Mary Semere v. Our Lady of Lourdes Hospital

Louisiana Court of Appeal·Decided June 9, 2004·No. WCA-0003-1702·Unknown

Opinion

STATE OF LOUISIANA

COURT OF APPEAL, THIRD CIRCUIT

03-1702

MARY SEMERE VERSUS OUR LADY OF LOURDES HOSPITAL

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APPEAL FROM THE

OFFICE OF WORKERS' COMPENSATION - # 4 PARISH OF LAFAYETTE, NO. 01-08460 SHARON M. MORROW, WORKERS COMPENSATION JUDGE

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MARC T. AMY

JUDGE

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Court composed of Sylvia R. Cooks, Billie Colombaro Woodard, and Marc T. Amy, Judges.

AFFIRMED.

Philip E. Roberts Roy, Bivins, Judice, Roberts & Wartelle Post Office Drawer Z Lafayette, LA 70502 (337) 233-7430 COUNSEL FOR DEFENDANT/APPELLANT:

Our Lady of Lourdes Hospital

Robert Morlas Schoenfeld Schoenfeld, Schoenfeld & Schoenfeld Law Corp.

810 Union Street, Suite 324 New Orleans, LA 70112 (504) 586-0025 COUNSEL FOR PLAINTIFF/APPELLEE:

Mary Semere

AMY, Judge.

In this workers’ compensation matter, the employee-claimant filed a disputed claim, seeking attorney’s fees and penalties on the grounds that her employer failed to authorize a referral visit to an orthopedist, failed to timely provide copies of accident and medical reports, and failed to timely authorize a wellness program recommended by her physician. The claimant dismissed the portion of the suit pertaining to the accident and medical reports, and, at the hearing in the matter, the employer was granted an involuntary dismissal as to the referral. The workers’ compensation judge found that the employer failed to timely authorize the claimant’s participation in the physician-recommended wellness program and awarded her penalties and attorney’s fees accordingly. The employer appeals. For the following reasons, we affirm.

Factual and Procedural Background The record of the proceedings below indicates that on January 4, 1999, Mary Semere, a nurse’s aide employed by Our Lady of Lourdes Hospital in Lafayette and the claimant herein, injured her lower back in the course and scope of her employment while lifting a patient. Ms. Semere testified that at the time of the accident, she and a co-worker were trying to put a patient back in bed. Ms. Semere indicated that she was on the “pulling side” of the patient; during the “pulling,” her back popped. The record reflects that for treatment for her injuries, Ms. Semere first consulted Dr. Joseph Schutte, who referred her to Dr. Leoni. Dr. Leoni, in turn, referred her to Dr. DeAlvare; after consultation, Dr. DeAlvare referred her to Dr. Joseph T. Gillespie, an anesthesiologist specializing in pain management. Ms. Semere underwent the first of two surgeries, a discectomy conducted by Dr. Leoni, on May 9, 1999. In August 2002, Drs. Schutte and Leoni performed a second discectomy and a laminectomy and

fusion. Ms. Semere testified that Drs. Gillespie and Leoni informed her that she could not return to her prior duties, and Dr. Gillespie recommended that she receive schooling and vocational rehabilitation that would enable and prepare her to take up another trade.

According to Ms. Semere’s testimony, as of October 2001, she still had not received approval for the wellness program, the vocational rehabilitation, and the schooling. On October 25, 2001, she retained an attorney. Ms. Semere filed the instant disputed claim for penalties and attorney’s fees on November 16, 2001, in which she asserted that Our Lady of Lourdes would not authorize an appointment with Dr. Blanda, pursuant to Dr. Gillespie’s referral; it did not timely provide medical and accident records; and it did not timely authorize the wellness program recommended by Dr. Gillespie.

At the hearing in the matter, conducted on September 9, 2003, Ms. Semere asserted that Dr. Gillespie first recommended a wellness program for her on October 26, 2000. She explained that this wellness program was to include treadmill exercise, light weight training, swimming and water aerobics, and hot tub/jacuzzi therapy. Ms. Semere stated that at the time the program was recommended, she was ready to begin therapy; however, months passed without its approval. She testified that during her treatment with Dr. Gillespie, she expressed her frustration that the program had not yet been approved. Ms. Semere indicated that she called Mr. George Jones, Our Lady of Lourdes’ workers’ compensation manager, to inquire as to when the program would be approved, explaining that she believed that she was required to get approval from Mr. Jones before she could begin. She recalled that Mr. Jones advised her to call Ms. Donna Hill, an insurance adjuster with Our Lady of Lourdes’ third-party administrator, Frank Gates Service Company (hereinafter “Frank Gates”), noting that

direct communication with Ms. Hill might expedite the approval process. Ms. Semere testified that she called Ms. Hill, whom she described as “ugly” and “rude” to her on the phone. She stated that during their conversation, she asked Ms. Hill about the wellness program but received no response. During her testimony, Ms. Semere maintained that she never told Mr. Jones or Ms. Hill that she did not wish to participate in the wellness program. The record indicates that the wellness program was approved on December 14, 2001, and as of the date of hearing, Ms. Semere continued to participate.

Ms. Donna Hill explained under cross-examination that Our Lady of Lourdes supplies “ProComp” forms to attending physicians in workers’ compensation cases, and the physicians indicate recommended courses of therapy on these forms.1 Ms. Hill testified that Dr. Gillespie’s October 26, 2000 ProComp form did not mention aqua therapy or a wellness program. Ms. Hill recalled that she first learned of the wellness program recommendation on May 7, 2001, when Mr. Jones faxed her Dr. Gillespie’s prescription for the program; after she received this prescription, another insurance adjuster with Frank Gates sent Dr. Gillespie a letter asking him to elaborate upon the types of wellness treatments recommended, but Dr. Gillespie did not respond. Ms. Hill testified that another letter was sent on June 28, 2001. Ms. Hill indicated that after they received Dr. Gillespie’s response, dated July 3, 2001, Mr. Jones began to research therapy costs and brochures.

Ms. Hill explained at the hearing that Ms. Semere could have initiated the wellness program herself by bringing her prescription to a wellness center. Ms. Hill indicated that the wellness center would have called Frank Gates for approval, and

1 The record reflects that neither Ms. Hill nor Mr. Jones brought their respective claims files with them to the hearing.

Frank Gates would have consented. She further noted that the particular wellness program that was eventually chosen for Ms. Semere required six months’ advance payment.

Ms. Hill recalled speaking to Ms. Semere over the phone on July 24, 2001, regarding the referral to Dr. Blanda.2 Ms. Hill testified that she told Ms. Semere that she wanted her to go to the wellness program office; however, she stated, Ms. Semere, who sounded “agitated,” insisted that she wanted to see Dr. Blanda. According to Ms. Hill’s testimony, Ms. Semere said that she was not interested in the wellness program, aqua therapy, or a dietician. However, Ms. Hill admitted that Frank Gates had received nothing from Dr. Gillespie indicating that Ms. Semere did not wish to participate. She recalled that the next recommendation for the wellness program came from Dr. Gillespie on October 25, 2001, and at this time, she and Mr. Jones decided to set up the program for Ms. Semere.

Our Lady of Lourdes moved for involuntary dismissal at the close of Ms.

Semere’s case. The workers’ compensation judge granted the motion as to the referral to Dr. Blanda, noting that the claim was reasonably controverted. However, the workers’ compensation judge denied the motion as to the wellness program, finding that La.R.S. 23:1201(E)3 does not involve “demand;” instead, she observed, it involves “notice.”

In its effort to defeat the remaining claim, Our Lady of Lourdes called Mr.

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