Washington’s Board of Industrial Insurance Appeals Provides Some Guidance in Applying Maphet
Ever since the Washington Court of Appeals issued the Clark County v. Maphet decision in late 2019, employers have struggled with the ramifications and implications of the decision. 10 Wn.App.2d 420 (2019). Under Maphet, if an employer authorizes treatment for a condition, it is also accepting the condition, even in situations where there is no causal connection to the underlying injury or occupational disease. In the past, it was typical to authorize such treatment while investigating whether a seemingly unrelated condition was proximately caused, aggravated, or otherwise related to an accepted condition. Maphet, however, turned that practice on its head and significantly raised the stakes of authorizing treatment under a claim and employers have had little to no guidance as to the extent and/or limits of Maphet. Thankfully, claims with Maphet implications are now working their way through the litigation process, and the Board has identified two tentatively significant decisions that will help employers administer claims and narrow the scope of accepted conditions.
In re Samuel Pena involved a worker who injured his back while working as a janitor. Dckt. No. 19 17589 (March 22, 2021). He alleged the Department accepted his preexisting bipolar disorder, anxiety, and ADHD conditions when it paid for medications designed to stabilize his mood and avoid manic episodes. Claimant’s psychiatrist testified at hearing about how claimant’s inability to provide for his family increased his anxiety and aggravated his bipolar disorder. Claimant argued Maphet applied, but the Board disagreed. The Board found the issue in Maphet was not whether the self-insured employer accepted a condition because it paid for treatment for the condition, but rather whether the employer accepted the condition because it authorized multiple surgeries to treat the condition. The Board specifically noted “[t]he holding in Maphet was not simply that payment equals acceptance.”
In re Jeremy Carrigan involved a worker who injured his low back and developed numbness in his legs and right hip pain. Dckt. No. 20 12899 (July 13, 2021). He was diagnosed with lumbar radiculopathy, an L5-S1 disc protrusion, and multilevel lumbar spine degenerative conditions. Claimant underwent two epidural steroid injections, and alleged the employer accepted the disc protrusion and degenerative conditions when it authorized the injections. The Board disagreed, finding the employer authorized treatment for a lumbar strain, which was the only accepted condition under the claim, and that epidural injections have both therapeutic and diagnostic purposes. Because the injections were not authorized for the purpose of treating disc protrusions or multi-level degenerative spine conditions, the Board found the employer’s authorization for treating the lumbar strain did not constitute acceptance of other conditions.
Both decisions also establish that in claimant appeals, it is claimant’s burden to show an industrial injury caused or aggravated a condition or, in the alternative, establish the employer accepted the conditions under Maphet when it authorized treatment.
These decisions provide helpful examples and explanations of how Maphet applies beyond cases with similar or identical facts. Not only do these decisions help narrow the scope of Maphet and its applicability to other claims, but they also provide some general principles for how to administer and navigate claims. What these decisions do not do, however, is relieve or lessen employer’s responsibilities to carefully examine and evaluate treatment authorizations and medical bills submitted for payment under a claim. SBH strongly recommends continuing to analyze treatment authorizations, medical bills and the listed CPT/diagnosis codes to determine if the conditions are accepted under the claim before issuing payment. SBH also recommends identifying the purpose of authorizing or paying for treatment and whether it is to address an accepted condition only or as an aid of recovery under WAC 296-20-055.
The nuances and applications of Maphet continue to impact claim administration and SBH provides employers assistance and answers questions regarding this evolving issue. Please do not hesitate to contact me at 503-412-3117 or for guidance as it is better to stay ahead of Maphet issues than risk accepting unrelated and/or preexisting conditions and diagnoses.