Opinion
BOARD No. 00046393
Filed: April 10, 1998
REVIEWING BOARD DECISION
(Judges McCarthy, Maze-Rothstein, and Smith.
APPEARANCES
Madeline G. Piper, for the employee.
James A. Garretson, for the insurer.
The insurer appeals from a decision ordering payment of all reasonable and adequate medical treatment for a secondary psychological injury. We find that where the only claim before the judge relating to the psychological injury was for past medical prescriptions, the judge's decision ordering payment for medical treatment for the psychological injury was beyond the scope of his authority and must be reversed.
As a result of an injury to her right foot and low back in January of 1993 while working as a banquet waitress, the employee was paid a closed period of temporary total incapacity benefits and ongoing partial incapacity benefits. On December 15, 1995, the insurer filed a request to modify or discontinue benefits, which was denied at a conference held on June 10, 1996. The insurer appealed to a hearing de novo. Prior to the hearing, the employee filed a motion to join her claims for payment of loss of function benefits pursuant to § 36, for payment of outstanding expenses for past chiropractic treatment, for payment of additional temporary total disability benefits, and for "payment of past medical expenses for psychiatric treatment totaling $460.00." (Motion to Join Employee's Claim 1.) The judge approved this motion on June 14, 1996. The case proceeded to hearing on August 19, 1996, where the judge specifically asked the employee's attorney if she was raising a psychiatric claim and if she was claiming medical benefits for that claim. (Tr. 6.) The attorney responded that she was raising a psychiatric claim, but that she was claiming "[p]rescription costs only, not the doctor's fee." ( Id.) The judge then asked the attorney to indicate her claim on her form so that there would be no question it was being raised. ( Id.) The attorney wrote on a form entitled "Opening Record and Hearing Form", "employee claims prescriptions = $400," and initialed the notation. ( Id. 6-7.) The judge then stated for the record:
The decision states that both parties appealed. (Dec. 2.) However, the record indicates that the only appeal was by the insurer.
The employee is also claiming Sections 13 and 30 medical benefits as it pertains to prescriptions for the psychiatric treatment totaling $400.
The insurer raises the following issues: liability, the insurer denies an industrial injury as to a psychiatric condition. The insurer also raises the issue of disability and extent of incapacity, causal relationship as to the psychiatric condition, and the insurer denies entitlement to sections 13 and 30 benefits as to the psychiatric condition.
(Tr. 7.) With the issues thus defined, the case proceeded to hearing and decision.
In his decision, the judge causally related the employee's depression to her industrial injury on a secondary basis. (Dec. 9-10.) The judge based this finding on the opinion of the psychiatrist whom the employee testified treated her for depression in 1994 and 1995. (Dec. 5, 9; Employee Exhibit 3.) The judge noted that the insurer submitted no opposing opinion regarding the psychiatric claim. (Dec. 9.) The judge found "that the employee's psychological depression arose out of her industrial injury on a secondary basis," (Dec. 10), and ordered, "That the insurer pay for all reasonable and adequate medical treatment as provided under § 30 of the Act, including psychological treatment." (Dec. 12.)
The insurer appeals, alleging that the part of the judge's order requiring the insurer to pay for all reasonable and adequate psychiatric treatment exceeds the scope of the claim and should be reversed. We agree.
As a general rule, where liability is established by a decision, an employee has the right to adequate and reasonable health care services causally related to the work injury. G.L. c. 152, §§ 13 and 30; Valles v. Logan Airport, 10 Mass. Workers' Comp. Rep. 305, 307 (1996). However, the scope of the administrative judge's authority at a § 11 hearing is limited to deciding those issues in controversy. G.L.c. 152, § 11B. Therefore, in order to properly present a dispute over medical benefits, an employee must actually file a claim for them. See Gebeyan v. Cabot's Ice Cream, 8 Mass. Workers' Comp. Rep. 101, 103 (1994); Welch v. A.B.V. Systems, 9 Mass. Workers' Comp. Rep. 407, 410 (1995). ("Where there is no claim and therefore no dispute, the judge strayed from the parameters of the case and erred in making findings on issues not properly before her."); see also G.L.c. 152, § 7G (documentation attached to claims) and its implementing regulation, 452 Code Mass. Regs. 1.07(2)(c)(1).
452 CMR 1.07 provides, in pertinent part:
(2) Pursuant to the provisions of M.G.L.c. 152, § 7G, the following documentation must be attached to a claim for benefits . . .
(c) 1. Claims for payment for adequate and reasonable health care services shall, where applicable, be accompanied by the following:
a. the dates of service;
b. the type of treatment or service and the itemized costs;
c. office notes, hospital records, or a statement from the attending physician or medical vendor that such visit, testing, prescription drug, therapy, or ancillary medical service device or aid was reasonable, necessary, and causally related to the injury for which the employee is eligible for benefits.
Here, the record clearly reflects that the employee limited her psychiatric claim to past prescription medications and specifically excluded any request for other treatment, including doctor's bills. Thus, there was no issue before the judge regarding payment for any specific psychiatric treatment other than prescribed medications. Therefore, though the judge properly found that the employee's psychological problems arose out of her industrial accident, he nevertheless erred in ordering that the insurer pay for all reasonable and adequate psychological treatment.
Because the judge exceeded the scope of his authority in awarding benefits that were not claimed, we reverse the award of psychological treatment. Because the judge made no specific finding on the reasonableness and adequacy of the claimed prescription medications and because the record is contradictory regarding the precise amount claimed, further findings on those issues are required. As the judge who issued the decision is no longer with the Board, the case is returned to the senior judge for reassignment to another administrative judge for further proceedings consistent with this decision. In all other respects, the decision is affirmed.
So ordered.
____________________ Suzanne E.K. Smith Administrative Law Judge
_____________________ William A. McCarthy Administrative Law Judge
_____________________ Susan Maze-Rothstein Administrative Law Judge
Filed: April 10, 1998