Caremore, Inc./Wooddale Nursing Home v. Hollis

642 S.E.2d 375, 283 Ga. App. 681, 2007 Fulton County D. Rep. 540, 2007 Ga. App. LEXIS 173
Court of Appeals of Georgia·Decided February 22, 2007·No. A06A1778·Published·Cited by 4 cases

Opinion

Ruffin, Judge.

Charlotte Hollis, who sustained a work-related injury, brought a workers’ compensation claim against Caremore, Incorporated/Wooddale Nursing Home and Royal & SunAlliance (collectively, “Caremore”).1 Following a hearing on stipulated facts, the State Board of Workers’ Compensation (the “Board”) assessed penalties against Caremore for violating Board rules and increased Hollis’s income benefits. After the superior court affirmed this ruling, we granted Caremore’s application for discretionary appeal. On appeal, Caremore asserts that: (1) the Board erred in imposing penalties pursuant to Board Rule 205, which is unlawful; (2) any alleged violation of Board rules could not be deemed “willful”; and (3) the Board erred in calculating Hollis’s income benefits. We disagree and affirm.

[682] In a workers’ compensation appeal, we view the evidence in a light most favorable to the party prevailing before the Board.2 The Board’s findings, if supported by any evidence, are conclusive and binding.3 Viewed in this manner, the evidence shows that Caremore began paying both medical and temporary total disability income (“TTD”) benefits to Hollis after she sustained a work-related injury. However, Caremore failed to timely file certain Board forms, including the employer’s injury report, notice of payment of benefits, and wage statement.4

Although Caremore clearly accepted a lower back injury as compensable, Hollis also complained of hip pain. Dr. George Kerr, Hollis’s authorized physician, sought to refer Hollis to Dr. Kenneth Kress to determine if the hip complaint was related to the work injury. On March 4, 2004, Dr. Kerr sent Caremore a Form WC-205, requesting preapproval of the evaluation. Under Board Rule 205, Caremore was required to respond within five days. However, Caremore did not respond until March 15, 2004, when it denied the request.5

On May 4,2004, Hollis requested a hearing to determine whether her TTD benefits should be increased. She also sought the imposition of attorney fees, litigation expenses, and statutory penalties against Caremore for its failure to timely file Board forms and to timely respond to her physician’s request for advance authorization of the evaluation.6 Finally, she argued that Dr. Kress’s evaluation should be deemed approved based upon Caremore’s failure to timely respond to the Form 205 request. However, on August 21, 2004, Caremore authorized the evaluation.

On January 12, 2005, the administrative law judge (“ALJ”) concluded that Caremore violated Board Rule 61 (b) (6) by failing to timely file certain Board forms, including its response to Dr. Kerr’s request for advance authorization of an evaluation. The ALJ further concluded that the violations were wilful because Caremore “is charged with knowledge of the Board Rules and was specifically made aware of Board Rule 205 upon receipt of the Form WC-205.” In addition, the ALJ found that the evaluation and testing requested by [683] Hollis’s physician stood pre-approved. The ALJ thus imposed penalties and attorney fees for Caremore’s violations. Finally, the ALJ increased Hollis’s weekly wage by $15 per week to include the economic benefit of the meal subsidy, which raised her TTD benefits.7

1. In its first enumeration of error, Caremore contends that the Board — and subsequently the superior court — erred in enforcing Board Rule 205, which it contends “is void as an invalid extension of statutory power not granted to the Board by the Legislature.” This rule provides, in pertinent part, that if an authorized medical provider seeks advance authorization for treatment or testing by submitting a WC-205 form, the employer/insurer must respond within five business days or “the treatment or testing stands pre-approved.”8 According to Caremore, this aspect of the rule “constitutes an impermissible extension” of the Board’s authority by conclusively determining the compensability of a disputed medical procedure. Care-more cites Holt Svc. Co. v. Modlin9 for the proposition that the Board lacks the power to make rules that abrogate its substantive rights.

Pretermitting the validity of Rule 205 (b) (3) (a), Caremore in fact approved Dr. Kress’s evaluation of Hollis before the ALJ ruled on the issue. Thus, the validity of that part of the rule precluding an employer from contesting the compensability of treatment is not before us. Caremore nonetheless argues that it is “aggrieved” by the rule because it “is subject to substantial civil penalty” for wilfully violating the rule. However, the rule at issue requires an insurer to respond to a physician’s request for preauthorization within five days — either authorizing or denying the requested treatment. Caremore did neither, and was thus penalized for failing to timely respond to the request for preauthorization.10 As a result of Caremore’s failure to provide any response whatsoever, the Board assessed civil penalties and attorney fees, which it is authorized to do.11 Under these circumstances, Caremore’s claim of error lacks merit.

2. Caremore also contends that there was no evidence to support the Board’s conclusion that Caremore wilfully failed to comply with Board rules. We disagree.

By specific agreement of the parties and with the permission of the ALJ, the parties submitted a stipulation of facts in lieu of an [684] evidentiary hearing. After a telephone conference with the attorneys and consideration of the parties’ factual stipulation, the ALJ imposed civil penalties against Caremore based upon the wilful violation of Board Rules 205, 221 (c), and 61 (b). The ALJ concluded that, notwithstanding its knowledge of Board Rules, Caremore elected to pay TTD benefits to Hollis, at less than the maximum amount set by law, without timely filing required Board forms, including the injury report, wage statement, and notice of payment of benefits. In addition, despite the language on Form WC-205 advising that the insurer was required to respond to the preapproval request within five days, Caremore failed to timely respond to the request for advance authorization. Thus, the ALJ specifically concluded that Caremore’s violation of the Rules was wilful, and the Appellate Division agreed.

We conclude that an employer or insurer’s conscious indifference to its duty to file required forms constitutes wilfulness.12 Thus, the evidence supports the Board’s finding that Caremore’s failure to timely file certain forms and to respond to a request for preapproval of medical services was wilful.13

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Caremore, Inc./Wooddale Nursing Home v. Hollis, 642 S.E.2d 375, 283 Ga. App. 681, 2007 Fulton County D. Rep. 540, 2007 Ga. App. LEXIS 173 (Ga. Ct. App. 2007).

642 S.E.2d 375 (Caremore, Inc./Wooddale Nursing Home v. Hollis) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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