Medical Benefits Must be “Reasonable and Necessary”—Not Just Beneficial

Virginia Employer Need Not Provide Specialized “Running Blade” Prosthesis

While all but a few American jurisdictions require employers to provide medical benefits that are essentially unlimited in terms of duration and amount [see e.g., Larson’s Workers’ Compensation Law (“Larson”) § 94.01], in most states such medical care need not be provided unless it is “reasonable and necessary.” A recent decision from Virginia, Pacheco v. J.P. Masonry, Inc., 2017 Va. App. LEXIS 294 (Nov. 28, 2017), illustrates the point that while an injured worker might derive some legitimate, real benefit from a medical procedure, prescription, or device, it does not necessarily follow that the cost of that medical expense must be borne by the employer. Specifically, although medical evidence clearly showed that an injured worker—who sustained a work-related accident that resulted in a below-the-foot amputation of his left foot—might benefit from the provision of a special “running blade” prosthesis used by amputees in various athletic activities, the special prosthesis was not medically necessary under Va. Code Ann. § 65.2-603.

Background

Claimant suffered a work-related accident in 2012 that resulted in the amputation of his left foot. He was awarded lifetime medical benefits and TPD indemnity and was also given a prosthesis to replace his left foot. He was placed on light-duty work, which included restrictions of no frequent standing or walking.

Prior to the accident, Claimant had been physically active, running five days a week and participating in multiple sports, such as soccer, tennis, and basketball. He had also enjoyed biking, climbing, skiing, snowboarding, and rafting, but he was unable to continue these activities after the accident.

In December 2014, Claimant sought approval for new prosthetic devices: an Elan Boot and an Endolite Blade XT (the “running blade”). The former offered Claimant a more natural walking gait and was better on uneven terrain. His physician opined that it was medically necessary. As to the running blade, evidence suggested that it would allow Claimant to resume at least some of his former athletic activity.

Medical experts disagreed, however, as to the necessity of the running blade. The orthopedic surgeon who conducted an IME concluded, for example, that the running blade was “only one way” to enable Claimant to return to high function. Based on that opinion, the employer agreed to supply the Elan Boot, but not the running blade.

Mandatory Duty to Compensate is Not Unlimited

Affirming a decision of the state’s Workers’ Compensation Commission that found the provision of the running blade was not medically necessary, the appellate court observed that Virginia employers had a mandatory, statutory duty to compensate an injured employee for medical expenses causally related to the injury, but only when such treatment was reasonable, necessary, and related to the industrial accident.

Here it seemed clear that provision of the running blade would be “beneficial,” but that was not enough. While the physician provided specific reasons as to why the Elan Boot was medically necessary, such was not the case for the other requested prosthesis. Quoting Larson, § 1.03, the appellate court said the purpose of workers’ compensation is not to restore the injured employee completely to his pre-injury state, but rather to compensate the employee for injuries that “either actually or presumptively produce disability and thereby presumably affect earning power.”

The court added that providing a running blade to enable Claimant to participate in sporting activities fell outside the range of benefits provided in the workers’ compensation statutes. The court noted that it was “empathetic to the grievous injury claimant suffered” [2017 Va. App. LEXIS 294], but empathy did not allow the court to expand legislative parameters and the prior adjudications of the scope of those parameters.

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