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Workers' Compensation Board

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Case # G0390004
Date of Accident: 01/19/2011
District Office: NYC
Employer: Penzetta Plumbing & Heating Inc.
Carrier: State Insurance Fund
Carrier ID No.: W204002
Carrier Case No.: 64649858
Date of Filing of Decision: 08/21/2017
Claimant's Attorney: Sher Herman & Bellone, PC
Panel: Kenneth J. Munnelly

MANDATORY FULL BOARD REVIEW
FULL BOARD MEMORANDUM OF DECISION

The Full Board, at its meeting on July 18, 2017, considered the above captioned case for Mandatory Full Board Review of the Board Panel Memorandum of Decision filed January 13, 2017.

ISSUE

The issue presented for Mandatory Full Board Review is whether the reimbursement for medical and transportation expenses was excessive.

The Workers' Compensation Law Judge (WCLJ) directed the carrier to reimburse the claimant for medical and travel expenses in the amount of $6,830.69.

The Board Panel majority affirmed the WCLJ decision, but also found that if the claimant requests further reimbursement for his medical care transportation expenses, he must first look for medical care that is reasonably closer to his home, and if none is available, then submit such evidence that adequate medical care is not available more proximate to his home.

The dissenting Board Panel member would find that the claimant is not entitled to reimbursement for his medical and transportation expenses because the claimant has not shown that the treatment he obtained in New York City is not available closer to his residence.

The carrier filed an application for Mandatory Full Board Review on January 26, 2017, arguing that the Full Board should adopt the dissenting opinion because the claimant was not entitled to reimbursement for long distance travel for medical care.

The claimant did not file a timely rebuttal.

Upon review, the Full Board votes to adopt the following findings and conclusions.

FACTS

This claim has been established for a compensable back injury that occurred on January 19, 2011, along with a consequential urological condition and consequential major depression. The claimant was classified permanently totally disabled in a WCLJ decision filed on December 18, 2015.

The claimant filed a Form C-257 (Claimant's Record of Medical and Travel Expenses) with the Board on April 25, 2016, requesting reimbursement of transportation expenses in the amount of $6,830.69 for doctors' visits from February 5, 2011, to October 3, 2015.

The carrier, in correspondence dated March 2, 2016, denied reimbursement to the claimant because the mileage was not customary nor reasonable.

At a hearing held on June 10, 2016, the WCLJ directed the carrier to reimburse the claimant $6,830.69 for his medical and transportation expenses incurred traveling from his home in the mid-Hudson Valley to see his treating doctors in Queens and Manhattan. No testimony was taken. The findings made at the June 10, 2016, hearing are reflected in a notice of decision filed on June 15, 2016.

In the carrier's application for administrative review filed on July 11, 2016, it argued that the WCLJ should have denied the claim for excessive travel expenses as unreasonable, absent proof that comparable treatment could not have been obtained nearer to the claimant's home.

In rebuttal, the claimant argued that the WCLJ's direction to pay was appropriate, and the WCLJ decision should be affirmed in all respects.

LEGAL ANALYSIS

"[U]nder the Workers' Compensation Law scheme, employers are required to pay for medical treatment, procedures, devices, tests and services (hereinafter medical care) for employees who sustain causally related injuries for such period as the nature of the injury or the process of recovery may require. However, medical necessity and appropriateness (hereinafter medical necessity) have always been prerequisites to an employer's obligation, and the denial of payment for medical care has been upheld where it is duplicative, excessive or inappropriate for the claimed injury, and accordingly of no benefit to the injured worker" (Matter of Kigin v State of N.Y. Workers' Compensation Bd., 109 AD3d 299 [2013] [internal citations and quotation marks omitted]).

"It is well settled that an injured employee is entitled to transportation to and from medical care (see Matter of Morrell v Onondaga County, 244 AD2d 695 [1997]; Matter of Simpson v Glen Aubrey Fire Co., 86 AD2d 909 [1982])" (Matter of Young v Ceramic Tile Contrs., 288 AD2d 570 [2001]). The statute has been broadly construed in order to effectuate the economic and humanitarian purposes of the Workers' Compensation Law to permit reimbursement for the expense of travel required to obtain necessary medical care (see Matter of Young v Ceramic Tile Contractors, 288 AD2d 570 [2001]). However, this broad construction does not obligate the employer to pay for expenses beyond what is reasonable under the circumstances of the case (see Matter of Morrell v Onondaga County, 244 AD2d 695 [1997]; Matter of Langford v William Rogers, Inc., 144 AD2d 785 [1988]).

A review of the record in this matter indicates that the claimant was making trips from his home in the mid-Hudson Valley to seek treatment in the New York City area, resulting in round trips of approximately 150 miles. The Board has previously found distances of this extent reasonable (see Matter of JMS Group, 2016 NY Wrk Comp G0459735, Matter of LaSalle School, 2017 NY Wrk Comp G0915549). The Board Panel in Matter of JMS Group found that reimbursement for medical and transportation of less than 200 miles was not unreasonable.

Therefore, the Full Board finds that a preponderance of the evidence supports the finding of that the WCLJ correctly directed the carrier to reimburse the claimant for transportation expenses in the amount of $6,830.69. However, with respect to future reimbursement requests, the claimant is hereby directed to obtain medical care nearer to his home or submit evidence that equivalent medical care is not available nearer to his home. Claimant is also directed to file all future claims for medical and transportation reimbursement within one year of the date on which the medical treatment occurs, or the medical cost is incurred, and failure to do so may result in the reimbursement request being denied.

CONCLUSION

ACCORDINGLY, the WCLJ decision filed June 15, 2016, is AFFIRMED. With respect to future reimbursement requests, the claimant is hereby directed to obtain medical care nearer to his home or submit evidence that equivalent medical care is not available nearer to his home. Claimant is also directed to file all future claims for medical and transportation reimbursement within one year of the date on which the medical treatment occurs, or the medical cost is incurred, and failure to do so may result in the reimbursement request being denied. No further action is planned by the Board at this time.