Court Opinion

ID: 9649527
Source: CourtListenerOpinion
Date Created: 2023-08-23 14:58:36.771479+00
Date Added: 2024-06-11T18:12:11.721105
License: Public Domain

DISSENTING OPINION BY
Judge PELLEGRINI.
My disagreement with the majority involves little, if any, money. It is limited to whether the matter should be remanded to the WCJ to decide whether a penalty should be imposed due to Employer’s failure to promptly pay a bill for $440 for two pairs of shoes. The majority is probably doing Claimant a favor because what is involved is so miniscule that it may be more trouble than it is worth to even seek penalties on remand. But while the “principal” may be small, the “principle” involved is important — cases should only be resolved on the issues raised.
The facts are simple. In 1991, Claimant suffered a work-related injury to her “left foot big toe” causing, among other things, a difference in the size of her feet. Employer accepted her injury by a notice of compensation payable.1
Claimant then filed a penalty petition because Employer refused to pay a medical bill for two pair of shoes that were ordered by her physician.2 Regarding the bill for the shoes, she testified before the WCJ that the bill was from Hanger Pros-thetics and Orthotics, Inc. (Hanger) and was for a pair of orthopedic shoes and for a pair of sneakers. She presented the original bill into evidence on which appeared her name, the insurance ID# , the referring physician — Stanley E. Boc, DPM (Dr. Stanley Boc) — the items ordered and price, invoice date, date of service and patient ID. On the front of the bill was written “not work related” and “see attached.” Attached to the bill was another form from Sedgwick CMS showing that the bill was being returned for the following reasons: “We have not received an Employer’s Report of Occupational Injury or Disease, please contact the employee or employer for additional information;” “Insured advised this is not a work related injury and/or they have no report;” “No date of injury on file.”
Before the WCJ, the only issue argued by Employer was whether Dr. Stanley Boc *370was actually the physician who prescribed the shoes for the bill in question,3 not whether Employer was denying payment of the bill for the shoes. On redirect, Claimant clarified that her physician was Stephen Boc, DPM, Stanley Boc’s brother, and that she had never treated with Stanley Boc. Claimant also offered into evidence a Utilization Review Determination reviewing a recommendation by Stephen Boc for a pair of orthopedic shoes and one pair of sneakers.
Even though never raised by Employer, the WCJ denied Claimant’s penalty petition regarding the shoes because it was not presented on the correct forms, supposedly either an HCFA Form 1500 or the UB92 Form. The majority affirms, finding that “it is not the burden of the employer to examine a medical invoice not presented on the ‘right’ forms required to be used in workers’ compensation claims, and then puzzle out whether the claim might be work-related injury.” It then goes on to state that “the Act and regulations place the burden upon the claimant to submit medical invoices on the proper form and with all the information needed to permit an employer to ascertain that the billed treatment is related to the work injury.”
I disagree because the majority ignores that the WCJ raised this issue sua sponte,4 If Employer had rejected the bill because it was not on the proper form, it may have *371served as a basis for rejecting payment. More likely, though, there would have been no penalty petition, because if Claimant knew why her bill was not paid, she would have then submitted it “correctly.” Ignoring all of that, the majority assumes that employers automatically salute and require medical bills to be on an “alphabet form” just because regulators say so. What that assumption ignores is that Claimant knew how to get her bills paid— over the years she submitted 341 bills, including bills for shoes, totaling $113,053.91.5 By raising the issue sua sponte, the WCJ deprived Claimant of the opportunity to prove that Employer did not require bills on prescribed forms. Perhaps Employer just found it easier to take the bill, enter the Claimant’s name in its computer system, find a claimant’s account just like every hospital, doctor’s office and even what this court does when accessing a claimant’s records. We will never know because the issue was not raised.
Accordingly, I respectfully dissent.

. For a full background of this case, see Sims v. Workers' Compensation Appeal Board (School District of Philadelphia) (No. 3071 C.D.2002, filed 9 September 2003).

. Once it is determined that an employer is liable for an injury under the Act, the employer is required to pay a claimant’s reasonable and necessary medical expenses that are causally related to the injury. Martin v. Workers’ Compensation Appeal Board (Red Rose Transit Authority), 783 A.2d 384 (Pa.Cmwlth.2001). Section 435 of the Act, 77 P.S. § 991(d), authorizes the imposition of penalties for violations of the Act.

. The questioning, in toto, by the Employer regarding the shoes was as follows:
Q: As far as the shoes go, it says on the shoe invoice here that a Doctor Stanley Bock ...
A: Stephen Bock is my doctor.
Q: That would be a typo, then, what they have there, Stanley Bock?
A: That’s my doctor’s brother.
Q: Did you ever see Stanley for anything?
A: No.
Q: Do you have any knowledge as to whether this was submitted by Doctor Bock to the insurance?
A: When I go to Hanger, my doctor gives me a scrip with his name on there and I take the scrip and I give them the scrip. I’ve been going there for years. That’s where I go.
You brought that to my attention, because all I saw was “Bock”. So I didn’t really, you know — but that the way- — I usually just take a scrip that my doctor writes out and I gave it to them because they have a file, and that’s where I usually go.
(Reproduced Record at 18.)

. In footnote 9, the majority responds to the dissent by admitting that the issue was never raised, but shifts its holding by boldly stating that the WCJ can do that because the WCJ can, sua sponte, raise that issue because "citing deficiencies in the documentary evidence is the job of any factfinder.” The unattended corollary to the majority's holding is that we would now be allowed to reverse a factfin-der's determination on appeal if the documentary evidence is insufficient, even if not raised simply because the factfinder did not do his or her job.
If that is not sufficiently disconcerting, the majority’s holding requires that medical bills be on the prescribed forms even if the employer does not require them on the prescribed forms. In this age of paperless office and electronically-transmitted bills, while it may warm the cockles of a regulator’s heart, the majority's holding is simply impractical.
Moreover, what the majority is blind to is that a claimant meets his or burden of proving that penalties may be in order when it is shown that he or she submitted a bill to the employer that was not promptly paid. The burden then shifts to the employer to set forth a legitimate reason why the bill was not promptly paid. If that reason is insufficient, penalties may be awarded at the WCJ’s discretion. See footnote 2. But if an employer does not require that certain information be submitted with a bill, it cannot later avoid penalties for that reason. See Kuemmerle v. Workers’ Compensation Appeal Board (Acme Markets, Inc.), 742 A.2d 229 (Pa.Cmwlth.1999) (provider’s failure to submit required written reports to insurance carrier did not excuse employer from penalties for failure to pay bills because it did not require medical reports in all instances for payment of medical services.)
*371Finally, there may be a good answer as to why Claimant did not call, fax, phone, write or visit Employer to find out why her bills were not paid, but again, we’ll never know, because the majority is now raising an issue that was not raised by the Employer or the WCJ below.

. In footnote 13, in further response to the dissent, the majority states that the dissent does not explain why Employer improperly denied the shoe bill.
What the majority ignores is that Employer subsequently paid the bill. This is no surprise, considering that a Utilization Review finding, albeit 4 years earlier, found that shoes of this type were reasonable and necessary medical treatment. (See Exhibit C-2, a bill from Hanger Orthopedic, with a March 16, 2005 date of service and Exhibit D-l listing a payment of a bill from Hanger Orthopedic with that date of service on June 6, 2005, while the hearing in this proceeding was underway. I recognize that the bill was for $440 and payment of the bill was for $316, but attribute the difference to the fact that medical bills are paid in accordance with the cost containment provisions of the Act. See 77P.S. § 531).
More importantly, though, it is not our responsibility to explain why an employer paid or did not pay a bill. Our responsibility is to decide whether an employer’s defense for non-payment was sufficient. Here, to repeat, Employer never ever alleged before the WCJ or this Court that the bill was not work-related or that it was submitted on the wrong form.