CHARLESTON – The West Virginia Supreme Court of Appeals has issued an opinion stating that a claims administrator who denied reimbursement for a meal during a workers’ compensation medical examination appointment was in the wrong.
Carlos Silveti, a claimant for workers’ compensation benefits, was ordered by his claims administrator to attend a medical examination that was 100 miles away from his home and during the six hours he spent traveling to, attending and from the medical examination, he ate one meal, according to the April 11 opinion.
Silveti sought reimbursement from the claims administrator for the meal expense incurred while attending the medical examination and the claims administrator denied the request on the ground that his travel did not require overnight lodging.
Justice Menis Ketchum authored the majority opinion. Justice Beth Walker dissented.
“We are asked whether the claims administrator had the discretion to deny Mr. Silveti’s request for reimbursement of his meal expense,” Ketchum wrote.
Ketchum said the court found that under the plain language of West Virginia Code § 23-4-8, the claims administrator did not have discretion to deny Silveti reimbursement for his meal expense on the ground that his travel did not require overnight lodging.
“We remand this case to the Workers’ Compensation Board of Review for an order consistent with state law,” Ketchum wrote.
Silveti was a chef at Ohio Valley Nursing Home in Parkersburg and he injured his left shoulder and left knee when he slipped and fell exiting the walk-in refrigerator at work. He filed a workers’ compensation claim, which was held compensable for sprain of the left rotator cuff capsule and left knee.
The claims administrator, for unknown reasons, sent Silveti to a workers’ compensation medical examiner in Fairmont instead of one in Parkersburg, and he was forced to spend six hours—from 11 a.m. until 5 p.m.—traveling to, attending and back home from the appointment.
Silveti, as a claimant, was entitled to reimbursement for reasonable travel expenses, including meals, incurred in connection with an ordered medical examination and he ate one meal in Bridgeport, approximately 20 miles from Fairmont and timely submitted a voucher with his meal receipt attached, asking for reimbursement for the meal expense.
The claims administrator decided not to reimburse the meal expenses, stating that it was not reasonable, as Silveti’s travel did not require overnight lodging. Silveti appealed the decision to the Office of Judges, who affirmed the claims administrator.
Silveti then appealed the decision to the Workers’ Compensation Board of Review, who affirmed the decision of the Office of Judges. Silveti then appealed the decision to the Supreme Court.
“Mr. Silveti spent six hours traveling to, attending and returning from a medical examination because the claims administrator decided to send him to an examiner one-hundred miles away in Fairmont,” Ketchum wrote. “In addition to placing this hurdle to Mr. Silveti obtaining his workers’ compensation benefits, the claims administrator decided that it was not reasonable for him to have eaten a meal during his six hours away from home because he did not spend the night in Fairmont.”
In doing so, Ketchum wrote, the claims administrator violated the clear mandate in West Virginia Code § 23-4-8 that Silveti be reimbursed his reasonable travel expenses.
“We recognize that the Insurance Commissioner may promulgate regulations interpreting West Virginia’s workers’ compensation statutes,” Ketchum wrote. “To that effect, there is already a regulation in place, West Virginia Code St. R. § 148-NA-4.1 limiting reimbursement for meal expenses so that it does not exceed the per diem rate established by the federal government for state employee travel.”
Ketchum said what the Insurance Commissioner may not do is contravene the plain language of a statute he or she is charged with administering through a regulation which takes away a right specifically granted by the Legislature.
“Because the Insurance Commissioner’s interpretation of ‘reasonable’ travel expenses in West Virginia Code St. R. § 85-1-15.1 and West Virginia Code St. R. § 148NA-4.3 is contrary to the plain meaning of West Virginia Code § 23-4-8, we are obliged to reject it,” Ketchum wrote. “ Therefore, we must remand this case to the Board for an order consistent with state law.”
Ketchum said under the plain language of West Virginia Code § 23-4-8, the claims administrator did not have discretion to deny reimbursement for a meal expense incurred in connection with travel to an ordered medical examination on the ground that the claimant’s travel did not require overnight lodging.
“The Board’s affirmance of the claims administrator’s decision clearly violated the plain language of the statute,” Ketchum wrote. “Therefore, we reverse the Board’s decision and remand the case for entry of an order consistent with state law.”
W.Va. Supreme Court of Appeals case number: 17-0746