Gros v. Gaudin

773 So. 2d 172, 0 La.App. 5 Cir. 1015, 2000 La. App. LEXIS 2659, 2000 WL 1637558
CourtLouisiana Court of Appeal
DecidedOctober 31, 2000
DocketNo. 00-CA-1015
StatusPublished
Cited by8 cases

This text of 773 So. 2d 172 (Gros v. Gaudin) 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
Gros v. Gaudin, 773 So. 2d 172, 0 La.App. 5 Cir. 1015, 2000 La. App. LEXIS 2659, 2000 WL 1637558 (La. Ct. App. 2000).

Opinion

| ^CANNELLA, Judge.

The Claimant, Linda Gros, appeals from the judgment rendered by the Office of Workers’ Compensation (OWC) in favor of Defendant, Maryland Casualty Company (Maryland), dismissing her claim for reimbursement of medical expenses. For the reasons which follow, we reverse and remand.

The facts giving rise to this controversy are not in dispute. The Claimant was employed at a law firm in 1992 when she sustained a severe back injury by slipping down in the office. Over the years, she has had two separate surgeries for this [173]*173injury and remains disabled. Her treating physician from the outset of her injury was Dr. Robert A. Fleming.

.On January 9, 1997, Dr. Fleming performed the second operation on claimant’s spine, a laminectomy at L5-S1, which included a bone graft. In his September 3, 1997 followup report, he expressed concern that the fusion was not solid and that a grafting procedure might be necessary. The Claimant was complaining of severe pain and numbness in her right leg, going down to her foot and a declining ability to walk without assistance. Dr. Fleming had Magnetic | ¡¡Resonance Imaging (MRI) performed and, based upon it and his examination of claimant, he recommended surgery and scheduled it for February 5, 1998. Maryland, objected to the surgery and refused to authorize payment for it. Maryland scheduled a January 20, 1998 second opinion exam by its physician, Dr. Robert A. Steiner. Dr. Steiner agreed that claimant had severe problems and was at this time disabled. However, he did not think that another operation would benefit her.

On March 10, 1998, Maryland filed a request with the OWC for an independent medical examination (IME) of Claimant by a physician chosen by OWC. On April 8, 1998, OWC forwarded a request to Maryland for' additional information. It was noted therein that failure to timely supply the information could result in the denial of the IME. There is nothing in the record to indicate whether Maryland responded timely. But, on April 27, 1998, OWC responded, denying Maryland’s request for an IME. OWC found that “the evidence presented does not reflect that there is presently a medical or factual dispute regarding the present physical status of this individual, as required by La R.S. 23:1123.” The Claimant returned to Dr. Fleming on May 20, 1998. Following his examination and confirmation of his earlier findings, he again recommended surgery. On June 4, 1998, the Claimant forwarded the surgery request to Maryland, noting the denial of the IME by OWC. On June 8, 1998, Maryland responded negatively, stating that “[a]t this point, Maryland will not consent to payment for this surgery....” After receipt of the Maryland letter, the hospital again cancelled the Claimant’s surgery. Thereafter, upon obtaining Medicare coverage through social security, Dr. Fleming again rescheduled the surgery for July 21, 1998. Maryland was again notified and again informed Dr. Fleming and |4the hospital that it would not pay for the surgery. In a follow up letter by Maryland to Dr. Fleming, Maryland notes: “I denied payment for any surgery ...”

The Claimant was operated on by Dr. Fleming on July 21, 1998. It is alleged, although support cannot be found in the record before us, that on the eve of the surgery a letter was received by someone on behalf of the Claimant informing her that an IME had been set for August 7,1998.

Following the surgery, the Claimant testified that her range of motion improved and her pain has significantly decreased. She can now walk without a walker. She again requested reimbursement for her remaining medical bills from this surgery and was again denied by Maryland. The Claimant filed with OWC a disputed claim form for recovery of her remaining medical expenses. In that claim, she also asserted that she had outstanding medical bills from her previous surgery that had never been paid by Maryland and also made demand for payment of those.

Following a hearing, the OWC rendered a judgment, without cited legal authority, denying the Claimant’s request for reimbursement of all her medical bills. Although the trial judge noted that it “was not impressed” with the Claimant, there were few other reasons for the ruling. It is from this judgment that the Claimant appeals.

On appeal the Claimant argues that the trial judge erred in denying her claim for [174]*174reimbursement of medical bills, both relating to her former and last surgeries. The Claimant contends that she met her burden of proof of showing that the injury from which she suffered was work related and covered by workers’ compensation benefits and that the medical treatment which she had was | ¿necessitated by the work related injury. Therefore, she contends that the trial judge erred in denying her reimbursement for the medical treatment which she received.

Maryland argues that, in the absence of their consent to the treatment, it is not liable for the medical treatment which the Claimant pursued. In the alternative, it argues that its liability is limited by La. R.S. 22:1142 to $750. Further, Maryland argues that since an IME was scheduled before the surgery, albeit noticed the day before, it should be relieved of liability for the surgery that was performed. As to the medical bills for the previous surgery, Maryland contends that there is a discrepancy in what the Claimant contends is owed and what it contends is owed and that the Claimant did not meet her burden of proving that the bills submitted related to treatment for the work related injury or that she paid the bills.

It is well settled that an employer or her workers’ compensation insurer is liable to an injured worker for any injury which she sustains by accident arising out of and in the course of her employment. La. R.S. 22:1031. This includes the employer’s duty to furnish all medical treatment and services necessitated by the work related injury. La. R.S. 22:1203.

There is no dispute that the Claimant’s injury was work related or that her disability resulted from the work-related injury. Nevertheless, Maryland contends that it should not pay for the Claimant's third surgery, relying on La. R.S. 22:1142, because she did not get prior approval for the surgery. We disagree.

La. R.S. 22:1142 provides in pertinent part:

LB. Nonemergency care. (1) Except as provided herein, each health care provider may not incur more than a total of seven hundred fifty dollars in nonemer-gency diagnostic testing or treatment without the mutual consent of the payor and the employee as provided by regulation. Except as provided herein, that portion of the fees for nonemergency services of each health care provider in excess of seven hundred fifty dollars shall not be an enforceable obligation against the employee or the employer or the employer’s workers’ compensation insurer unless the employee and the payor have agreed upon the diagnostic testing or treatment by the health care provider.
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D. Fees and expenses.

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Cite This Page — Counsel Stack

Bluebook (online)
773 So. 2d 172, 0 La.App. 5 Cir. 1015, 2000 La. App. LEXIS 2659, 2000 WL 1637558, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gros-v-gaudin-lactapp-2000.