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Further Developments on Maximum Medical Improvement Language

February 12, 2010
tags: , ,
by Scott Mancuso

William Capicotto MD PC and State Farm Mut. Auto. Ins. Co.

AAA Case No. 412009030888, Arbitrator Kent L. Benziger
Amount in Dispute: $315.13

In this arbitration, an orthopedic surgeon conducting an independent medical examination on behalf of the Respondent insurer, contended the Assignor’s prognosis was poor but that his condition had “stabilized.”  Arbitrator Benziger stated that in sum, the examining doctor meant that the Assignor had reached “maximum medical improvement.”

The arbitrator stated that more recent decisions have tried to side-step the use of the term “maximum medical improvement” and hold that treatment is no longer necessary where it is “not improving or otherwise benefiting a claimant.”  Treatment that is not providing any “curative” or palliative” benefits may no longer be necessary.

The arbitrator stated that “palliative” would be defined in this instance as treatment that lessens the severity of pain and suffering and improving the quality of life without necessarily affecting a cure.

As the examining doctor in this arbitration used the “stabilized” language however, the arbitrator determined this was not enough to establish a lack of medical necessity defense, and the award was granted in full.

This arbitration gives more of an indication as to what type of IME language will serve to uphold a lack of medical necessity defense.  ”Stabilized” is out and “no more palliative benefit” is in.

from → Arbitration
One Comment leave one →
  1. Larry Rogak permalink
    February 15, 2010 11:48 am

    It’s so comforting to see the triumph of semantics over substance in a quasi-judicial decision. Not.

    Reply

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