4.7 MEDICAL BENEFITS
4.701 Scope.
A. In General. The Act requires employers to furnish all reasonable and necessary physician care and medical attention for any injury sustained in a compensable accident or occupational disease. The term "medical attention" is very comprehensive and embraces surgery, medical and surgical supplies, hospital service including room, board, and nursing service, and whatever else may be necessary to cure the employee of the injuries. 210 When appropriate, an injured worker may also be eligible for vocational rehabilitation services. The purpose of the provision of the Act governing medical treatment of the employee is twofold: to place the cost of medical care on the
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employer and to restore the employee's good health so that the employee can return to useful employment as soon as possible. 211
Medical benefits are provided free of charge. 212 There is no limitation on the time period for which the employer is required to furnish medical treatment. Under the Act, medical benefits must be provided "as long as necessary." 213
B. Relation to Injury. The employer is only responsible for medical treatment and attention that is causally related to the work injury or occupational disease. An employer may be found liable for diagnostic treatment, but if medical conditions are discovered that are not traceable to a compensable injury, the employer is not required to furnish further medical treatment of the condition. 214
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If medical treatment or hospitalization is required for conditions both related and unrelated to injury, the charges should be apportioned. 215 For example, where an employee was hospitalized for the amputation of part of a finger rendered necessary by a compensable accident, but the period of hospitalization had to be extended for treatment for delirium tremens secondary to chronic alcoholism, the employer was held liable for only the portion of the bill relating to the amputation. 216 An employer cannot be required to pay the entire bill for a claimant's hospitalization but only the portion of the bill related to the compensable injury unless an enumerated problem must be treated before the treatment is given for the compensable injury. 217
C. Reasonable and Necessary Care. Under the Act, the employer's liability is limited to reasonable or necessary medical care. The employer is not required to pay for medical treatment that is not considered necessary, and prior payments do not estop the employer from denying future payments. 218 The employer is not liable for the expense of the claimant's self-prescribed medications 219 or the cost of a private room when the attending physician is of the opinion that a ward room is adequate for the care of the injured employee. 220 Generally, the employer is responsible for furnishing adequate medical treatment to the claimant, and any additional treatment will be procured at the claimant's own expense. 221
When the employee decides to seek a second medical opinion and does so without authorization from the employer or the Commission and without a referral from his or her treating physician, the employer has no duty to pay for this opinion. 222
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D. Failure to Provide Medical Attention Once Aware of Need for Care. If the employer does not fulfill its duty to furnish medical treatment, it is required to pay for treatment secured by the employee. 223 But if the employer does not know about the original injury or about a change in condition that requires additional medical care, the employer is not required to furnish medical attention, and it is not liable for the cost of treatment procured by the employee without notice.
E. Emergency Care. If the employee receives treatment on an emergency basis from a physician other than one provided by the employer, the employer is required to pay for its cost. 224 In this case, the employee has the burden of proof that there was a true emergency and that the employee could not obtain treatment from an authorized treating physician. 225
4.702 Physician Care.
A. Treating Physician. Section 65.2-603 requires the employer to furnish to the employee a panel of at least three physicians from which the employee is to select the initial treating physician. An employee who asserts an employment-related injury is not required to seek medical care from an employer's panel of physicians unless the employer authorizes the employee to do so at the employer's expense. 226 The employee is under no duty to see the employer's doctor for which the employer has disclaimed responsibility. 227
Once a selection is made from an appropriate panel, that physician becomes the treating physician. Likewise, in cases where a valid panel was not timely provided or the employer disputes compensability, the physician
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selected by the injured worker becomes the treating physician. 228 For compensable injuries, the treating doctor makes all decisions relating medical treatment and attention. The cost of such care, including referrals to other health care providers, becomes the responsibility of the employer.
Where the employer pays or assumes the cost of all or part of the claimant's health care coverage, either as a self-insured or part of a group policy, the employer, upon request, must inform the worker whether each physician is eligible to receive payment under the provided health care coverage. 229 The attending physician selected by the employee becomes the treating physician if the employer fails or refuses to provide a panel of physicians. 230
Once a treating physician is selected, a change cannot be made without the permission of the employer, the insurance carrier, or the Commission. 231
B. Panel of Physicians. The panel of physicians must include physicians from at least three different medical groups. Virginia Code section 65.2-603(F) provides that a chiropractor may be included on a panel where the injury is within the scope of chiropractic care, and section 65.2-603(D) provides that chiropractic services, treatment, and reports are included in the terms "medical attention," "medical service," "medical care," and "medical report." Section 65.2-603 does not require the employer to select one of the doctors on a panel as the treating physician when the employee refuses to do so. 232
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1. Prompt Offer of a Panel. An employee must be provided with a panel of physicians as soon as possible after the injury; otherwise, he or she may seek treatment from the doctor of his or her choice. 233 If the employer fails to offer a panel of physicians or denies compensability, the employee is justified in securing his or her own treatment. 234 Although the Act does not specify the period within which the panel of physicians must be offered to the employee, the test is reasonableness depending on the circumstances of the particular case. 235 A delay in providing the panel is reasonable if an employer does not know of the need for medical treatment and an employee has not commenced a course of treatment with his or her own physician. 236
Posting a notice or advising employees of the company panel during safety meetings is not sufficient. 237 An employer's offer of a panel of physicians several days after the claimant's supervisor initially acquiesced to treatment with the claimant's own health care insurer was not untimely or unreasonable, and the employer was not liable for the claimant's continued treatment by her own physician. However, the claimant was entitled to wage loss benefits for her period of disability; her continued treatment with her own physician is not the same as a refusal of medical services that would bar benefits altogether. 238
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2. Panel Requirements. The panel of physicians must contain not only a list personally brought to the attention of the employee but also the names of three physicians who do not share a community of interest in a joint practice. 239 As long as the employer furnishes an employee with adequate medical attention, any additional unauthorized treatment is obtained at the employee's expense. 240 An offer of a panel of physicians was found to be defective when the physicians were located so far from the employee's residence that it was unreasonable to require her to accept their treatment. 241 Similarly, a panel of physicians, one of whom was unwilling to see the claimant, was found defective. The claimant was justified in selecting a treating physician not on the panel list. 242 Where a panel is defective, an injured worker may seek treatment from a physician or chiropractor (where appropriate) of his or her own choice. 243 However, once treatment has commenced, the selected physician becomes the treating doctor. 244 An employer cannot deny a claim and still control medical care. Therefore, if at any point the employer denies compensability, the injured worker may select or change to a physician of his or her own choosing. 245
C. Specialist. The employer must provide the services of a specialist if they are deemed necessary by the attending physician or the Commission. Neither the employer nor its insurance carrier may place limits
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on the number of physicians, specialists, or treatment facilities to which the claimant may be referred for treatment. 246 In Harris v. Crompton-Shenandoah Co., 247 an employer was required to pay for the services of three doctors, each of whom had a different specialty, when the employer had failed to object to the attending physician's referral of the employee to the specialists. As long as a causal relationship between the industrial accident and the complaints that are the subject of the referral is shown, the employer is financially responsible for the medical attention that the attending physician deems necessary subject to review by the Commission. 248 However, the employer is not responsible for the cost of treatment where the employee changed physicians without...
