State of Washington Court of Appeals: Clark Cty. v. Maphet
“Self-insured employers have the responsibility to challenge treatment before authorization if there is a question as to whether treatment should be provided.”
The Washington Court of Appeals issued a ruling on August 6, 2019 that may affect self-insured employers’ decisions when authorizing treatment under a workers’ compensation claim.
In the case of Clark Cty. v. Maphet, No. 51170-3-II, 2019 Wash. App. LEXIS 2057, Ct. App. Aug. 6, 2019) (link to the opinion available here), Division II of the Washington Court of Appeals held that when a self-insured employer authorizes treatment for a condition, the employer accepts the condition as part of the claim as a matter of law. According to the Court of Appeals, this rule applies whether or not the condition is proximately caused by the employment-related injury.
In Maphet, the Court applied this rule alongside the compensable consequences doctrine. In doing so, the Court held a self-insured employer responsible for all complications flowing from a surgery authorized by the employer to treat a non-industrially-related condition.
The issues of this case first began ten years ago when a correctional officer at the Clark County Jail fell down a flight of stairs at work and injured her right knee. The worker subsequently underwent nine surgeries. After four surgeries, the worker still had pain in her knee and the employer authorized surgery to remove scar tissue. During this fifth surgery, the surgeon performed a lateral retinacular release in the worker’s knee because he noticed the kneecap had been pulled “to the outside of the knee abnormally.” The Court deemed the release procedure to be an “unnecessary surgical action” unrelated to the industrial injury. The release procedure caused the worker to develop patellofemoral instability and ultimately, the need for the sixth, seventh, eighth, and ninth surgeries.
The County paid for the sixth, seventh, and eighth surgeries, but refused to authorize and pay for the ninth surgery. The County conceded that the ninth surgery was proper and necessary for the instability condition, but argued that the release procedure performed during the fifth surgery was not proximately related to the industrial injury and thus the County should not be responsible for complications flowing from the surgery.
The Court of Appeals disagreed with the County. In doing so, the Court applied the compensable consequences doctrine, which establishes that if treatment performed for an industrial injury causes complications or aggravates the injury, the claim covers subsequent treatment. The Court also looked at the definitions of “acceptance” and “authorization” in the Washington Administrative Code. The Court found that “[a]uthorization is the self-insured employer’s notification that it will provide treatment for an accepted condition.” So by authorizing the sixth, seventh, and eighth surgeries to treat patellofemoral instability, the County accepted a subsequent knee condition that was unrelated to the industrial injury. Therefore, the County was responsible for all residuals of the authorized surgeries.
The County further argued that as a matter of policy, such a rule would incentivize employers to deny or dispute treatment benefits “because if they pay for the wrong procedure, the financial consequences could be massive.” The Court found that this incentive is part of Washington workers’ compensation law, and that “[s]elf-insured employers have the responsibility to challenge treatment before authorization if there is a question as to whether treatment should be provided.” The Court believed any negative implications arising from employers’ incentives to challenge treatment are offset by the benefits to injured workers not having to guess whether treatment will be covered under the claim.
Also at issue in the case was Washington Rule of Evidence 409, which provides that “[e]vidence of furnishing or offering or promising to pay medical, hospital, or similar expenses occasioned by an injury is not admissible to prove liability for the injury.” The County argued that the rule bars the introduction of evidence that a self-insured employer authorized treatment to prove that a condition was proximately caused by the industrial injury. The Court disagreed and held that such evidence is admissible in workers’ compensation cases. The Court reasoned that the rule only applies to “evidence of furnishing or offer or promising to pay . . . expenses,” and not to authorization of payment. Further, the rule only applies to situations when the evidence is used to prove liability, not to prove a fact that a condition was caused by an injury.
Takeaway from the Case
The major takeaway from Maphet can be summarized by the following statement by the Court of Appeals in its opinion: “Self-insured employers have the responsibility to challenge treatment before authorization if there is a question as to whether treatment should be provided.” If there is any doubt as to whether treatment is proper, then an employer should raise the issue at the authorization stage. Not doing so may lead to large, unpredictable claims for conditions not caused by employment.
Maphet is currently unpublished so its use as precedent is limited. Nonetheless, the Court’s reasoning for the decision is persuasive and should be considered by employers during the decision-making process of authorizing treatment.
If you have further questions regarding this recent Washington Court of Appeals decision, or what it means for employers in Washington, please do not hesitate to contact the attorneys at Wallace, Klor, Mann, Capener & Bishop, P.C.
*This article/blog entry is not to be construed as legal advice for any specific situation or employer. To inquire about the impact this decision or any other article may have on your business or an individual set of facts, please contact an attorney.