Court: Louisiana Court of Appeal; April 1, 2015; Louisiana; State Appellate Court
A work-related accident involving Jason Montou, who sustained a shoulder injury while employed by Boise Cascade Company, has led to a dispute over additional neck and back injuries and his disability status. Both parties agree on the shoulder injury but contest the claims regarding the neck and back. A workers’ compensation judge (WCJ) ruled that Montou’s neck and back injuries are compensable and that he remains disabled and entitled to indemnity benefits. However, the WCJ found that Boise is not liable for penalties or attorney fees, prompting Boise to appeal.
The key issues for the court’s review include: 1) whether the WCJ erred in linking Montou's neck and back injuries to the work accident; 2) whether Montou provided sufficient evidence to prove his entitlement to indemnity benefits; and 3) whether the WCJ made an error by not awarding penalties and attorney fees to Montou.
Montou reported his injury on November 22, 2010, completing an incident report that focused solely on his shoulder. Medical records from Oakdale Community Hospital noted right shoulder pain and numbness in his fingers. Subsequent treatment involved surgery for his shoulder and referrals for back pain, where he continued to report symptoms of numbness and tingling. Although Dr. Hale suggested Montou could return to work based on shoulder recovery, Dr. Lowry withheld clearance pending further MRI approvals, which were not authorized by Boise. In October 2013, an examination by Dr. Douglas Bernard concluded Montou had reached maximum medical improvement and found no link between his neck and back issues and the work incident. Following this assessment, Boise terminated Montou’s benefits.
The appellate court affirmed the WCJ's findings, indicating no manifest error in the conclusions regarding Montou's injuries and entitlements.
Dr. Bernard's report on Mr. Montou was sent to Dr. Lowry for approval, but benefits were terminated before Dr. Lowry could respond. Dr. Lowry had not evaluated Mr. Montou personally for nearly two years and approved Dr. Bernard's findings without conducting an independent assessment. After the termination of benefits, Mr. Montou began treatment with Dr. Gunderson, who concluded that Mr. Montou remained disabled due to neck and back injuries and recommended cervical and lumbar MRIs, which Boise refused. Mr. Montou subsequently filed a claim with the Office of Workers’ Compensation for medical expense reimbursement and reinstatement of indemnity benefits, alleging Boise's handling of his claim was arbitrary and capricious.
Due to conflicting opinions from Dr. Bernard and Dr. Gunderson, the Workers' Compensation Judge (WCJ) appointed an Independent Medical Examiner (IME), Dr. Frazer Gaar, who diagnosed Mr. Montou with preexisting lumbosacral degenerative disc disease and stated he was at maximum medical improvement (MMI) and able to do light-duty work. The IME noted that the light-duty status was related to the degenerative condition rather than work-related injuries. Despite this, the WCJ believed Mr. Montou was credible and had sufficiently demonstrated continued disability, ordering Boise to accept his neck and back injuries as compensable, approve the requested MRIs, and reimburse Dr. Gunderson's treatment. The WCJ also reinstated Mr. Montou's indemnity benefits retroactively at $505.38 per week. However, the WCJ did not award penalties or attorney fees due to Boise's actions not being deemed arbitrary and capricious, as benefits were terminated based on a credible doctor's assessment. Boise is appealing, while Mr. Montou is requesting penalties and attorney fees in response.
The standard of review states that factual findings in workers' compensation cases are evaluated for manifest error or clear wrongness, requiring the appellate court to determine if the trial court's conclusions were reasonable based on the entire record. The burden of proof lies with the employee to demonstrate that an accident caused a disability, supported by objective findings rather than mere degenerative conditions.
An accident occurs when heavy lifting or strenuous efforts lead to a physical breakdown or accelerate the occurrence of a pre-existing condition. An employee's testimony can establish that an accident occurred if there is no discrediting evidence and if the testimony is corroborated by subsequent circumstances. The trial court must accept uncontradicted testimony from a party, unless there are reasons to doubt its reliability. The credibility of the worker's testimony is a factual determination that is not typically disturbed on appeal unless clearly erroneous. Mr. Montou must demonstrate a causal relationship between his claimed disability and the accident, and a presumption of disability exists if he can show that symptoms did not manifest before the accident and appeared thereafter, with evidence supporting a causal link. In the case at hand, Mr. Montou's shoulder injury is not disputed, but there is contention regarding his back and neck injuries being compensable. He reported numbness and tingling in his right arm and hand immediately after the incident, which was documented in emergency room records and continued during his treatment. Dr. Hale noted concerns regarding potential cervical issues related to Mr. Montou's symptoms. Although back pain was not recorded until three months post-accident, Mr. Montou indicated it had been persistent since the incident, worsening after shoulder surgery. As established in precedent, there is no evidence that Mr. Montou experienced back or neck pain prior to the accident.
Mr. Montou experienced persistent tingling, numbness in his right arm, and back pain following an accident. Despite Boise's claim that Drs. Bernard and Gaar diagnosed him with a genetic degenerative disc disease, evidence indicated he was not disabled before the accident and had worked without issues. The Workers' Compensation Judge (WCJ) found Mr. Montou to be a credible witness, supporting his testimony about his injuries. The WCJ determined that his neck and back injuries were compensable.
On appeal, the focus shifted to whether Mr. Montou remains disabled and entitled to retroactive indemnity benefits. To qualify for such benefits, he must demonstrate an inability to work through clear and convincing evidence. Boise contended that the WCJ incorrectly reinstated benefits retroactive to October 23, 2013, citing the opinions of Drs. Bernard, Lowry, and an Independent Medical Examiner (IME) who believed he could return to work. In contrast, Mr. Montou relied on the opinion of Dr. Gunderson, his treating physician, who had a more significant basis for assessing his condition.
Although Dr. Gunderson had seen Mr. Montou only once, his role as the treating physician typically carries more weight than that of evaluative physicians. The IME acknowledged that the accident exacerbated Mr. Montou’s degenerative disc disease. Under Louisiana workers' compensation law, pre-existing conditions do not bar recovery if they are aggravated by a work-related incident.
The WCJ's decision to favor Dr. Gunderson's opinion over others was upheld, with no evidence of manifest error. Consequently, the determination that Mr. Montou is still disabled and entitled to retroactive indemnity benefits was affirmed, reinstating his temporary total disability benefits at a rate of $505.38 per week.
Penalties and attorney fees can be awarded under the Workers’ Compensation Act when an employer fails to approve necessary medical treatment or improperly discontinues indemnity benefits, as outlined in La.R.S. 23:1201(E) and La.R.S. 23:1201(1). Employers or insurers are mandated by La.R.S. 23:1203(A) to provide necessary medical treatment, and failure to do so results in penalties unless the employer can reasonably controvert the claim. A court assesses whether a claim is reasonably controverted based on whether the employer engaged in a nonfrivolous legal dispute or had sufficient factual or medical information to counter the claimant's assertions.
In Mr. Montou's case, he argued that Boise should face penalties for not authorizing and paying for treatment by Dr. Gunderson for his neck and back issues. Although medical records document Mr. Montou's complaints of pain and numbness, Boise possessed a report from Dr. Bernard indicating Mr. Montou could return to work, which provided a reasonable basis to contest the claim. Consequently, the Workers' Compensation Judge (WCJ) found no error in denying penalties and attorney fees.
Regarding the improper termination of benefits, La.R.S. 23:1201(1) states that an employer discontinuing claims without probable cause may face penalties and attorney fees. The Louisiana Supreme Court has defined arbitrary and capricious behavior as actions taken without regard for relevant facts. The WCJ found that Boise had an objective reason for terminating benefits based on Dr. Bernard's report, which indicated Mr. Montou was beyond maximum medical improvement (MMI) and could return to work without restrictions.
Dr. Bernard, the sole physician who treated Mr. Montou in the two years prior to the discontinuation of his benefits, concluded that Mr. Montou had no ongoing issues with his right shoulder and believed the neck injury reported was unrelated to the work accident, particularly due to the negative findings from EMG and Nerve Conduction Studies. He reviewed MRIs indicating a low back strain and degenerative disk disease, attributing these conditions to genetic factors, and found no nerve root compromise, recommending no further treatment. In an addendum, Dr. Bernard characterized any back injury from the accident as a minor strain. Consequently, Boise terminated Mr. Montou’s benefits based on this medical opinion.
In assessing whether Boise improperly discontinued benefits, the court examined the facts available to the employer at that time, referencing Johnson v. St. Frances Nursing, Rehab. Ctr. The workers' compensation judge (WCJ) acknowledged a belief that Dr. Bernard's conclusion of non-disability was incorrect but determined that Boise acted on competent medical advice. Despite noting Boise’s eagerness to terminate benefits, the WCJ found their actions did not constitute arbitrary and capricious behavior, as they were based on nearly two years of medical records and Dr. Bernard's evaluation. The court upheld the WCJ's decision that Boise had probable cause for terminating benefits, denying penalties and attorney fees under La.R.S. 23:1201(1). The conclusion affirmed that there was no manifest error in the WCJ's judgment, and costs of the appeal were assigned to the defendant-appellant. Notably, while Mr. Montou did not report neck complaints until five months after the accident, he consistently reported tingling and numbness in his upper right extremities immediately after the incident.
