The Indiana Worker’s Compensation Act requires that an injured employee’s compensable medical care be provided by medical providers who have been authorized by the employer. There are three exceptions; those being in the case of an emergency, or where the employer has refused to provide medical treatment, or “because of any other good reason”. It is the “other good reason” exception which comes up most often when the attending physician deems the employee’s injury to be at maximum medical improvement and the employee thereafter pursues unauthorized medical treatment.
The Indiana Supreme Court has established three tests for the employee to meet in order to claim from the employer the cost of unauthorized medical treatment:
- The employee must have acted in good faith in having the unauthorized treatment. This means that the employee must notify the employer regarding the proposed additional medical treatment and seek the employer’s approval for that treatment; and
- The employee must establish that the authorized medical care was inadequate; and,
- The employee must establish that the unauthorized medical care was medically reasonable and necessary.
Of course, if an unauthorized physician proceeds with treatment, it is likely that such physician will testify that the prior treatment was inadequate and that the unauthorized treatment was reasonable and necessary. And, if, the employee testifies that improvement occurred after the disputed treatment, then that tends to support the reasonableness and necessity for the same. Thus, it is the good faith requirement which is crucial in defending a claim for unauthorized treatment. The fact that the employee was not satisfied with the authorized treatment is not sufficient to establish good faith. The employee must provide the employer with adequate notice of the additional treatment being proposed and ask that the same be authorized. If the employer refuses to provide that treatment, then it does so at its peril. But, if the employee fails to give to the employer adequate notice of the proposed treatment and an opportunity to provide it, then the claim for the unauthorized treatment should be denied.