Workers’ Compensation Must Reimburse for Medical Marijuana Costs in Pennsylvania
Injured workers in Pennsylvania are entitled to be reimbursed for medical marijuana costs under the state’s workers’ compensation law.
The Commonwealth Court of Pennsylvania has ruled that while the Medical Marijuana Act (MMA) does not require insurers or self-insured employers to provide coverage for medical marijuana, the marijuana law also does not alter the mandate under the Workers’ Compensation Act (WC Act) that they reimburse workers for reasonable and necessary out-of- pocket costs of medical treatment.
Insurers’ and employers’ fear of liability under federal laws that prohibit the sale or distribution of marijuana are unfounded, the appeals court also ruled in the opinion written by Judge Anne E. Covey in a case involving an employee of Firestone Tire & Rubber.
On September 19, 1977, Paul Sheetz sustained an injury during the course and scope of his employment with Firestone. Beginning in 1977, he received medical treatment including two back surgeries. Due to the severe pain in his back and legs, his doctor prescribed opiates and narcotics, including OxyContin. At the recommendation of his doctor, he began taking medical marijuana in January 2019, with the hope of eliminating the need for the opiates and narcotics he had been taking for approximately 30 years. Medical marijuana afforded him pain relief and reduced his need for the opiates and narcotics. As a result of taking medical marijuana, Sheetz weaned himself off Diazepam and OxyContin. In September 2019, a utilization review found that his medical marijuana use was reasonable and necessary.
In October 2019, Sheetz alleged that his employer violated the WC Act by failing to pay for his medical marijuana treatment, despite the utilization review determination that the treatment was reasonable and necessary. In October 2020, the workers’ compensation judge denied Sheetz’s petition, concluding that he failed to prove that the employer’s refusal to pay for the medical marijuana treatment violated the WC Act. The workers’ compensation appeals board affirmed that judge’s decision and the claimant’s estate appealed to the Commonwealth Court seeking reimbursement and penalties.
The court noted that under the WC Act, although the burden is initially on the claimant to establish that the injury is work-related, once the employer acknowledges liability for the injury, the claimant is not required to continually establish that medical treatment of that compensable injury is causally related. Thereafter, the employer has the burden of proving that a medical expense is unreasonable, unnecessary, or is not related to the accepted work injury.
Medical Marijuana Act
Under the MMA, use or possession of medical marijuana is lawful within the Commonwealth. Medical marijuana may only be dispensed, however, to patients who receive certifications.
The marijuana statute states that part of its intent is to provide a “program of access to medical marijuana which balances the need of patients to have access to the latest treatments with the need to promote patient safety.”
The main argument centered around Section 2102 of the MMA that says: “Nothing in [the MMA] shall be construed to require an insurer or a health plan, whether paid for by Commonwealth funds or private funds, to provide coverage for medical marijuana.”
Sheetz’s estate argued that Section 2102 only prohibits an insurer or health plan from being compelled “to provide coverage for medical marijuana.” The plaintiff contended that coverage refers to the insurer paying the provider directly for a medical service, while reimbursement signifies the insurer paying the patient for the costs of medical treatment already incurred and paid.
Firestone maintained that lawmakers included that language in the MMA to avoid a possible conflict between the MMA and the Federal Drug Act as it pertains to employers/insurers and that the MMA’s plain language exempts employers/insurers from being required to cover medical marijuana.
But the court found that while the MMA provides that an insurer is not required to include medical marijuana as a risk under its insurance policy, there is no language in the MMA precluding a workers’ compensation carrier from repaying a claimant for out-of-pocket medical treatment costs found to be reasonable and necessary for a work-related injury as the WC Act mandates.
Regarding liability for paying for a drug considered illegal under the federal law, the court noted that the MMA contains an immunity provision protecting patients from government sanctions. Moreover, Congress has expressly prohibited the federal Department of Justice from using allocated funds to prevent states, including Pennsylvania, from implementing their medical marijuana laws.
Firestone tried to argue that its workers’ compensation provider was not an insurer under the marijuana law but the court said the legislature considered workers’ compensation carriers and self-insured employers as insurers in the WC Act and there is no reason to conclude that the General Assembly intended to narrow the interpretation in the MMA.
The court concluded that the employer’s failure to reimburse the employee for his out-of-pocket costs for medical marijuana to treat his work-related injury was a violation of the WC Act.