Cotton v. Wal-Mart Stores, Inc.

552 So. 2d 14, 1989 La. App. LEXIS 2088, 1989 WL 134815
CourtLouisiana Court of Appeal
DecidedNovember 8, 1989
Docket88-821
StatusPublished
Cited by5 cases

This text of 552 So. 2d 14 (Cotton v. Wal-Mart Stores, Inc.) 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
Cotton v. Wal-Mart Stores, Inc., 552 So. 2d 14, 1989 La. App. LEXIS 2088, 1989 WL 134815 (La. Ct. App. 1989).

Opinion

552 So.2d 14 (1989)

Cassandra COTTON, Plaintiff-Appellee,
v.
WAL-MART STORES, INC., Defendant-Appellant.

No. 88-821.

Court of Appeal of Louisiana, Third Circuit.

November 8, 1989.

*15 Charles W. Seaman, Lisa C. McCowen, Natchitoches, for plaintiff-appellee.

Stafford, Stewart & Potter, James D. Kirk, Alexandria, for defendant-appellant.

Before YELVERTON, KNOLL and KING, JJ.

KING, Judge.

The issues presented by this appeal are whether defendant's employee's health plan covers expenses incurred by the plaintiff for the capping of her teeth and whether or not judicial interest can run on an award for court costs.

Cassandra Cotton (hereinafter plaintiff), an employee of Wal-Mart, brought suit against Wal-Mart Stores, Inc. (hereinafter defendant) to recover benefits for treatment of temporal mandibular joint syndrome (hereinafter TMJS) under the Wal-Mart Associates Group Health Plan (hereinafter the Plan). After a trial on the merits, the trial court rendered judgment in favor of the plaintiff and against defendant in the sum of $3,803.35, together with legal interest, from date of judicial demand, until paid, which money judgment also included certain expenses taxed as court costs. A formal written judgment was signed. Defendant timely appeals. We affirm.

FACTS

While plaintiff was employed by Wal-Mart, she began experiencing severe headaches and pain in her jaw. As a result, she consulted Dr. Steven M. Brown, III in June, 1985. Dr. Brown, a dentist, performed selective grinding of plaintiff's teeth and prescribed muscle relaxants. This treatment is considered to be a conservative treatment for TMJS, but it provided no relief for plaintiff. After another attempt to adjust the plaintiff's bite, which failed, Dr. Brown provided plaintiff with an acrylic appliance that covers the teeth, *16 more commonly referred to as a splint. This splint provided relief from the pain, but plaintiff continued to suffer from the headaches. At that point, Dr. Brown referred plaintiff to Dr. Carlton, an oral surgeon, to see if there was a problem with the mandibular joint which could be corrected through surgery.

Dr. Carlton saw plaintiff on August 9, 1985 at which time plaintiff complained of headaches in the temporal region that had bothered her for about three months. Dr. Carlton testified in his deposition as follows:

"Examination revealed some tenderness in her cranial facial muscles, specifically the right masseter muscle which is a large muscle that extends from the cheek bone to the jaw, primarily on the right side. She [plaintiff] was able to open her mouth widely and there were no particular dysfunctions of the jaw. She had a markedly abnormal bite, as I recall ..."

Dr. Carlton also stated that plaintiff's symptoms were included within those common to TMJS. Dr. Carlton did not recommend surgery, but suggested to Dr. Brown that he alter the splint.

Dr. Brown then continued to gradually add acrylic to adjust the thickness of plaintiff's splint. The splint became unusually thick, as plaintiff's bite was opened four or five millimeters in the back, before she was able to obtain relief. The splint interfered with plaintiff's speech to the extent that Wal-Mart no longer allowed plaintiff to operate the cash registers. It also interfered with plaintiff's eating and drinking. Plaintiff, however, wore the splint constantly, otherwise her headaches returned.

Finally, after plaintiff had worn the splint for about one year and Dr. Brown felt that plaintiff's condition had progressed to a position where the relationship between her ligaments, muscle attachments, and joints were in harmony, thus stopping the stress on her muscles and, thereby, the headaches, Dr. Brown decided to permanently adjust plaintiff's bite by capping, or crowning, her teeth. Plaintiff's molars, bicuspids, cuspids, and incisors across the top were capped, and after this was done, plaintiff did not have to use the splint and had no more complaints of pain or headaches.

Dr. Brown further stated that if it were not for the TMJS, there would have been no need for plaintiff's teeth to be capped and that the capping, in this instance, was performed to correct the TMJS, not for dental reasons. Dr. Brown opined that the use of orthodontics, in plaintiff's case, would not have solved her problem. Dr. Brown, while admitting that the classification of TMJS as either medical or dental "seems to be a big boogaboo among a lot of people," stated that "it seems to be classified as a medical problem, but treated by the dental profession." Dr. Carlton acknowledged in his deposition that capping is an accepted form of treatment for TMJS. He even stated that it is often required to normalize the bite to eliminate TMJS.

Section V of the Plan entitled Major Medical Benefits, under which plaintiff claims she is entitled to benefits, lists as a "covered charge":

"N) Charges by a Doctor of Dentistry or Dental Surgeon for treatment of fractures and dislocations of the jaw and for cutting procedures in the oral cavity, including the surgical removal of impacted wisdom teeth, but excluding all care of the teeth and gums."

The Plan also lists in Section VI, Limitations and Exclusions, the following limitation and exclusion:

"D) charges for any treatment or service by a Doctor of Dentistry or Dental Surgeon except as specifically provided by the Major Medical Benefits and if, as the result of an ACCIDENT, the expenses are incurred within twelve (12) months after the ACCIDENT, unless treatment is delayed beyond this period of time due to the medical condition or future growth of the patient."

On February 19, 1986, an amendment was made to the Plan, effective March 1, 1986, which reads in pertinent part, as follows:

"DENTAL BENEFITS: Limited to surgical removal of impacted teeth and treatment of accidental injury to teeth *17 if treatment is within 12 months of the injury date.
* * * * * *

TMJ SYNDROME: Lifetime maximum of $5,000.00 per Plan participant. Within this $5,000.00, a maximum of $500.00 will be allowed for splinting and a maximum of $750.00 will be allowed for orthodontics.

* * * * * *
This list is not intended to be inclusive of all benefits and limitations of the Wal-Mart Plan. All charges submitted to the Wal-Mart Plan are subject to the provisions of the legal Plan Document."

On February 2, 1987, the defendant wrote a letter to Dr. Brown in response to his previous letter inquiring as to why he had not received payment of his bill for the capping of plaintiff's teeth. Defendant's letter reads:

"Dear Dr. Brown:
Thank you for your letter regarding coverage for Cathy Cotton's TMJ. Under the Wal-Mart Group Health Plan any charges for the medical treatment of TMJ is covered subject to the following limitations: $5000 lifetime maximum, $750 for orthodontics, $500 for splinting. Upon review of her X-rays, our Medical Advisory Board recommended no coverage for the $4,015.00 crowns as they are dental rather than medical in nature. Under the Wal-Mart Group Health Plan there are no dental benefits.
If you have additional documentation to submit we will be glad to review the charges again."

Dr. Brown wrote the defendant again explaining that the plaintiff had a "severe medical problem (headaches) as a result of TMJ dysfunction" and that the crowning, though dental, was the preferred treatment for plaintiff's TMJS.

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Bluebook (online)
552 So. 2d 14, 1989 La. App. LEXIS 2088, 1989 WL 134815, Counsel Stack Legal Research, https://law.counselstack.com/opinion/cotton-v-wal-mart-stores-inc-lactapp-1989.