State of Connecticut Workers' Compensation Commission, Stephen M. Morelli, Chairman
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CRB Case Annotations re: Section 31-279(c)

Employer sponsored plan for medical care and treatment.

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Full texts of opinions, statutes and court decisions should be consulted and all citations and references fully researched by the reader.

The Annotations to Compensation Review Board Opinions are presented “as is” and the Commission makes no warranties as to the suitability of this information for any given purpose.
Please note also that Annotations change periodically due to several factors including, but not limited to, Appellate and Supreme Court decisions issued in workers’ compensation cases.

Johnson v. State, 6132 CRB-4-16-9 (August 21, 2017).

Claimant brought claim after adverse utilization review decision. At hearing, claimant sought to introduce evidence not part of that record, which was denied; and then declined to present the actual decision. Respondent declined to present the actual decision as evidence and trial commissioner denied claim citing no evidence on record. Claimant appealed arguing she was denied de novo hearing. CRB affirmed decision. Precedent limits commissioner’s review to the record presented in the utilization review process. Burden on claimant is to present prima facia case MCP decision was “unreasonable, arbitrary or capricious.” Absent such evidence commissioner had to dismiss claim.

Caraballo v. Specialty Foods Group, Inc./Mosey’s Inc., 5082 CRB-1-06-4 (July 3, 2007).

Claimant asserted that respondent’s medical care plan (see Sec. 31-279(c)) had treated a work-related injury prior to her filing an admittedly late Form 30c. Respondents denied she satisfied “medical care exception.” Trial commissioner dismissed claim. CRB determined evidentiary hearing needed to determine if medical care exception is met, and remanded matter, See also Caraballo, § 31-294c, § 31-301. Appeal procedure.

Jurado v. New Milford Nursing Home, 5089 CRB-7-06-5 (May 10, 2007).

Trial commissioner approved psychiatric treatment for claimant by treater outside respondent’s medical care plan. Respondent appealed asserting statute barred such an approval. CRB affirmed trial commissioner. Terms of statute permit trial commissioner to authorize “out of network” treatment if evidence justifies such an order; claimant’s testimony and respondent’s expert witness provided such justification. Trial commissioner must reach factual determination of what is “reasonable and necessary” treatment. See also, Jurado, § 31-294d.

Byrd v. Bechtel/Fusco, 4765 CRB-2-03-12 (December 17, 2004).

Claimant had compensable ankle injury. Medical care plan physicians recommended treatment for back, knee, hips due to effects of injury. Respondent contested liability for treatment. Held: Trial commissioner had jurisdiction to decide whether other symptoms were compensable sequelae of ankle injury. Issue of whether other body parts were related to ankle injury goes beyond utilization review process of Admin. Reg. § 31-279-10(e). See, Byrd, § 31-301. Appeal procedure, § 31-301. Factual findings. Prior decision at Byrd, 4656 CRB-2-03-4 (July 14, 2004), aff’d, 90 Conn. App. 641 (2005), cert. denied, 276 Conn. 919 (2005), § 31-278, § 31-280.

Figueroa v. Rockbestos Co., 4633 CRB-1-03-2 (July 20, 2004).

CEO of medical care plan denied surgery pursuant to dispute resolution review under § 31-279-10(f). On review of that decision, trial commissioner found it unreasonable. CRB reversed and remanded for further proceedings. Trier had improperly considered additional medical evidence that had not yet been submitted to utilization review process, and had relied on CEO’s lack of medical training as basis for finding decision unreasonable. Board explained that regulations do not require CEO to have medical training. However, trier may consider CEO’s relationship with employer or insurer, along with his track record in reviewing decisions, in determining whether CEO may be predisposed to particular outcomes. Board expressed concern that CEO/decision-maker here had been previously involved in case as advocate for employer.

Byrd v. Bechtel/Fusco, 4656 CRB-2-03-4 (July 14, 2004), aff’d, 90 Conn. App. 641 (2005), cert. denied, 276 Conn. 919 (2005).

Claimant who had suffered compensable ankle injury alleged that medical care plan administrators did not comply with applicable law and regulations, and sought finding by trial commissioner that such noncompliance led to denial of treatment. Trier bifurcated proceedings, splitting issue of compensability of back, hip and knee symptoms off for separate resolution, while noting that claimant was neither seeking the specific medical treatment that had been denied pursuant to the utilization review process, nor was he appealing decision of a medical plan CEO pursuant to Admin. Reg. § 31-279-10(f). Trier held that request for review of respondents’ conduct in administering medical care plan encroached on chairman’s statutory authority to approve medical care plans. Proper avenue for relief was to submit allegations in writing to chairman for review and investigation. CRB affirmed. Medical care plan statute and regulations do not suggest that trial commissioner should become involved in oversight of medical care plan’s operation. As respondents were entitled to contest compensability of alleged injuries to additional body parts, claimant could not yet allege that treatment for those injuries had been denied due to malfunctions in plan. Trial commissioner lacks jurisdiction to consider remaining complaint regarding operation of plan, which lies with chairman under § 31-279, § 31-280 and § 31-279-10. Board also explained in dicta that general procedures set forth in Administrative Procedure Act (§ 4-182 C.G.S.) would apply to such complaints filed with chairman. See also, Byrd, § 31-278, § 31-280. Subsequent decision at Byrd, 4765 CRB-2-03-12 (December 17, 2004), § 31-279(c), § 31-301. Appeal procedure, § 31-301. Factual findings.

Doherty-Clements v. Yale-New Haven Hospital, 4548 CRB-3-02-7 (October 27, 2003).

Medical care plan provided that eligible employees (i.e., employees who have suffered injuries arising out of and in course of employment) who resided at least fifteen miles outside of Connecticut had option of treating outside plan network. CRB held that this provision applied to claimant, who had moved to Texas prior to seeking out-of-network care. Thus, trial commissioner had jurisdiction to determine whether claimant’s treatment was reasonable and necessary pursuant to § 31-294d. Utilization review procedures of Admin. Reg. § 31-279-10 did not apply. As plan did not specify that claimant must notify employer when making choice to treat outside plan, she could not be penalized for having failed to do so. Trier’s determination that surgery was reasonable and his retroactive authorization of payment was affirmed by CRB.

Gonzalez v. Coca-Cola Bottling Co. of New York, 4284 CRB-8-00-8 (September 13, 2001).

Where employer refused to authorize initial treatment at Industrial Health Care due to claimant’s failure to report injury to employer in writing, trier had authority under § 31-279(c) to authorize payment of compensation to claimant even though he initially treated with a doctor outside the medical plan. Moreover, medical care plans do not begin to play a role in claimant’s choice of treaters until the subscribing employer accepts responsibility for providing initial treatment. See also, Gonzalez, § 31-294d.

Trimachi v. State/Workers’ Compensation Commission, 3749 CRB-1-97-12 (August 25, 1999).

See also, Trimachi, § 31-294d, § 31-307.

Coles v. Star, Inc., 16 Conn. Workers’ Comp. Rev. Op. 67, 3239 CRB-7-95-12 (October 25, 1996).

On appeal to CRB, respondents contested the trial commissioner’s decision to authorize the claimant to treat with a physician who was not in the approved medical care plan’s list of authorized treaters. CRB remanded the matter to the trial commissioner for a formal hearing and decision because without a transcript or findings of fact, it was unable to engage in meaningful review and could not properly consider this appeal in accordance with § 31-301 C.G.S. See also, Coles, § 31-301. Appeal procedure.

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State of Connecticut Workers' Compensation Commission, Stephen M. Morelli, Chairman
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