Court: Louisiana Court of Appeal; February 3, 2015; Louisiana; State Appellate Court
Gilchrist Construction Company, LLC (Gilchrist) appeals a judgment favoring former employee Mr. Marlon Lavalais, which grants him Temporary Total Disability Benefits (TTDs), coverage for past medical expenses, future medical treatment, travel expenses, penalties, attorney fees, and costs. The court denied Gilchrist’s defense under La.R.S. 23:1208.1, which sought to deny benefits due to alleged falsehoods in a pre-employment medical questionnaire. Mr. Lavalais responded to the appeal and requested attorney fees for the appellate process.
On November 2, 2012, while employed by Gilchrist, Mr. Lavalais was injured in a vehicle accident involving a company car. He sustained neck, back, and knee injuries and has not returned to work since the incident. Mr. Lavalais had completed a medical questionnaire on August 28, 2012, prior to his hiring, where he falsely answered 'NO' to questions about prior injuries, including knee, neck, and back injuries, as well as current medications. Despite Mr. Lavalais’ claims that the response regarding medication use was not his own, he signed the questionnaire, indicating he understood and affirmed its contents. The questionnaire contained clear warnings that failure to answer truthfully could lead to the forfeiture of workers' compensation benefits. The court ultimately affirmed the initial ruling with amendments.
Mr. Lavalais, following an accident on November 2, 2012, sought workers' compensation benefits from Gilchrist Construction Company. During an investigation, it was revealed through a conversation between Mr. Lavalais and Ms. Kim Sandrock of Travelers Insurance that Mr. Lavalais had previously suffered injuries to his neck, back, and right knee, which he failed to disclose on his pre-employment questionnaire. Citing La.R.S. 23:1208.1, Gilchrist denied his benefits, asserting that this statute allows employers to inquire about prior injuries and mandates truthful responses; failure to do so can lead to forfeiture of benefits. The statute requires that employees be notified in writing about the consequences of untruthful answers, with the notice prominently displayed.
On February 8, 2013, Mr. Lavalais filed a LDOL Form 1008 for benefits related to his accident. Gilchrist responded on March 19, 2013, claiming Mr. Lavalais had violated La.R.S. 23:1208.1 and forfeited any benefits. After a trial, the Workers' Compensation Judge (WCJ) found that while Gilchrist had obtained recorded statements revealing Mr. Lavalais's prior injuries, they failed to prove that he forfeited his benefits under the statute. The WCJ awarded Mr. Lavalais temporary total disability (TTD) benefits of $320.43 per week starting November 3, 2012, and mandated ongoing medical treatment, including surgeries. Additionally, the WCJ ordered payment of past medical expenses totaling $16,607.07, medical travel expenses of $1,349.82, and imposed penalties of $4,000.00, attorney fees of $12,000.00, and costs of $2,525.83, all accruing legal interest until paid. Gilchrist appealed the WCJ's decision, arguing that the lower court erred in finding that Mr. Lavalais did not forfeit his benefits due to untruthful responses on the medical questionnaire.
The standard of review for workers’ compensation claims is established, primarily following the manifest error-clearly wrong standard, particularly when an employer denies benefits based on allegations of fraud under La.R.S. 23:1208.1. In *Lanclos v. Coastal Food, LLC*, the appellate court emphasized that it will not disturb a workers’ compensation judge’s reasonable factual inferences or credibility assessments. However, if objective evidence contradicts a witness's testimony or if the testimony is internally inconsistent, appellate courts may find the judge’s conclusions manifestly erroneous. A de novo review applies in cases where legal errors affect the fact-finding process, as noted in *Aisola v. Beacon Hosp. Mgmt. Inc.* and other cases. Additionally, La.R.S. 23:1208 addresses false statements made by claimants to obtain benefits after an accident, whereas La.R.S. 23:1208.1 pertains to false statements made during employment-related inquiries about prior medical history, distinguishing the applicable contexts for each statute.
Gilchrist asserts that Mr. Lavalais should lose his benefits under La.R.S. 23:1208.1 due to his allegedly false responses regarding his neck, back, and knee conditions, which are pertinent to his benefits claim. To succeed, Gilchrist must demonstrate three elements of fraud as outlined in City of Eunice v. Carrier: 1) untruthfulness; 2) prejudice to the employer; and 3) statutory notice. Simply providing false answers is insufficient; Gilchrist must show that the untruthful statements harmed the employer and that the employer provided necessary notice to Mr. Lavalais. The statute applies when an employee is dishonest on a medical questionnaire prior to an injury, as clarified in Resweber v. Haroil Const. Co., which emphasizes that forfeiture occurs only when the employer suffers prejudice due to false statements that directly relate to the medical condition claimed or affect reimbursement from a second injury fund. The application of this statute is strict, placing the burden of proof on Gilchrist to support all three elements.
Regarding notice, both parties agree that Gilchrist properly informed Mr. Lavalais according to La.R.S. 23:1208.1. The WCJ concluded that the employer did not establish grounds for forfeiture, noting that the questions about neck and back pain were innocuous and did not yield information about any prior disabilities. The questionnaire required that if any conditions were answered affirmatively, further details should be provided, but ambiguous responses do not satisfy the employer's burden of proof. The employer must also seek clarification of ambiguous answers to justify forfeiture.
Mr. Lavalais answered 'NO' to questions about his neck, back, and knee on an employer's medical questionnaire, which asked if he had ever had or been treated for those conditions. Legal precedent indicates that a 'NO' answer is considered untruthful if the respondent has a known medical condition. Mr. Lavalais confirmed that he filled out the questionnaire himself and maintained that he was not trying to mislead anyone, believing the questions pertained only to current pain rather than past conditions. Upon questioning, he acknowledged he now understands that the form asked about any prior injuries. He admitted to informing a claims adjuster about these injuries shortly after an accident and noted that his treating physician was aware of them due to a previous motor vehicle accident. Although Mr. Lavalais had been able to work, his failure to disclose past injuries could impact his eligibility for workers' compensation benefits, potentially leading to restrictions on his work. Legal interpretation of Louisiana's workers' compensation statute suggests that untruthful answers regarding prior medical conditions may result in forfeiture of benefits.
The Gilchrist medical questionnaire included a clear instruction for Mr. Lavalais to disclose any current or past medical conditions, to which he answered 'No.' At trial, Mr. Lavalais testified about his educational background and heavy manual labor job at Boise Cascade at the time of his knee injury in 2006, during which he was off work for six months. He opted against surgery for his ACL tear to avoid missing work, despite all his treating physicians agreeing that surgery was necessary for the repair. Mr. Lavalais had an ongoing lawsuit related to a May 2011 car accident, which involved claims for neck, back, and knee injuries, but he was uncertain if the case settled before or after he completed the Gilchrist questionnaire. He had not been released by Dr. Mounayar, his physician for the 2011 accident, and continued to experience pain in those areas prior to his hiring by Gilchrist in August/September 2012.
The Workers' Compensation Judge (WCJ) was deemed manifestly erroneous in concluding that Mr. Lavalais was truthful in his questionnaire responses. The next issue was whether Mr. Lavalais’ untruthful statements caused prejudice to Gilchrist under La.R.S. 23:1208.1. To prove this, Gilchrist needed to show a direct relation between the untruthful answers and the medical conditions claimed. This direct relation requires evidence that a subsequent injury was likely due to preexisting conditions, beyond mere anatomical connections. The WCJ stated that Gilchrist failed to show that Mr. Lavalais’ injuries from a November 2, 2012 incident were inevitable due to preexisting conditions and did not address whether the injuries were "very likely" to occur due to those conditions. This omission is a primary focus of Gilchrist's appeal.
The record indicates that the WCJ did not consider testimony from Mr. Lavalais’ treating physicians or medical records that supported Gilchrist's argument that Mr. Lavalais' previous unresolved injuries made him more susceptible to re-injury, thereby suggesting that a subsequent injury was likely due to his undisclosed conditions. The summary of relevant testimony and findings from Dr. Phillip Badila will follow.
Dr. Badila treated Mr. Lavalais for a right knee injury sustained in a 2006 four-wheeler accident, diagnosing a torn ACL that required surgery, which Mr. Lavalais was reluctant to undergo due to potential work disability. He deemed the ACL tear chronic by the time of a subsequent accident on November 2, 2012. Dr. Badila confirmed that prior knee injuries increase the risk of future injuries, stating that Mr. Lavalais’ 2006 injury made subsequent injuries more probable. He used terms like "could" and "more likely to occur," contrasting with the 'direct relation test' which necessitates proving that subsequent injury was "inevitable" due to a preexisting condition.
Mr. Lavalais was later referred to Dr. Louis Blanda, who echoed Dr. Badila's findings regarding the injury link. Dr. Blanda asserted that an untreated ACL tear does not heal and leaves the knee vulnerable to further injuries. He confirmed that prior injuries increase susceptibility to additional damage and specified that a weakened area makes it easier for further trauma to occur. When discussing Mr. Lavalais’ low back injury from a May 2011 accident, Dr. Blanda noted that prior low back injuries could also lead to further damage if symptomatic or evidenced by MRI findings. He differentiated between soft tissue muscle strains, which heal in weeks, and ligament sprains or strains, which require months to heal and can cause further instability or damage.
Dr. Blanda testified regarding Mr. Lavalais’ injuries, indicating that a ligament sprain from a May 2011 accident likely contributed to his ongoing neck and back issues through March 2012. He noted that such prior injuries could increase susceptibility to re-injury, including potential disc problems, but did not assert that re-injury was 'inevitable' or 'very likely' as per the standards set in Wise and Taylor.
Dr. Elias Raymond Mounayar, who treated Mr. Lavalais for injuries from both the May 2011 and a subsequent November 2012 work-related accident, also confirmed that previous injuries could make a patient more susceptible to re-injury, particularly when accidents occur in close succession. He reported Mr. Lavalais’ neck pain was persistent, rating it an eight out of ten, and recommended an orthopedic consultation due to a lack of improvement. Dr. Mounayar did not state that re-injury was 'inevitable' or 'very likely.'
Dr. Joe Morgan, who conducted an Independent Medical Examination (IME) on July 22, 2013, acknowledged that a prior ACL tear could increase susceptibility to further knee injuries. However, in his deposition, he noted that while an unrepaired ACL tear could lead to degenerative arthritis, he could not definitively say it would cause further injuries. The WCJ referenced Dr. Morgan's review of past medical records, noting that Mr. Lavalais had a chronic ACL tear, but focused on the uncertainty surrounding the potential for further knee injury.
Dr. Morgan's testimony indicated that while a prior knee injury does not make re-injury inevitable, it increases susceptibility to future injuries. He noted that Mr. Lavalais had ongoing issues with his neck, back, and knee prior to the accident, which were aggravated by the incident in question. Medical evidence confirmed that Mr. Lavalais’ preexisting conditions made him more prone to re-injury. However, the employer, Gilchrist, must prove that Mr. Lavalais' injury was either inevitable or very likely to occur to escape liability. No medical testimony supported the assertion that re-injury was inevitable. The court acknowledged the harsh nature of statutory forfeiture and emphasized a strict interpretation favoring worker relief under La.R.S. 23:1208.1. The judge's ruling that Gilchrist was not prejudiced by Mr. Lavalais' non-disclosure was upheld, based on his consistent work history without restrictions and the nature of the accident occurring en route to a job site, rather than during regular duties. The court concluded that while Mr. Lavalais was untruthful in the medical questionnaire, Gilchrist did not meet its burden of proof regarding prejudice, aligning with precedents that support workers' compensation benefits.
Mr. Lavalais has responded to the appeal and is seeking additional attorney fees for the work required in relation to the Gilchrist appeal. According to the applicable legal standard, an increase in attorney fees on appeal is granted when the defendant appeals without success, and this necessitates additional work from the plaintiff's attorney, provided the plaintiff requests it. Referencing Dugas v. AutoZone, Inc., the court has affirmed the Workers' Compensation Judge's (WCJ) decision and awarded Mr. Lavalais an extra $2,500.00 for his attorney’s work on the appeal. Additionally, all costs associated with the appeal are to be borne by Gilchrist Construction Company, LLC.
Gilchrist's defense in the pre-trial memorandum referenced both La.R.S. 23:1208 and La.R.S. 23:1208.1. However, its post-trial memorandum clarified that the only relevant statute considered by the WCJ was La.R.S. 23:1208.1. Gilchrist did not assert that Mr. Lavalais' responses hindered its ability to claim from the second injury fund.
