Burch v. Home

649 So. 2d 545, 94 La.App. 3 Cir. 489, 1994 La. App. LEXIS 2999, 1994 WL 597485
CourtLouisiana Court of Appeal
DecidedNovember 2, 1994
DocketNo. 94-489
StatusPublished
Cited by2 cases

This text of 649 So. 2d 545 (Burch v. Home) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Burch v. Home, 649 So. 2d 545, 94 La.App. 3 Cir. 489, 1994 La. App. LEXIS 2999, 1994 WL 597485 (La. Ct. App. 1994).

Opinion

| iLABORDE, Judge.

Defendant nursing home appeals the hearing officer’s decision that it was responsible for plaintiffs 21 day stay, when it only authorized two days of hospitalization, and the award of penalties and attorney’s fees. After a review of the record, we affirm, finding no error committed by the hearing officer.

[547]*547FACTS

Plaintiff, Irma Burch, was employed by Affiliated Nursing Homes, Inc. in Tioga Man- or Nursing Home as a cafeteria worker. On March 26, 1991, Burch was injured when she received an electric shock from the equipment she was working on. Dr. James David diagnosed Burch with bilateral thoracic outlet syndrome. He subsequently recommended surgery for a right sided first rib resection, which was scheduled to be performed on March 31, 1992.

Before Burch was admitted to the hospital, her case had to be reviewed under |2a pre-certification process as required under R.S. 23:1291. As Affiliated was self-insured for workers’ compensation, it hired F.A. Richard & Associates, Inc., to adjust the claim. Richard in turn hired Medical Rehab Consultants to perform the utilization review functions. Elaine Stillwell, a registered nurse who owned and operated Medical Rehab, approved Burch for a two day stay at Rapides Regional Medical Center.

Burch entered Rapides on March 31, 1992 and surgery was performed by Dr. David. On the third day after surgery, Burch developed complications from surgery due to a staph infection she contracted while in the hospital. The infection caused increased fluid in her lungs which eventually developed into pneumonia. Thus, Burch was not discharged from the hospital after two days but remained in the hospital until April 24, 1992.

Burch returned to Rapides on May 7,1992, again due to complications from the surgery. When Rapides contacted F.A. Richard for approval of Burch’s re-admission, Kay Love, an adjustor, approved the re-admission as long as it was related to the first surgery. Burch was also treated in the emergency room at Rapides on April 29, 1992 and July 10, 1992.

The bill for Burch’s hospital stay of March 31 through April 24 totalled $31,991.81. Affiliated was required to pay this bill within 60 days of .receipt under R.S. 23:1201.2. However, it did not pay until September 15,1992, and at that time it paid only $5,565.50 for the two days of hospitalization it originally authorized. A trial was.held concerning this disputed bill on July 15, 1993, with Rapides intervening to recover its unpaid medical bill. Hearing Officer Brenza Irving found in favor of claimant and Rapides, finding that defendant had acted arbitrarily and capriciously in refusing payment for Burch’s extended hospital stay and awarded ^penalties and attorney’s fees.

ASSIGNMENTS OF ERROR

Defendant alleges that the hearing officer erred in finding that:

1. Affiliated Nursing Homes, Inc., was responsible for the expenses incurred in a 21 day hospitalization when the employer’s representative had only authorized two days of hospitalization; and
2. Affiliated Nursing Homes, Inc., was arbitrary and capricious in its refusal to pay for 19 days of hospitalization which was neither authorized nor requested, and in awarding $15,000 in attorneys fees and $2,500 in penalties for a $26,000 medical bill.

LAW

In defendant’s first assignment of error, it claims it was not responsible for claimant’s entire hospital stay because it only authorized two days of hospitalization for claimant. The hearing officer rejected defendant’s claim, finding that it was required to review claimant’s condition before she was discharged from the hospital under Title 40, Labor and Employment, Chapter 27, § 2707. We affirm this conclusion, and also the award of penalties and attorney’s fees, adopting the well written reasons for judgment of the hearing officer.

On or about March 26, 1991, Irma Burch, claimant herein, sustained personal injury by accident arising out of and in the course of her employment with Tioga Manor Nursing Home, Inc. Affiliated Nursing Homes, Inc. is a management company operating fourteen nursing homes throughout Louisiana. Tioga Manor Nursing Home is managed by Affiliated Nursing Homes, Inc. Affiliated Nursing Homes, Inc. is the self-insured employer, within the scope of Louisiana Workers’ Compensation Law, of Irma Burch (hereinafter, Affiliated Nursing Homes, Inc. [548]*548will be referred to as “Affiliated”). Affiliated hired F.A. Richard & Associates, Inc. (“F.A. Richard”), an adjusting company, to administer its self-insured Workers’ Compensation program. F.A. Richard hired Medical Rehab Consultants, Inc. (“Medical Rehab”) to assist with Affiliated’s pre-certification and utilization review matters.

| ¿tirina Burch was electrically shocked while working in the cafeteria at Tioga Man- or Nursing Home. As a result of the electrical shock and corresponding trauma produced by the shock, Irma Burch suffered thoracic outlet syndrome. After approximately seven months of conservative treatment to cure the thoracic outlet syndrome, surgery became necessary. As surgery was a necessary medical procedure resulting from the thoracic outlet syndrome, Irma Burch received approval for right rib resection surgery from Medical Rehab, the pre-certification company utilized by Affiliated. Irma Burch was pre-approved for two days hospitalization at Rapides Regional Medical Center (hereinafter “Rapides”).

Irma Burch entered Rapides on March 31, 1992 and remained hospitalized for twenty-two days until April 21, 1992. The extended hospitalization was due to complications associated with the surgery. While hospitalized, Irma Burch developed fever, a staph infection in the surgical wound, and pleural effusion which necessitated the continued hospitalization.

The necessary and reasonable value of the medical services rendered to Irma Burch as a result of the March 31, 1992 through April 21, 1992 hospitalization (hereinafter referred to as the “Hospitalization”) was $31,991.81. On September 15, 1992, Affiliated, through its agent, F.A. Richard, paid $5,565.50 to Rapides for the Hospitalization (Rapides Exhibit 6). This amount represented the total charges incurred by Irma Burch for the first two days hospitalized (testimony of Lyman Phillips and Elaine Stillwell). Affiliated refuses to pay the remaining balance on the bill of $26,426.31.

Affiliated, in its pre-trial statement, asserts that it is not responsible for the $26,426.31 balance because the medical providers simply failed to comply with Continual Stay Provisions.

IsThe first issue therefore, is who (Affiliated or Rapides) failed to comply with the Utilization Review Procedures, Section 2707D.1, the Continued Stay Review provision. The second issue before the court is whether Affiliated’s failure to pay the $26,-426.31 balance for the medical treatment rendered to Irma Burch by Rapides is arbitrary, capricious and without probable cause, subjecting Affiliated to penalties and attorney’s fees.

Affiliated agreed to pay for right rib re-section surgery to treat Irma Burch’s thoracic outlet syndrome. Pursuant to the Department of Labor, Office of Workers’ Compensation, Chapter 27 Utilization Review Procedures (“Utilization Review Procedures”), Sections 2703 and 2705, the pre-admission certification process for Irma Burch was completed. Rapides and Dr. James David’s office were in contact with Affiliated, through its agent, Medical Rehab, for pre-admission certification.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Fontenot v. Reddell Vidrine Water Dist.
836 So. 2d 14 (Supreme Court of Louisiana, 2003)
Ferrier v. Jordache-Ditto's
662 So. 2d 14 (Louisiana Court of Appeal, 1995)

Cite This Page — Counsel Stack

Bluebook (online)
649 So. 2d 545, 94 La.App. 3 Cir. 489, 1994 La. App. LEXIS 2999, 1994 WL 597485, Counsel Stack Legal Research, https://law.counselstack.com/opinion/burch-v-home-lactapp-1994.