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Furnival State Machinery v. Workers' Compensation Appeal Board8/10/2000
liability for worker's compensation benefits, to those fees specified. I can find nothing in the statute or in the appellate caselaw which would support the claimant's argument to the effect that a party seeking subrogation/reimbursement is entitled to demand more than the claimant and medical providers were entitled to receive from the worker's compensation carrier. WCJ's Opinion, at 4.
The Workers' Compensation Appeal Board (Board) reversed. In its opinion, the Board found that Section 306(f.1)(3) is not relevant to the current inquiry, as it is directed at providers, not insurers. Instead, the Board relied upon that portion of the Act upon which the third party insurer based its claim for subrogation--Section 319 of the Act--which provides in relevant part:
Where an employe has received payments for the disability or medical expense resulting from an injury in the course of his employment paid by the employer or an insurance company on the basis that the injury and disability were not compensable under this act in the event of an agreement or award for that injury the employer or insurance company who made the payments shall be subrogated out of the agreement or award to the amount so paid, if the right to subrogation is agreed to by the parties or is established at the time of hearing before the referee or the board. 77 P.S. ยง 671 (emphasis added).
The Board found that under the plain language of this section, the third-party insurer is entitled to the full amount paid, even if that amount exceeds 113% of the Medicare reimbursement rate. The workers' compensation insurance carrier then appealed to this court.
We agree with petitioners that the purpose and spirit of Act 44's cost containment provisions are best furthered by limiting subrogation under Section 319 to the amounts specified in Section 306(f.1)(3). Nevertheless, we cannot agree that the purposes of Section 306(f.1)(3), however salutary they may be, control the outcome in this case, in the face of specific language to the contrary in Section 319. Petitioner's primary argument is that the third-party health insurer should be found to "stand in the shoes" of the claimant. Since a workers' compensation claimant is only entitled to receive medical treatment for a work-related injury pursuant to the Workers' Compensation Act, an insurance carrier should only recover through subrogation what the workers' compensation claimant is entitled to receive in payment. Petitioner's brief, at 8.
However, the cost containment provisions of Section 306(f.1)(3) do not limit what a claimant may recover, nor limit the medical payment obligation of employers and their compensation carriers. By its terms that section limits only what a medical provider may charge when it is to be compensated by an employer under the Act. Here, the provider did not submit its charges for payment pursuant to the terms of the Act, but pursuant to a contract of insurance unconnected with the Workers' Compensation system. In that situation, the insurance contract controls the charges for which medical providers may be compensated, not Section 306(f.1)(3). Petitioner's policy argument and the analysis of the WCJ might nonetheless prevail were it not for the plain language of Section 319. As noted above, that section specifically provides that the payor shall be subrogated "in the amount so paid."
Accordingly, the order of the Workers' Compensation Appeal Board is affirmed.
BONNIE BRIGANCE LEADBETTER, Judge
ORDER
AND NOW, this 10th day of August, 2000, the order of the Workers' Compensation Appeal Board in the above captioned matter is affirmed.
BONNIE BRIGANCE LEA
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