical Director. After reviewing Mr. Burnett’s medical records, the Medical Director determined that the surgery was in accordance with the OWC Medical Treatment Guidelines and should be covered.
The Appeal
Full Force Staffing and LUBA appealed the Medical Director’s decision, arguing that the surgery was unnecessary and did not comply with the Medical Treatment Guidelines. They also asserted that Mr. Burnett had not undergone sufficient conservative therapy before opting for surgery.
Court’s Decision:
The Court of Appeal reviewed the case and found that Mr. Burnett’s medical records clearly showed that conservative treatment had failed to relieve his pain. The court also noted that the Medical Director had likely reviewed additional medical records not presented in court, further supporting the decision to approve the surgery.
The court ultimately affirmed the OWC’s judgment, upholding Mr. Burnett’s right to receive the recommended shoulder surgery. It concluded that the appellants failed to provide clear and convincing evidence to overturn the Medical Director’s decision, especially since they did not present any countervailing medical evidence to dispute Dr. Savoie’s recommendation.
Key Takeaways:
This case is an essential reminder that injured workers in Louisiana have the right to receive medically necessary treatment, even if it requires surgery. The Medical Treatment Guidelines provide a framework for determining appropriate care, and the OWC Medical Director plays a critical role in resolving disputes.
If your workers’ compensation claim for medical treatment is denied, you can challenge that decision. It is crucial to consult with an experienced workers’ compensation attorney who can guide you through the dispute resolution process and advocate for your right to receive the necessary medical care.