Opinion ID: 885192
Heading Depth: 1
Heading Rank: 5

Heading: gastrointestinal medication

Text: ¶ 60 S.L.H. suffered from recurring gastroesophageal reflux which became more severe in 1997. In response to the exacerbated condition, Dr. Dietrich requested authorization to prescribe Prevacid, a more expensive medication than previously had been prescribed. The State Fund's claims examiner initially denied payment and requested Dr. Dietrich's notes. Upon receipt of the notes, she continued to deny payment for the medication. ¶ 61 As mentioned earlier, absent at least a minimal investigation of a claim's validity, denial of a claim for benefits is unreasonable. Lovell, 260 Mont. at 288, 860 P.2d at 101. The claims examiner's investigation consisted solely of her request for Dr. Dietrich's office notes. In those notes, Dr. Dietrich stated I would view this as an exacerbation of an underlying condition due to the stress, mostly all of which is connected in some way to her assault and subsequent problems. He also attributed the worsening of the condition to the stress of the trial, the Workers' Compensation case, vocational rehabilitation, the multitude of evaluations that she has had, the depositions, etcetera.... ¶ 62 In its ruling, the court stated that [i]n denying authorization for the ... Prevacid, Hunt [the claims examiner] acted on her own without any medical consultation or advice (other than the advice supplied by Dr. Dietrich). However, the court held that the denial was not unreasonable because the State Fund's liability for the more expensive medication was reasonably debatable as it may be reasonably argued that the more costly medication is attributable to the stress of the impending trial, not to the injury.... ¶ 63 S.L.H. contends that the State Fund had no medical evidence that the exacerbation of the condition, and the resultant need for different medication was not related to her injury. ¶ 64 The State Fund responds that S.L.H.'s treating physician, Dr. Dietrich, himself noted that the exacerbated condition was related to an upcoming trial of S.L.H.'s third-party claim against the manufacturer of the alarm system at her former employer's place of business. Relying on this opinion expressed by S.L.H.'s treating physician, the State Fund asserts that its denial of payment for the medication was not unreasonable. ¶ 65 In this case, although the claims examiner denied payment for medication prescribed by the claimant's treating physician, she did not ignore Dr. Dietrich's opinion. Rather, the claims examiner relied on the treating physician's notes in which the doctor stated that the exacerbation of the condition may have been attributable to an impending civil trial, rather than to her injury. A claims examiner cannot, without any medical consultation or advice, reasonably ignore the opinion of a claimant's treating physician and refuse to pay for medication prescribed by the treating physician. Plooster v. Pierce Packing Co. (1993), 256 Mont. 287, 846 P.2d 976. However, we cannot say that the notes from S.L.H.'s treating physician in this case were unequivocal. ¶ 66 The claims examiner here performed a very minimal investigation before denying payment, but she did complete some investigation, and the information she received from Dr. Dietrich was arguably sufficient to create a question as to the State Fund's liability for the exacerbation of S.L.H.'s reflux condition. Because there is substantial credible evidence, although not necessarily a preponderance, to support the Workers' Compensation Court's ruling that the State Fund had a reasonably debatable argument for denying payment for the more expensive medication, we affirm the court's decision that the State Fund's actions were not unreasonable and that S.L.H. was therefore not entitled to either penalties or attorney fees on that issue.