Court: Louisiana Court of Appeal; April 7, 1995; Louisiana; State Appellate Court
Defendants Albano Cleaners and Employers Insurance of Wausau appeal a judgment from the Office of Worker’s Compensation that awarded plaintiff Elaine Lacava worker’s compensation benefits, including penalties, attorney’s fees, and medical expenses. At the time of her injury on October 19, 1991, Lacava was tasked with additional physically demanding duties in preparation for an inspection, which included cleaning machinery and removing stickers. She experienced significant back pain and shooting pains down her leg shortly after starting these tasks. Although she reported her condition to a supervisor on October 21, 1991, and was subsequently referred to a doctor, her injury was reported to the insurer on October 23, 1991, and her claim was denied on November 11, 1991, on the grounds that her injury did not constitute an 'accident' as per La.R.S. 23:1021(1). Lacava filed a disputed claim, and the hearing officer awarded her weekly compensation benefits, medical expenses, and attorney’s fees. On appeal, the defendants challenge whether Lacava's injury qualifies as an 'accident,' her entitlement to benefits during unemployment compensation periods, and whether the denial of her claim was arbitrary and capricious.
To recover worker’s compensation benefits, an employee must demonstrate that their injury resulted from an 'accident' occurring during the course of employment, as defined by La.R.S. 23:1031 A. Defendants argue that the plaintiff has not shown a compensable injury because she failed to identify a specific event that resulted in objective findings, which is necessary under La.R.S. 23:1021(1). Prior to a 1989 amendment, an accident was defined as an unexpected event producing immediate objective symptoms. The amended definition specifies that an accident must be an unexpected, identifiable event that directly causes objective findings of injury, excluding gradual deterioration.
Defendants assert that this amendment aimed to limit worker’s compensation coverage to injuries that meet the statutory definition of 'accident.' The court previously addressed this amendment in Dyson v. State Emp. Group Ben. Program, noting it was not intended to exclude those suffering from work-related wear and tear. In Robin v. Schwegmann Giant Supermarkets, Inc., the court found sufficient evidence linking the plaintiff’s injury to her lifting duties on a specific day, rejecting the employer's claim that no identifiable event marked the injury. The ruling highlighted that the onset of different pain after strenuous work constituted an identifiable event leading to the injury.
The factual scenario in this case parallels that in Robin, with significant evidence indicating that plaintiff's injury was caused by strenuous cleaning and scrapping activities on October 19, 1991. Plaintiff reported experiencing pain shortly after starting these tasks, and Dr. Hontas suggested a strong likelihood that these activities led to her disability. Thus, the cleaning and scrapping work on that date is deemed an 'accident' under La.R.S. 23:1021(1).
Regarding unemployment compensation, defendants argue that the hearing officer improperly awarded worker’s compensation benefits for weeks during which plaintiff also received unemployment benefits, violating La.R.S. 23:1225 B. Plaintiff acknowledged receipt of unemployment benefits starting in early December 1991 for twenty-six weeks, overlapping with her worker’s compensation from October 19, 1991, to March 13, 1992. Consequently, the judgment must be amended to credit defendants for these overlapping weeks, and the matter is remanded to the Office of Worker’s Compensation Administration (OWC) to determine the specific weeks of unemployment compensation received.
Defendants also contest the hearing officer's award of penalties and attorney’s fees, asserting that the refusal to pay compensation was justified due to reasonable grounds for contesting the claim. Under La.R.S. 23:1201 E, penalties for nonpayment are warranted unless the employer or insurer could not control the nonpayment or if the employee’s entitlement to benefits is reasonably disputed. Additionally, La.R.S. 23:1201.2 allows for attorney’s fees against an insurer that arbitrarily refuses to pay. Defendants maintain that the ambiguity surrounding whether plaintiff's injury constituted a compensable accident justified their challenge.
The hearing officer found that the claims adjuster for Wausau inadequately investigated the plaintiff's claim by not consulting Dr. Baier or Dr. Hontas about the plaintiff's condition or causation. Additionally, the adjuster failed to seek legal advice regarding the definition of an "accident" under the worker’s compensation act. However, the conclusion that the defendants' failure to pay benefits was arbitrary and capricious was deemed incorrect. The claims adjuster gathered statements from the plaintiff and her supervisor and obtained medical records, which were deemed sufficient for the investigation. The denial of benefits was based on the determination that the circumstances of the injury did not meet the statutory definition of an accident as per La. R.S. 23:1021(1). Further discussions with the doctors would not have changed this conclusion. While a mistaken belief that an injury was not an accident does not exempt a failure to pay benefits, the defendants had a reasonable basis for denying the claim due to the ambiguous legal definition at the time of denial, following the 1989 amendment. Consequently, the award of statutory penalties and attorney’s fees to the plaintiff was reversed. The matter was remanded to the Office of Worker’s Compensation Administration to determine the dates of the plaintiff's unemployment compensation, after which the defendants are to receive credit accordingly. The judgment of the hearing officer was affirmed in other respects, with both parties responsible for half of the appeal costs.
