American Manufacturers Mutual Insurance v. Sullivan

Chief Justice Rehnquist delivered the opinion of the Court.[†] Pennsylvania provides in its workers’ compensation regime that an employer or insurer may withhold payment for disputed medical treatment pending an independent review to determine whether the treatment is reasonable and necessary. We hold that the insurers are not “state actors” under the Fourteenth Amendment, and that the Pennsylvania re [*44] gime does not deprive disabled employees of property within the meaning of that Amendment. hH Before the enactment of workers compensation laws, employees who suffered a work-related injury or occupational disease could recover compensation from their employers only by resort to traditional tort remedies available at common law. In the early 20th century, States began to replace the common-law system, which often saddled employees with the difficulty and expense of establishing negligence or proving damages, with a compulsory insurance system requiring employers to compensate employees for work-related injuries without regard to fault. See generally 1 A. Larson & L. Larson, Larson’s Workers’ Compensation Law §§5.20-5.30, pp. 2-15 to 2-25 (1996).

Following this model, Pennsylvania’s Workers’ Compensation Act, Pa. Stat. Ann., Tit. 77, § 1 et seq. (Purdon 1992 and Supp. 1998) (Act or 77 Pa. Stat. Ann.), first enacted in 1915, creates a system of no-fault liability for work-related injuries and makes employers’ liability under this system “exclusive ... of any and all other liability.” § 481(a). All employers subject to the Act must (1) obtain workers’ compensation insurance from a private insurer, (2) obtain such insurance through the State Workmen’s Insurance Fund (SWIF), or (3) seek permission from the State to self-insure. § 501(a). Once an employer becomes liable for an employee’s work-related injury — because liability either is not contested or is no longer at issue — the employer or its insurer[1] must pay for all “reasonable” and “necessary” medical treatment, and must do so within 30 days of receiving a bill. §§531(l)(i), (5).

[*45] To assure that insurers pay only for medical care that meets these criteria, and in an attempt to control costs, Pennsylvania amended its workers’ compensation system in 1993. 1993 Pa. Laws, No. 44, p. 190. Most important for our purposes, the 1993 amendments created a "utilization review” procedure under which the reasonableness and necessity of an employee’s past, ongoing, or prospective medical treatment could be reviewed before a medical bill must be paid. 77 Pa. Stat. Ann. §531(6) (Purdon Supp. 1998).[2] Under this system, if an insurer “disputes the reasonableness or necessity of the treatment provided,” §531(5), it may request utilization review (within the same 30-day period) by filing a one-page form with the Workers’ Compensation Bureau of the Pennsylvania Department of Labor and Industry (Bureau). § 531(6)(i); 34 Pa. Code §§ 127.404(b), 127.452(a) (1998). The form identifies (among other things) the employee, the medical provider, the date of the employee’s injury, and the medical treatment to be reviewed. Ibid.; App. 5. The Bureau makes no attempt, as the Court of Appeals stated, to "address the legitimacy or lack thereof of the request,” but merely determines whether the form is “properly completed — i.e., that all information required by the form is provided.” Sullivan v. Barnett, 139 P. 3d 158, 163 (CA3 1998); see 34 Pa. Code § 127.452(a). Upon the proper filing [*46] of a request, an insurer may withhold payment to health care providers for the particular services being challenged. 77 Pa. Stat. Ann. §531(5) (Purdon Supp. 1998); 34 Pa. Code § 208(f).