Pa. court says adjuster’s error in accepting cancer claim doesn’t bar compensability

An appeals court in Pennsylvania has affirmed the partial acceptance of a workers compensation claim for a Philadelphia firefighter with colon cancer that a claims adjuster said had been mistakenly accepted because she made a computer error.

As documented in City of Phila. and PMA Mgmt. Corp v. Bell (WCAB), filed in the Commonwealth Court of Pennsylvania, the city’s risk management counsel and employee disability manager had instructed the adjuster to deny John Bell’s 2022 claim for colon cancer, arguing “there was no evidence of a causal relationship between Claimant’s condition and his employment as a firefighter.”

The adjuster, however, said she “partially denied” the claim, which the computer then accepted as “medical-only.” As evidence of the mistake, the city submitted emails between the adjuster and the risk department in which the adjuster recommended a denial of the claim and the risk department agreed.

After reviewing the submitted evidence, a workers compensation judge found the adjuster “did not understand” the process “and chose ‘partially deny’ within the internal software to ensure payment of any treatment with a panel provider.” While the WCJ accepted that adjuster made a mistake and did not intend to generate the medical-only claim, the WCJ was not willing to set it aside. Writing that “(a)llowing…  documents to be set aside when mistakes are made is not a precedent this (judge) is going to set.”

The Workers’ Compensation Board affirmed, writing “that there is no allegation that Claimant supplied incorrect information to (employer) which led to the (medical-only notice of compensation payable) and there is no assertion that (employer] later learned of facts indicating Claimant’s claim was not compensable, thus making the acceptance of the claim erroneous.”

On appeal, the commonwealth court ruled no error was made in the judge’s decision to not set aside the medical-only claim when a mistake had been made, writing the judge “had discretion to decide whether to set aside the Medical-Only NCP. Even after she found it was incorrectly issued, (state law) did not require her to set aside the incorrectly issued Medical-Only NCP.”