Can an employer be liable for the cost of a worker’s unnecessary cardiac procedure? And, what is a potential strategy for the employer to use?
The employer should determine whether the employee’s injury or disease leading to a need for cardiac treatment arose out of and occurred in the course of the employee’s employment, and whether the treatment was reasonable and medically necessary.
Workers’ compensation statutes provide for compensation to employees for an injury that arises out of and in the scope of the worker's employment and, in some circumstances, for occupational diseases or conditions that result from a worker’s employment. In some jurisdictions, the injury must be the result of an accident to be compensable. When an employee submits a worker’s compensation claim requesting coverage for medical treatment for a heart attack, heart disease, or another cardiac condition or injury, the employer’s first step should be to determine whether the injury, disease, or condition was “work-related” or occurred “in the course of the employment.” See generally: Workers' Compensation—Compensable Coronary Episode (Heart Attack), 10 Am. Jur. Proof of Facts 3d 669; Cause of Action for Workers' Compensation for Heart Attack, 51 Causes of Action 2d 291.
An employer generally may be able to avoid liability for a workers’ compensation claim for medical treatment related to a heart attack, heart disease, or other cardiac condition or injury by demonstrating that no causal link existed between the claimant’s injury, disease, or disorder and the claimant’s employment. See: Am. Jur. 2d Workers' Compensation §§ 192 to 195, Overview; Cause and Nature of Injury or Disability; In General; Modern Workers Compensation Ch. 110, Employment Connection; C.J.S. Workers' Compensation § 409, Compensable Injuries, Arising out of and in Course of Employment, Causal connection between injury and employment.
For example, if a worker with heart disease suffers an injury on the job, or in connection with the worker’s employment, and the employee’s heart disease does not qualify as an occupational disease under state law, the prior existence of the worker’s heart disease may affect whether the injury is compensable under workers compensation statutes. The worker will need to demonstrate that the “injury” for which compensation is sought meets the applicable statutory requirement for a compensable injury, generally defined as an accidental injury, an injury by accident, or an injury caused by an accident. Some states, however, have no requirement that an injury be accidental in order for the injury to be compensable. See generally: Modern Workers Compensation § 108:1, Accidental injury requirement.
Similarly, when the claim is related to an employee’s heart attack, the claimant must prove that the heart attack was caused by employment-related factors. The heart attack generally will be considered accidental in nature if it was caused by an accident or if it was an unexpected result of the usual performance of the employee's duties. The heart attack will be considered to have occurred in the course of employment if the employee can be shown to have been in a place where the employee reasonably could be expected to be as part of his or her employment, and if the injury took place during the period of employment, while the employee was performing the duties of employment, or something incidental to those duties. When this is the case, the heart attack injury and necessary treatments may be considered compensable. See generally: Workers' Compensation—Compensable Coronary Episode (Heart Attack), 10 Am. Jur. Proof of Facts 3d 669; Cause of Action for Workers' Compensation for Heart Attack, 51 Causes of Action 2d 291.
Workers compensation statutes generally require employers to cover the costs of medical care only if the treatment is reasonable, necessary, or “medically necessary” to treat a claimant’s compensable injury. An employer may refuse to pay for medical treatment for an employee if the treatment does not qualify as reasonable or necessary under the circumstances. A cardiac procedure that is not medically necessary thus would not be compensable under workers’ compensation. See: Modern Workers Compensation § 202:5, Requirement that treatment be necessary; Modern Workers Compensation § 202:39, Cost containment.
An employee’s cardiac stent procedure was found to be treatment that was reasonable, necessary, and related to a workplace accident, and thus was compensable. The claimant suffered a heart attack while working as a security guard for the employer. The employer argued that the claimant's injuries resulted from preexisting coronary disease, and that the claimant was feeling seriously ill even before he responded to the emergency, which required him to run across the employer’s campus, and then up and down four flights of stairs, in a short time period. As a result of the heart attack, the claimant underwent quadruple bypass surgery and then a second surgery to place a stent in his coronary artery. The workers’ compensation board determined that the claimant’s heart attack was related to his employment and awarded compensation. It initially found that the stent placement was insufficiently related to the heart attack to be compensable, but later decided that the stent placement was a compensable work injury. The employer argued on appeal that the stent placement would have been required due to the claimant’s pre-existing heart condition, and thus should not be compensable. The court noted the expert medical testimony that the claimant’s medical care (including the placement of a stent) was “reasonable, necessary, and related to the work accident.” The court concluded this testimony was sufficient evidence to support the board's conclusion that the claimant's heart attack and the ensuing complications resulted from his workplace exertion and, thus, his medical care (including the placement of the stent) was compensable. See: Day & Zimmerman Sec. v. Simmons, 965 A.2d 652 (Del. Supr., Dec. 23, 2008).
For the employer to be found not subject to worker’s compensation liability for an employee’s cardiac procedure, proof must be presented that:
- The employee's injury, disability, or death related to a heart attack, heart disease, or other cardiac condition, which led to the cardiac procedure, was not work-related and did not occur in the course of employment
- The employee’s heart disease was not an occupational disease
- The procedure used to treat the employee’s injury, disease, or disorder related to heart attack, heart disease, or other cardiac condition was not reasonable, necessary, or medically necessary
See: Practice the Techniques - Checklists providing an example fact checklist that can be used to determine an employer’s liability for the costs of an employee’s cardiac procedure