School District's Denial Opens Possibility of Off-Plan Provider for Special Ed Teacher

Rapid City, SD (WorkersCompensation.com) – The issue of whether a doctor is part of a plan can determine whether workers’ compensation coverage will pay for treatment.

In Dittman v. Rapid City School District, Nos. 29548, 29576 (S.D. 06/15/22), South Dakota’s top court found that while a special education teacher chose a provider that wasn’t part of the plan, her school district employer’s denial of compensation let her go off plan.

The teacher experienced a back injury at work and sought treatment. After a surgical evaluation, one of her doctors determined that the teacher was not a surgical candidate, but the teacher indicated that she would continue researching potential surgeons.

Eventually, the teacher found a surgeon, but the insurer denied her request for a surgical consultation. In response, the teacher filed a petition for hearing. The insurer contended that the teacher sought a second opinion, which would be at her expense. The Department of Labor and Regulation ruled in favor of the insurer, holding that she was not entitled to receive treatment from a provider outside her managed care plan.

The teacher appealed, arguing that state law entitled her to receive treatment because the insurer denied compensability at the time she received a referral to the surgeon from whom the teacher sought a consultation.

In court, the teacher came up short again, prompting her to appeal to the South Dakota Supreme Court.

In South Dakota, workers’ compensation insurance policies must include a case management plan, and a medical provider who is not participating in the plan may provide medical services to an employee when compensability is denied by the insurer.

In this case, the court explained that the insurer denied compensability only to later amend its answer to say it did not.

“Despite the amended answer, the fact remains that [the insurer] initially denied and continued to deny the compensability of [the teacher’s] claim from the time of its original answer,” the court explained.

Although the surgeon was an “out-of-network provider,” state law authorized his services, and thus the court reversed the decisions of the department and lower court.

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