Tyler v. Rockwood Insurance Co.

Citations: 690 So. 2d 834; 96 La.App. 1 Cir. 0326; 1997 La. App. LEXIS 410; 1997 WL 77860Docket: No. 96 CA 0326

Court: Louisiana Court of Appeal; February 13, 1997; Louisiana; State Appellate Court

SummaryOriginalCytator Case TreatmentBackward CitatorAnalysis

EnglishEspañolSimplified EnglishEspañol Fácil

Whitney Tyler initiated a workers' compensation claim for total disability, medical expenses, attorney’s fees, and penalties due to injuries incurred while working for Harvey Hyland, Inc. The trial court ruled in favor of Tyler, granting him supplemental earnings benefits and some medical expenses. Tyler, employed as a supervisor, sustained a back injury on January 18, 1989, while lifting a heavy desk. He was diagnosed with a recurrent disc rupture, underwent surgery on February 21, 1989, and was released to return to work by November 6, 1989. Harvey’s insurer, Rockwood Insurance Company, provided temporary total disability benefits of $175 weekly and subsequently paid supplemental earnings benefits of $752.50 monthly. Tyler filed a lawsuit on February 20, 1990, after the insurer allegedly stopped payments. After procedural developments, including the substitution of Louisiana Insurance Guaranty Association (LIGA) as a defendant, the trial court awarded Tyler $447.92 monthly in supplemental earnings benefits retroactive to August 25, 1994, and $4,892 for medical expenses. The court also mandated rehabilitation services but denied additional medical expenses, penalties, and attorney’s fees. Tyler appealed the reductions and denials, while LIGA and Harvey countered by seeking a reduction of the medical expenses awarded and suggested offsetting for any social security disability benefits Tyler may receive if deemed permanently totally disabled.

In workers’ compensation cases, appellate court reviews of factual findings adhere to the manifest error or clearly wrong standard, involving a two-part test: (1) whether a reasonable factual basis exists for the trial court's findings, and (2) whether these findings are not manifestly erroneous. The appellate court should not disturb reasonable credibility assessments or factual inferences made by the trial court, even if it believes its own evaluations are superior. 

The trial court made several factual determinations regarding Tyler's case: his condition was permanent and he had reached maximum medical improvement; he was not entitled to permanent total disability benefits; and he was capable of minimum wage employment for approximately 25 hours weekly. Additionally, the court found that Dr. Stewart's services were non-emergency, and LIGA denied responsibility for costs incurred after July 18, 1991, communicating this refusal to Dr. Stewart's office on November 7, 1991. The appellate court confirmed that these findings were supported by the record and were not manifestly erroneous.

The issue of LIGA's liability for Dr. Stewart's medical services arose, with the trial court limiting LIGA's responsibility to $4,892 for expenses incurred prior to November 7, 1991. Tyler argued that LIGA's denial of compensability negated the mutual consent requirement of LSA-R.S. 23:1142(B) and instead invoked LSA-R.S. 23:1142(E) due to repeated denials of his injury's compensability. He cited a case, INA v. Hayes, to support his position. Conversely, the defendants claimed the trial court erred in awarding the $4,892, asserting that LSA-R.S. 23:1203(A) only covers necessary treatment costs, and LSA-R.S. 23:1142(B) restricts recovery to $750 due to lack of consent. They argued that the claimant must demonstrate a link between the medical expenses and the work injury while proving the necessity and value of those services, as mandated by LSA-R.S. 23:1203(A), which aims to ensure the claimant receives necessary medical care at no cost. LSA-R.S. 23:1142 further limits reimbursement for certain medical expenses.

LSA-R.S. 23:1142(B) restricts health care providers to $750 in nonemergency diagnostic testing or treatment without mutual consent from the payor and employee. Employees must obtain prior approval from their employer for nonemergency medical care related to work injuries. If a provider incurs more than $750 without consent, they cannot enforce payment from the employee, employer, or workers' compensation insurer. 

Tyler, after his surgery, consulted Dr. Stewart on July 20, 1990, complaining of pain and headaches. Dr. Stewart recommended treatment, which Rockwood approved for epidurals. He later informed Rockwood that Tyler required ongoing treatment as he reached maximum medical benefit. Between July 20, 1990, and July 19, 1991, Rockwood paid $13,313.50 for Tyler’s treatment before ceasing payments due to liquidation on August 26, 1991. Despite not receiving notice of treatment denial, Dr. Stewart continued care without confirmation of financial responsibility from LIGA. At trial, Tyler's unpaid balance was $38,039.50. In October 1991, LIGA’s representative reviewed Tyler’s file, and on November 7, 1991, denied authorization for further treatment, which was confirmed by a subsequent letter from Dr. Stewart to Tyler’s attorney.

The trial court determined that Ms. Husser’s communication on November 7, 1991, effectively withdrew Rockwood’s prior agreement to pay for medical expenses. Rockwood had voluntarily paid Dr. Stewart from August 1990 to July 1991 but ceased payments due to its liquidation, with LIGA assuming obligations in late August 1991. However, LIGA's representative did not review Tyler's file until October 1991. Following Ms. Husser's notification of LIGA's refusal to pay, the court found a reasonable factual basis supporting the continuous mutual consent for payment until November 7, 1991, and that this conclusion was not manifestly erroneous. Citing a precedent (Johnson case), the court noted that initial authorization by Rockwood for Dr. Stewart's treatment established Tyler's entitlement to medical expenses until approval was withdrawn. Post-November 7, 1991, Tyler's recovery for additional expenses is contingent upon proving medical necessity for treatments rendered by Dr. Stewart, as there was no mutual approval for such treatments after this date. The trial court did not specifically determine the necessity of Dr. Stewart’s post-November treatments but indicated that LIGA's refusal to pay was supported by the record, implying these services were not medically necessary. Dr. Flynn, who initially treated Tyler, discharged him in November 1989, stating no further treatment was needed, while Dr. Stewart, who treated Tyler from July 1990 onward, believed ongoing treatment was necessary despite a lack of supporting medical evidence. Dr. Flynn reaffirmed his initial opinion during reevaluations in 1993 and 1994.

Dr. Flynn criticized Dr. Stewart's treatment of Tyler, stating it was unnecessary for his condition and excessively indefinite. Dr. John E. Nyboer, an expert in physical medicine, supported this view, asserting that Dr. Stewart's passive modalities were ineffective and did not provide lasting relief. Nyboer deemed the treatments excessive and would not have recommended them for such duration. Tyler bore the burden of proving that his post-November 7, 1991 medical services were necessary, but the evidence presented was insufficient. Consequently, the trial court found that the defendants were not required to pay for these services under LSA-R.S. 23:1203. Additionally, Tyler's claim for reimbursement under LSA-R.S. 23:1142(E) was denied, as that statute limits reimbursement to necessary treatments, which Tyler failed to establish. The court affirmed the trial court's judgment and assessed the costs of the appeal to Tyler. In a related case, treatment without prior payor approval was deemed nonemergency, and the provider was awarded only a statutory limit, emphasizing the requirement of proving treatment necessity for reimbursement. The defendants in this case had continuously paid disability benefits, differentiating it from other cited cases where benefits were terminated.