Nowlin v. Breck Const. Co.

715 So. 2d 112, 1998 La. App. LEXIS 1640, 1998 WL 329635
CourtLouisiana Court of Appeal
DecidedJune 24, 1998
Docket30622-WCA
StatusPublished
Cited by30 cases

This text of 715 So. 2d 112 (Nowlin v. Breck Const. Co.) 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
Nowlin v. Breck Const. Co., 715 So. 2d 112, 1998 La. App. LEXIS 1640, 1998 WL 329635 (La. Ct. App. 1998).

Opinion

715 So.2d 112 (1998)

David NOWLIN, Plaintiff-Appellee,
v.
BRECK CONSTRUCTION COMPANY, Defendant-Appellant.

No. 30622-WCA.

Court of Appeal of Louisiana, Second Circuit.

June 24, 1998.

*113 Neal Lane Johnson, Jr., Monroe, for Defendant-Appellant.

C. Daniel Street, Monroe, for Plaintiff-Appellee.

Before NORRIS, GASKINS and CARAWAY, JJ.

NORRIS, Judge.

The employer, Breck Construction Company, appeals a Workers Compensation Judge ("WCJ") decree ordering it to pay, inter alia, penalties of $1,500 and attorney fees of $3,500 for withholding authorization for a necessary surgical procedure and failing to pay the scheduled fee for the surgery. The claimant, David Nowlin, has answered, seeking only an increase in attorney fees for the appeal. Finding no abuse of discretion, we affirm the award of penalties and fees, and award additional attorney fees for the appeal.

Factual and procedural background

Nowlin, a construction worker, was injured on the job on July 29, 1996, moving a heavy tool rack through a doorway at a site in Sterlington. He was immediately taken by co-workers to the emergency room at North Monroe Hospital, where he was seen by an orthopedic surgeon, Dr. Scott McClelland.

Breck is self-insured; its third party claims administrator, Hewitt, Coleman & Associates of Jackson, Mississippi, first received notice of the injury on August 9. The case was assigned to Darlene Gray, a claims manager. Ms. Gray testified that she received Dr. McClelland's report on August 15 and authorized admitting Nowlin to North Monroe for a bone scan and myelogram. These tests showed Grade II spondylolisthesis with pars inarticularis defects and possible disc herniation of the S1 nerve root. The attached report, with a consultation from a neurosurgeon, Dr. John Whitley, stated that Nowlin needed a "Gill procedure with L5-S1 fusion." Dr. Whitley became Nowlin's treating physician.

On August 27, Dr. Whitley phoned Ms. Gray and recommended surgery, but the next day, according to Ms. Gray, Nowlin himself was still apprehensive. She advised him that he had the right to be examined by another physician of his choice. Nowlin chose Dr. Baer Rambach, an orthopedic surgeon in Shreveport. Dr. Rambach examined Nowlin in September and advised Ms. Gray that he agreed with Dr. Whitley's diagnosis of spondylolisthesis, Grade II, with nerve involvement, and that Nowlin needed the surgery.

*114 The following day, Dr. Whitley's office again called Ms. Gray, reporting that Nowlin was requesting pain medication and his condition was getting worse; without prompt surgery, he could sustain permanent nerve damage. Ms. Gray approved the operation, but also scheduled an examination by an orthopedic surgeon of Breck's choice, Dr. Brian Bulloch. At any rate, the operation was scheduled for Monday morning, October 28, at North Monroe.

Ms. Gray testified that after this, certain events caused her to withdraw her authorization for the surgery. On October 23, Nowlin's father-in-law phoned her, reporting that Nowlin "planned" the accident, faked the injury, was not really hurt, and was scheming to defraud Breck. The next day, Nowlin's estranged wife called with a similar report. Also, Dr. Bulloch examined Nowlin and faxed his report to Ms. Gray. Like the other three doctors, Dr. Bulloch diagnosed Grade II spondylolisthesis with impingement and traction of the L5-S1 nerve roots, and recommended surgical decompression and fusion.

Ms. Gray testified, however, that she phoned Dr. Bulloch to say she suspected a false claim because of the tips from Nowlin's family. According to Ms. Gray, Dr. Bulloch replied that Nowlin had a pre-existing pars defect which made him susceptible to spondylolisthesis; minor flexion and rotation, such as from tucking in a bed sheet, could aggravate it. Ms. Gray did not recall inquiring whether spondylolisthesis could be faked, but Dr. Bulloch later testified it was an objective finding and reliable.

The next day, October 25, Ms. Gray revoked authorization for the surgery; Dr. Whitley learned of this only when his office called to confirm authorization on the Friday before the scheduled operation. She testified that she investigated the fraud allegations "intensely," but offered no details or results of her investigation. Later she asked Dr. Bulloch for his opinion of Nowlin's pre-existing back condition and causation. She did not testify that she ever received any reply; however, in a letter of November 7 Dr. Bulloch said that despite the prior condition, it was "quite reasonable that he injured his back and exacerbated his problem as a result of the acute accident at work." He added that the surgery was "very reasonable" and "quite possibly necessary." Ms. Gray then decided that Nowlin should be examined by a neurosurgeon of Breck's choice, but she never actually scheduled this. She did approve an EMG and nerve conduction study, but by mid-November they had not been performed.

On November 12, Nowlin filed the instant rule for surgery, including a prayer for penalties and attorney fees. At the hearing on December 2, Nowlin testified and offered reports from all four doctors who had examined him and recommended surgery. Breck produced no evidence at this hearing. The WCJ granted the rule, ordering Breck to provide surgery.

Ms. Gray complied and authorized the surgery, but a fee dispute arose with Dr. Whitley. According to Ms. Gray, Dr. Whitley refused to operate without a written guarantee that he would be paid 100% of his normal fee. Ms. Gray's position was that the employer was required only to pay according to the Workers Compensation fee schedule.

Dr. Whitley ultimately performed the operation on January 22, 1997, and submitted two bills totaling $28,496.00. Ms. Gray forwarded these to AccuMed, a utilization review company under contract to Hewitt Coleman. AccuMed replied that the schedule authorized only $8,657.23 for the procedure; Ms. Gray paid Dr. Whitley that amount. The doctor contested AccuMed's explanation of benefits; on re-evaluation, AccuMed authorized an additional payment of $2,864.49, and this was paid on April 17.

On March 31, Nowlin filed the instant supplemental petition, demanding an unpaid balance of $4,238.27 due Dr. Whitley, and seeking penalties and attorney fees for failure to pay the proper amount.[1] This hearing was held in June. Dr. Whitley testified by deposition, *115 describing the surgical codes and scheduled fees for Nowlin's procedure, and concluded that the amount still due was actually $6,351.77. Ms. Gray testified for Breck, defending her decision not to approve the surgery in October (Breck had offered no evidence at the first hearing). She claimed she had no idea of the amount still claimed until a mediation conference held six days before the hearing. Ms. Gray also tried to explain how AccuMed figured medical benefits from surgical codes, but this was excluded as hearsay. Breck did not call anyone from AccuMed to explain its review process.

The WCJ ruled from the bench, ordering Breck to pay Dr. Whitley's outstanding bill, $6,351.77, and casting his deposition as cost; these portions of the order are not challenged on appeal. The WCJ further found that Breck was arbitrary and capricious for failing to approve the surgery from September 24 to December 3, 1996; she awarded attorney fees of $3,000 and penalties of $500 for this.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Dombrowski v. PATTERSON-UTI DRILLING COMPANY, LLC
63 So. 3d 308 (Louisiana Court of Appeal, 2011)
Flanigan v. City of Shreveport
50 So. 3d 938 (Louisiana Court of Appeal, 2010)
Key v. Monroe City School Board
32 So. 3d 1144 (Louisiana Court of Appeal, 2010)
Whatley v. NABORS DRILLING USA, LP
26 So. 3d 253 (Louisiana Court of Appeal, 2009)
Buxton v. IOWA POLICE DEPT.
3 So. 3d 641 (Louisiana Court of Appeal, 2009)
Marvin W. Buxton v. Iowa Police Dept.
Louisiana Court of Appeal, 2009
Johnson v. Bossier Parish School Board
3 So. 3d 580 (Louisiana Court of Appeal, 2009)
Brien v. Leon Angel Constructors, Inc.
978 So. 2d 576 (Louisiana Court of Appeal, 2008)
Lee v. Heritage Manor of Bossier City
954 So. 2d 276 (Louisiana Court of Appeal, 2007)
Hammock v. Weyerhaeuser
917 So. 2d 733 (Louisiana Court of Appeal, 2005)
Hays v. Western Refractory Construction, Inc.
903 So. 2d 666 (Louisiana Court of Appeal, 2005)
Young v. Christus Schumpert Medical Center
902 So. 2d 1180 (Louisiana Court of Appeal, 2005)
Black v. Lofland Co.
869 So. 2d 264 (Louisiana Court of Appeal, 2004)
Longoria v. Brookshire Grocery Co.
862 So. 2d 1172 (Louisiana Court of Appeal, 2003)
Thomason v. Wal-Mart Stores, Inc.
852 So. 2d 1283 (Louisiana Court of Appeal, 2003)
Lee v. Schumpert
836 So. 2d 1214 (Louisiana Court of Appeal, 2003)
Feild v. General Motors Corp.
828 So. 2d 150 (Louisiana Court of Appeal, 2002)
Robbins v. Schumpert Medical Center
814 So. 2d 737 (Louisiana Court of Appeal, 2002)
Figueroa v. Hardtner Medical Center
805 So. 2d 1267 (Louisiana Court of Appeal, 2002)
Shields v. GNB Technologies, Inc.
768 So. 2d 774 (Louisiana Court of Appeal, 2000)

Cite This Page — Counsel Stack

Bluebook (online)
715 So. 2d 112, 1998 La. App. LEXIS 1640, 1998 WL 329635, Counsel Stack Legal Research, https://law.counselstack.com/opinion/nowlin-v-breck-const-co-lactapp-1998.