Lynn v. Berg Mechanical, Inc.

649 So. 2d 139, 1995 La. App. LEXIS 55, 1995 WL 26172
CourtLouisiana Court of Appeal
DecidedJanuary 25, 1995
DocketNo. 26,353-CA
StatusPublished
Cited by3 cases

This text of 649 So. 2d 139 (Lynn v. Berg Mechanical, 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
Lynn v. Berg Mechanical, Inc., 649 So. 2d 139, 1995 La. App. LEXIS 55, 1995 WL 26172 (La. Ct. App. 1995).

Opinions

11 STEWART, Judge.-

This appeal was reargued before a five judge panel in accordance with LSA-Const. Art. 5 see. 8(B).

Following a second suit against his former employer and its worker’s compensation insurer, Jerry C. Lynn appeals the partial denial of his medical expenses claim and the rejection of his request for statutory penalties and attorney’s fees. We amend to award penalties and attorney’s fees, and, as amended, affirm.

FACTUAL AND PROCEDURAL HISTORY

Lynn, a plumber employed by Berg Mechanical, Inc., suffered serious injuries at a jobsite on August 31, 1981, while assisting a delivery driver with the repair of an eighteen-wheeler. A metal spring, forcibly propelled from the air brake system of the truck, struck plaintiff in the head and knocked him to the ground. As a result, he sustained four fractures to the skull, severe trauma to the forehead, cervical and lumbar strain complicated by spinal distortion, vertebral displacement and spinal fixation, temporomandibular joint syndrome (TMJ), depression, and other psychological detriment.

In November 1985, Lynn filed suit against his former employer and its worker’s compensation insurer, Travelers Insurance Company. The trial court, in May 1990, determined plaintiffs claim for weekly disability benefits to be prescribed, while further finding only some of his unpaid medical expenses [142]*142to be causally related to the accident. In an opinion rendered on June 19, 1991, another panel of this court affirmed the decision below, but amended the judgment to grant penalties and attorney’s fees, together with additional medical expenses. See Lynn v. Berg Mechanical, Inc., 582 So.2d 902 (La. App. 2d Cir.1991).

Subsequent to the first trial (May 2-3, 1990), Lynn began again seeking treatment for his various complaints. When Travelers refused to pay any of these expenses, the former employee once more filed suit. Before the second trial (November 19, 1992), plaintiff had accrued medical bills totalling over $58,000. After considering both the earlier record and all evidence presented at the later proceeding, the lower court deemed |2the insurer liable for all charges except those related to the emplacement of plaintiffs dental implants. Lynn now appeals, claiming the orthodontic treatment to have been necessitated by the 1981 accident. Additionally, he seeks review of the denial of his claim for penalties and attorney’s fees.

DISCUSSION

Medical Benefits — Prosthodontics

Maintaining that the accident-caused TMJ necessitated his dental implants, appellant argues that the trial court wrongly disallowed the associated expenses. We disagree. LSA-R.S. 23:1203 requires the employer to furnish all necessary drugs, supplies, hospital care and services, medical and surgical treatment, and any nonmedical treatment recognized by the laws of this state. In seeking medical benefits under the worker’s compensation law, an injured employee must prepon-derately prove by specific evidence, and to a reasonable certainty, that his claim is related to his work injury. Lynn, supra, and authorities therein.

In May 1990, Lynn began seeing an oral surgeon, Dr. Daniel Lew, and his staff at LSU-MC, for facial pain associated with the temporomandibular joint and osteoarthritis. Dr. Lew eventually concluded that his patient would benefit from replacing his traditional dentures with prosthodontics (permanently implanted dentures). Although the physician conceded that the previous removal of all of plaintiffs teeth may have contributed to the TMJ and osteoarthritis, he could not attribute the need for new dentures to the 1981 accident. Dr. Peyton Cunningham, a dentist, acting at the request of Dr. Lew, manufactured appropriate prosthetic devices to fit the implants. While agreeing that there existed a medical necessity for the dental implants and prosthodontics, Dr. Cunningham refused to speculate as to whether the accident caused plaintiffs condition.

Dr. Charles Mclnnis testified at both trials by deposition. Lynn first visited his office in January 1989. The patient at that time had only eighteen teeth, most having been capped; the crowns appeared worn and the gums had significantly receded. At Lynn’s insistence, Dr. Mclnnis extracted all of the remaining teeth. When questioned, |3however, the dentist could not say that the 1981 accident caused plaintiffs condition. Instead, he explained that many patients with similar symptoms had never been involved in a traumatic incident. This court thus previously concluded that the need for dentures could not reasonably be related to the work injury. Indeed, the appellate opinion indicated that, immediately after the accident, Lynn’s oral symptoms included only chipped (not missing) teeth and a fractured bridge.

Accordingly, the trial court did not err in denying plaintiffs current claim for all medical expenses related to the dental implants.

Penalties & Attorney’s Fees

LSA-R.S. 22:658 provided the applicable law at the time of Lynn’s 1981 accident. It then provided that penalties and attorney fees shall be awarded when benefits were terminated by the employer or insurer without probable cause and in an arbitrary and capricious manner.

After LSA-R.S. 23:1201.2 was amended by Acts 1983, 1st Ex.Sess., No. 1, sec. 1, effective July 1, 1983, LSA-R.S. 22:658 was no longer applicable to worker’s compensation cases. The 1983 amendment was substantive in nature. We therefore apply the standard found in LSA-R.S.

[143]*14322:658. See Cooper v. AMI, Inc., 454 So.2d 156 (La.App. 1st Cir.1984), writ denied. The statute is to be strictly construed. Lewis v. Alloy Casting of La., Inc., 465 So.2d 847 (La.App. 2d Cir.1985).

Whether termination of, or refusal to pay, worker’s compensation benefits is arbitrary, capricious or without probable cause depends primarily on the facts known to the employer or insurer at the time of termination or refusal. Lamette v. Morrison Assur. Co., 461 So.2d 351 (La.App. 2d Cir.1984).

The insurer is required to make a reasonable effort to determine the insured’s condition at the time when compensation benefits are terminated. Wiley v. Southern Casualty Ins. Co., 380 So.2d 214 (La.App. 3d Cir.1980). Refusal to pay without having substantial reason or upon mere protestation that the matter is unclear from a legal standpoint will support an award of penalties. Brasseaux v. Argonaut Ins. Co., 432 So.2d 1153 (La.App. 3d Cir.1983). Travelers refused to pay Lynn’s medical expenses incurred since the 1990 court order without ever investigating the matter. Therefore, we agree with Lynn’s contention that Travelers was arbitrary and capricious in its failure to pay. Lynn is entitled to penalties of 12% of the $29,725.37 total medical benefits award, or. $3567.04.

Additionally, a claimant is entitled to reasonable attorney’s fees if the failure to pay “claims arising under this Chapter” is found to be arbitrary, capricious, or without probable cause. LSA-R.S. 23:1201.2; McKenzie v. City of Bossier City, 585 So.2d 1229 (La.App. 2d Cir.1991). Of course, such a matter essentially presents a question of fact, and the trial court’s determination will not be disturbed absent manifest error. McKenzie, supra.

After making payment' in accordance with the initial judgment, appellees refused to reimburse Lynn for any medical expenses subsequently incurred.

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649 So. 2d 139, 1995 La. App. LEXIS 55, 1995 WL 26172, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lynn-v-berg-mechanical-inc-lactapp-1995.