A Carluzzo Rochkind & Smith note: Following is an article by Virginia Lawyers Weekly. We did not handle this case, but it brings up important points your workers’ compensation attorney should be familiar with. For more than 20 years our workers’ compensation lawyers in Manassas have helped clients with such matters in Prince William County, Fairfax County, Woodbridge, and throughout Northern Virginia. If you have any questions or would like to schedule an appointment, please contact our law firm at (703) 361-0776.
Standing to challenge alleged medical payment shortfall
By Virginia Lawyers Weekly – 5/31/2023
Although a workers’ compensation claimant had standing to challenge an alleged medical payment shortfall, the claim fails on the merits because there were no outstanding medical bills and the medical providers are not seeking to recover any shortfall.
Overview
On Aug. 16, 2015, Greatheart, a Hampton police officer, injured his ankle while on the job. He had surgery at Careplex Orthopaedic Ambulatory Surgery Center. Careplex billed $20,677. The city of Hampton paid $12,643.51.
A credit adjustment reduced the $8,033.49 balance to zero. “After this adjustment, the medical providers never sought or requested additional payment.” …
Greatheart and the city settled in 2019 and sought the commission’s approval. On Nov. 1, 2019, “[t]he Commission approved the settlement. Under the terms of the agreement Greatheart received $15,000 and assurances of various future actions by the City.
“The order further provided that ‘payment for reasonable and necessary medical treatment’ … ‘relating to the injury of August 16, 2015, shall continue for the period between the date of the accident and the date of this Order.’
“At the same time, the order provided that ‘defendants shall be released and forever discharged from any and all further liability to the claimant, and to all persons claiming through the claimant, for all claims of any nature including, but not limited to, claims for … medical benefits.’”
The settlement recited that all claims were extinguished. Greatheart signed an affidavit that stated the settlement “forever closes my case, including any and all compensation or medical benefits except those specifically listed in the settlement.”
Seeks full payment
“On May 18, 2021, Greatheart requested a hearing, asserting that the City ‘underpaid the billed charges’ on the Careplex bill. The City moved to dismiss Greatheart’s claim, emphasizing the release language of the settlement order. The City asserted that Greatheart had ‘released’ his claim for ‘payment of a medical bill balance’ and ‘agreed that it was discharged and extinguished by the settlement order’ and he was ‘unequivocally bar[red]’ from pursuing it.
“Greatheart opposed the City’s motion, contending that the settlement order ‘expressly’ provided that payment for reasonable and necessary medical treatment ‘shall continue for the period between the date of the accident and the date’ of the order. The sum sought arose during this period.
“The deputy commissioner denied the City’s motion to dismiss and set the matter for an on-the-record proceeding.” Following the hearing, the deputy commissioner ruled that Greatheart lacked standing to bring the claim. The full commission affirmed the deputy commissioner’s decision.
Standing
“Standing can be established if a party alleges he or she has a ‘legal interest’ that has been harmed by another’s actions. … Here, we find that the parties’ settlement vested Greatheart with a right to have the medical bills at issue paid by the City.
“As part of the settlement order, the City promised to pay a lump sum to Greatheart and to pay reasonable and necessary medical expenses through the date of the entry of the order. This was a negotiated agreement with bargained for consideration.
“Greatheart gave up the right to seek future workers’ compensation benefits in exchange for the City’s promises. Greatheart, as a party to the settlement agreement, has a ‘substantial legal right’ to enforce that agreement. …
“As Greatheart points out, the City’s assurance that payment shall continue for reasonable and necessary medical treatment up to the date of the settlement order would be meaningless if he lacked standing to enforce it.”
On the merits
“The City … urges us to find that the release language is broad enough to fully extinguish all of Greatheart’s claims for relief. Greatheart claims the agreement expressly carved out reasonable and necessary medical expenses incurred before November 1, 2019 from the release language.
“We need not resolve these competing (and arguably conflicting) terms, because we can decide the case on narrower grounds. …
“We find dispositive the Commission’s findings that Careplex accepted the sum tendered as payment in full and that the balance due was $0.00. The record reflects that the City paid Careplex the amount of $12,643.51 in 2016 for its care to Greatheart.
“Greatheart complains that this left a shortfall of $8,033.49 from the original bill. However, a credit adjustment was made in the amount of $8,033.49, leaving a balance of $0.00. There is nothing within the language of the order that states the medical treatment payments cannot be adjusted, or that the providers cannot accept a lesser sum than initially charged.
“There is nothing in the record to indicate that the provider has ever sought further payment since 2016. The Commission found that, after the credit adjustment, there was ‘no further payment owed.’ In the Commission’s words: ‘the medical provider does not aver that it is owed a debt by the employer. It instead accepted the workers’ compensation credit adjustment that was applied to the bill in question.’”
Affirmed.
Greatheart Jr. v. City of Hampton, Record No. 0689-22-1, May 16, 2023. CAV (unpublished opinion) (Friedman). From the Virginia Workers Compensation Comm’n. Philip J. Geib for appellant. Steven H. Theisen for appellee. VLW 023-7-173, 22 pp.
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