Opinion ID: 1578063
Heading Depth: 1
Heading Rank: 5

Heading: Alternate Medical Care.

Text: An alternate medical care claim brought by an injured worker prior to a final determination of liability of an employer has its roots in the statutory duty of an employer to provide medical care. This duty, however, is imposed only when the employer does not contest the compensability of the injury. See Iowa Code § 85.27(1). This is an important proposition under the statute because it means the issue of compensability is totally removed from the alternate medical care process. Instead, the commissioner's role under section 85.27 at this stage is limited to determining the reasonableness and necessity of medical care sought by an employee as an alternative to the care furnished by the employer. Thus, if a compensability issue arises in the course of an alternate care dispute, the commissioner cannot order that the alternate care sought by the employee be furnished by the employer prior to a determination of the compensability of the injury in a contested case proceeding or some other proceeding. See Iowa Admin. Code r. 876-4.48(7) (Petitions for alternate care where liability of the employer is at issue should be filed pursuant to rule 4.1.). Administrative rule 4.48 is consistent with this approach. See id. r. 876-4.48. On the other hand, in those cases where compensability of the injury is not at issue and the employer furnishes medical care to the employee, the commissioner is authorized to order the employer to provide alternate care if the employee establishes the alternate medical claim upon reasonable proof of necessity for the care. [2] Iowa Code § 85.27(4); see West Side Transp., 601 N.W.2d at 693-94 (commissioner can order alternate care upon sufficient proof). If the commissioner orders alternate care, the employer is required to furnish the care. Of course, if the commissioner finds the employee has failed to establish the necessity for the alternate care, the employer has no responsibility to furnish or pay for such care. Nevertheless, such a finding by the commissioner does not mean the employee may not still choose to obtain the alternate care. It only means the employer will not be responsible for the expense of the care. If the employee chooses to obtain the alternate care after the commissioner has denied a petition for alternate care on its merits, the employee will be responsible for the expense. Thus, the employer's statutory right to choose the care under section 85.27(4), commonly referred to as the right to control and direct medical care, does not prevent an employee from obtaining alternate care against the directions of the employer. Instead, it enables the employer to assert an authorization defense in the event the employee later seeks to have the employer pay for the unauthorized care. The denial of a petition for alternate care on the merits implies the employer has attained its qualified right under the statute to choose medical care. Like the right to choose the care, the authorization defense is limited in its scope. While it applies to cases when the commissioner has denied a petition for alternate care on its merits, the defense does not apply to cases where the commissioner has denied a petition for alternate care on procedural grounds that prevent the commissioner from adjudicating the merits of a petition, such as a dispute over the compensability of the injury. Under such circumstances, there can be no implicit finding that the employer has satisfied its duty to furnish reasonable medical care and has no obligation to furnish alternate care. Thus, the issue is properly left for future determination. R.R. Donnelly's argument in support of the continued viability of the authorization defense following the commissioner's denial of the petition for alternate care in this case fails to consider the limited nature of the authorization defense. R.R. Donnelly asserts it is entitled to continue to direct the course of treatment for Barnett by separating compensable from uncompensable medical conditions, so that it can continue to use the authorization defense as to those conditions it agrees are compensable. Yet, such a distinction between compensatory and noncompensatory conditions does not permit the employer to assert the authorization defense for the alternate medical treatment at issue in this case. Once an employer takes the position in response to a claim for alternate medical care that the care sought is for a noncompensatory injury, the employer cannot assert an authorization defense in response to a subsequent claim by the employee for the expenses of the alternate medical care. Of course, this approach does not mean the authorization defense may not be available for other forms of alternate medical care obtained by an employee not authorized by the employer or not submitted to the commissioner under section 85.27. R.R. Donnelly injects other issues into the case to help justify its claim that the denial of the compensability of one medical condition by an employer should not result in the loss of the right to continue to choose medical care for the injured worker, and to assert the authorization defense, for medical conditions that are accepted as compensable as if the employer had denied the entire claim. In particular, R.R. Donnelly claims that the record before the commissioner did not support an implicit finding by the commissioner that it denied the entire claim. It also claims such an implicit finding operates to alter the burden of proof to establish compensability of an injury. Finally, R.R. Donnelly argues that there was no evidence to support a finding that Barnett properly invoked the alternate care provisions of the statute by giving R.R. Donnelly a reasonable opportunity to resolve the dispute before filing a petition. We need not address the substance of these issues. The decision by the commissioner in this case to deny the petition for alternate care, and to bar the authorization defense, was not tantamount to a finding that R.R. Donnelly denied the compensability of the entire claim, and the finding made by the deputy commissioner that the compensability of the condition could not be separated does not impact the operation of section 85.27(4). Under the statute, R.R. Donnelly simply never acquired an authorization defense to assert. Furthermore, issues as to the timeliness of the petition for alternate care were rendered moot by the dismissal of the petition by the commissioner. The important factor from our review of the record is there was substantial evidence before the commissioner that R.R. Donnelly denied compensability of a condition or injury Barnett allegedly suffered and for which she sought alternate medical treatment or care. This evidence and admission were sufficient to support the deputy commissioner's decision to dismiss the application by Barnett for the requested alternate medical care without deciding the merits of the claim, and to bar R.R. Donnelly from asserting a defense as to the expenses of the care that would only be available when an application is decided on the merits. This approach under the statute does not preclude R.R. Donnelly from later contesting liability for this treatment on the basis of the lack of compensability of the injury or unreasonableness of the care, nor does it alter R.R. Donnelly's right to choose care for those injuries that it concedes are compensable.