Court: Louisiana Court of Appeal; December 14, 1995; Louisiana; State Appellate Court
Thelma Robyn Starks filed an appeal against Universal Life Insurance Company following a judgment from the Office of Workers' Compensation regarding her workers' compensation claim. Starks, who was employed as an insurance collector, sustained injuries from a fall on January 29, 1992, for which she received compensation benefits until October 21, 1992. In May 1994, a doctor diagnosed her with a central disc protrusion and recommended surgery, which Universal refused to cover. Starks subsequently filed a Disputed Claim for Compensation in June 1994, seeking additional benefits. Universal countered that her claim had prescribed and that she was not disabled.
During the trial, several stipulations were made, including her average weekly wage and the total amount of benefits already paid. The hearing officer ruled in favor of Universal, concluding that Starks' claim for weekly benefits had prescribed, she was not entitled to temporary total disability benefits, and Universal’s denial of benefits was not arbitrary and capricious. Starks was ordered to pay the costs, and her claims were dismissed with prejudice. She appealed, arguing that the hearing officer erred in her findings regarding the prescription of benefits, the entitlement to temporary total disability benefits, the arbitrary nature of Universal's denial, and the dismissal of her motion to appeal in forma pauperis.
The legal basis for the prescription of compensation claims is outlined in LSA-R.S. 23:1209 A, stating that claims must be filed within one year of the accident unless payments have been agreed upon or a formal claim has been filed within that timeframe. The limitations may extend based on the timing of the last payment made.
Injuries that do not manifest immediately after an accident have a limitation period that begins one year from the injury's development, barring any claims unless proceedings are initiated within two years of the accident. Jurisprudence equates the development of an injury with the onset of disability, which is defined as the point at which an employee can no longer satisfactorily perform job duties. Under LSA-R.S. 23:1209 B, claims for developing disabilities must be filed within two years of the accident.
In this case, Universal paid the plaintiff weekly compensation benefits until October 21, 1992, giving her until October 21, 1993, to file a claim, which she did not do until June 21, 1994, making her claim prescribed. The plaintiff attempted to use the developmental theory to argue that her claim had not prescribed since she learned in May 1994 that surgery was needed. However, the statute requires that any claim be filed within two years of the accident for the developmental theory to apply, which was not the case here.
Regarding medical benefits, LSA-R.S. 23:1209 C states that claims are barred unless agreed upon within one year after the accident or filed formally within that time. If payments have been made, the limitation starts three years after the last payment. Since Universal was still covering the plaintiff's medical expenses at trial, her claim for medical benefits had not prescribed. However, the hearing officer found that the plaintiff did not have a disabling condition related to the January 29, 1992, accident, but rather a preexisting condition not aggravated by the accident. This determination implies that her medical claims were not necessitated by the accident. The plaintiff must prove her claims to a reasonable certainty and by a preponderance of the evidence.
Medical expense awards for injured employees are restricted to costs necessitated by work-related accidents, with the burden of proof on the claimant to substantiate these expenses. Case law establishes that a trial court's determination of medical benefits is a factual issue, and appellate courts may only overturn such decisions in cases of manifest error. Credibility assessments and factual inferences made by the trial court are typically upheld unless clearly unreasonable. In the present case, the record includes testimonies and medical reports from the plaintiff and her treating physicians, Drs. Franklin and Gary. Dr. Franklin, who first examined the plaintiff in July 1991, noted findings related to a prior injury. Following the work-related accident in January 1992, he diagnosed her with sciatica and a contusion, later identifying potential lumbar spine issues through imaging. Dr. Gary, who treated the plaintiff thereafter, corroborated the diagnosis of low back pain and diagnosed a lumbar disc herniation, noting that the imaging results indicated changes from prior examinations dating back to a 1985 injury.
Dr. Gary diagnosed the plaintiff with a herniated disc at L-5, accompanied by acute back pain and left sciatica. Following an epidural steroid injection on April 3, 1992, the plaintiff reported no improvement by April 13, leading Dr. Gary to consider recommending a discectomy if symptoms persisted, though the plaintiff declined surgery. On June 26, 1992, Dr. A. Delmar Walker, Jr. evaluated the plaintiff, finding mild degenerative changes in the L-5 disc, typical for someone of her age and size, with no evidence of nerve root pressure or significant deformity that would justify surgery. Dr. Walker noted the presence of pre-existing abnormalities and opined that the L-5 disc deformity had actually decreased since 1985.
Dr. Gary later scheduled a second epidural steroid injection on July 27, 1992. By August 10, he deemed the plaintiff to have reached maximum medical improvement and recommended exercise and weight loss, indicating no need for surgery and attributing a 10% whole body permanent physical impairment. In September 1992, Dr. Gary observed a slight increase in the disc protrusion compared to 1985 but maintained that surgery was unnecessary.
In May 1994, MRI and EMG studies revealed nerve root impingement and a central disc protrusion, prompting Dr. Gary to recommend surgery due to the lack of improvement and progression in the EMG results. On June 14, 1994, Dr. Gordon P. Nutik assessed the plaintiff, noting inconsistencies in her low back examination and suggesting she had a soft tissue strain on top of a pre-existing disc issue, with no objective findings linking her symptoms to a fall on January 29, 1992. He also recommended weight loss and strengthening exercises rather than surgery.
On July 11, 1994, Dr. Walker reiterated that the plaintiff was a poor surgical candidate due to her borderline abnormalities and obesity, as well as her lack of participation in exercise. The hearing officer concluded that the plaintiff did not have a disabling condition resulting from the January 29, 1992, accident, attributing her condition to pre-existing issues that were not exacerbated by the incident. This conclusion was supported by the evidence reviewed.
Plaintiff's medical condition post-fall on January 29, 1992, was found to be similar to the status following a prior injury in 1985, leading to the hearing officer's conclusion that the plaintiff did not sufficiently prove her entitlement to medical benefits. The hearing officer's decision is deemed not manifestly erroneous. Regarding penalties and attorney's fees, the plaintiff argues that Universal acted arbitrarily and capriciously by denying physical therapy. Under LSA-R.S. 23:1201 E, a 12% penalty may be applied for late compensation payments, but penalties are not warranted if the employer or insurer reasonably contests the employee's right to benefits. LSA-R.S. 23:1201.2 stipulates that insurers must pay claims within sixty days of notice, with penalties for arbitrary non-payment. A finding of arbitrary or capricious action is required for imposing attorney's fees. The statutes regarding penalties must be strictly interpreted, and an assessment is appropriate unless the employee's rights are reasonably controverted. The determination of whether the insurer had reasonable grounds to challenge the employee's claims is factual and not to be overturned without manifest error. In this case, the hearing officer noted that while physical therapy was discussed, it was only recommended by Dr. Franklin and authorized when suggested by either Dr. Franklin or Dr. Gary, who opted for steroid injections and surgery instead.
A dispute exists regarding the recommendation for surgery for Ms. Starks, with disagreement between the reviewing doctor and her treating orthopaedist, Dr. Gary. The defendant has maintained authorization and payment for treatments by Dr. Franklin and Dr. Gary up to the trial date. The court concludes that the defendant was not arbitrary and capricious, thus denying the plaintiff's request for attorney's fees and penalties. A review of the records supports the hearing officer's findings, with no manifest error found.
Under LSA-C.C.P. art. 5181, individuals unable to pay court costs due to poverty may litigate without advance payment. This privilege is intended to help indigent persons access courts and is interpreted liberally. Courts assess a litigant's ability to pay based on their net income after essential expenses and debts. The trial court has broad discretion in granting this privilege, and appellate courts typically do not interfere unless there is clear abuse of discretion.
In this case, the plaintiff argues that the hearing officer wrongly denied her motion to appeal in forma pauperis. However, since the plaintiff has already advanced the costs, the issue is rendered moot. Consequently, the hearing officer's judgment is affirmed in all respects, with appeal costs assigned to the plaintiff.
Additional notes reference the involvement of Judge Hillary J. Crain as judge pro tempore, the plaintiff's weight reported by Dr. Walker, and a penalty provision for unpaid compensation or medical benefits under LSA-R.S. 23:1201 E. Lastly, it suggests that a more appropriate method to challenge a denial of in forma pauperis status is to apply for supervisory writs as illustrated in the case of Benjamin v. National Super Markets, Inc.
