Illinos worker's "doctor shopping" blocks benefits
The Illinois Workers' Compensation Commission awarded the worker permanent disability to the extent of 5 percent of the person as a whole under Section 8(d)2 of the Illinois Workers' Compensation Act. However, the arbitrator limited the medical treatment award based on the worker's failure to prove that certian pain treatment was reasonable, necessary and related to the work accident.
Case name: Calabrese-Simplicio v. St. Alexis Hospital, 17 ILWCLB 115 (Ill.W.C.Comm.2009).
Simplicio testified that she was working as a respiratory therapist and asthma educator at the defendant's hospital when she injured her back while pushing and pulling a ventilator. She also alleged a second work accident. She underwent lumbar surgery but continued to complain of debilitating pain. She was placed in a 28 day pain program. After the program, she continued to be treated with narcotic medications. The arbitrator found a causal connection between Simplicio's work injury and "some level of ill being."
However, the arbitrator further found Simplicio's subjective complaints grossly outweighed the verifiable evidence of disablity related to the work accident. The arbitrator awarded permanent disability to the extent of 5% loss of a person as a whole under Section 8(d)2. In addressing Simplicio's extensive pain management treatment, the arbitrator noted the treatment consisted almost entirely of increasing use of narcotic pain medications. Despite this treatment, Simplicio's condition did not improve. Also, the treating doctor indicated a lack of understanding of Simplicio's history and the extent of her psychiatric history. The arbitrator concluded that Simplicio did not meet her burden of proving that the pain treatment was reasonable, necessary, and related to the work accident.
Moreover, the arbitrator noted that Simplicio presented evidence of a tenuous chain of referral leading to two of her doctor's. The arbitrator further noted that although an employee is entitled under Section 8(a) to two separate choices of physicians, as well as the referrals made within that particular chain, the WCA does not approve the type of doctor shopping that appeared to have occurred in this case. When Simplicio was confronted with options she did not care for, she would simply switch back and forth between separate chains of referral to obtain treatment that was otherwise not recommened. In this regard, Simplicio's actions were similar to the type of doctor shopping referenced in the Commission's decision Morales v. Scholle Corp, in which the Commission refused to award medical expenses incurred after a specific date. Accordingly, the arbitrator declined to award additional expenses to Simplicio.
Upon review the Commission affirmed and adopted the decision of the arbitrator.
