Smalley v. Integrity, Inc.

722 So. 2d 332, 1998 WL 847665
CourtLouisiana Court of Appeal
DecidedDecember 9, 1998
Docket31,247-WCA
StatusPublished
Cited by22 cases

This text of 722 So. 2d 332 (Smalley v. Integrity, 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
Smalley v. Integrity, Inc., 722 So. 2d 332, 1998 WL 847665 (La. Ct. App. 1998).

Opinion

722 So.2d 332 (1998)

Otis SMALLEY, Plaintiff-Appellee,
v.
INTEGRITY, INC., and Louisiana Home Builders Association-Self Insurers Fund, Defendants-Appellants.

No. 31,247-WCA.

Court of Appeal of Louisiana, Second Circuit.

December 9, 1998.

*333 Pettiette, Armand, Dunkelman, Woodley & Byrd by Robert A. Dunkelman, Shreveport, Counsel for Defendants-Appellants.

Kelly, Townsend & Thomas by Donald G. Kelly, Natchitoches, Counsel for Plaintiff-Appellee.

Before MARVIN, C.J., and NORRIS and STEWART, JJ.

NORRIS, Judge.

In this worker compensation case, the employer and its insurer appeal a judgment awarding the claimant weekly compensation benefits. The appellants urge the WCJ erred in failing to find that the claimant forfeited all benefits because of fraud; alternatively, they urge the WCJ failed to grant proper credit for disability insurance benefits *334 partially funded by the employer. For the reasons expressed, we affirm.

Factual and procedural background

The claimant, Otis Smalley, was a journeyman carpenter employed by Integrity Inc., an industrial contractor. On August 24, 1995 he injured his back while unloading metal desks on the job. He initially went to a hospital in Alexandria, near the site of the accident, but the following week his supervisor sent him to Dr. Carl Goodman, an orthopedist in Shreveport. Dr. Goodman performed an L5 lumbar discectomy at the Highland Clinic and, after some therapy, sent Smalley back to medium-duty work in December 1995. Smalley complained, however, that he was working in constant back and leg pain. He testified that he quit work in March 1996; at this point, Integrity's compensation carrier resumed paying him temporary, total benefits of $296.48 a week.

Although Smalley complained that increased activity aggravated his back and leg, Dr. Goodman continued to recommend that he return to work in some capacity. Smalley then selected his own orthopedist, Dr. Austin Gleason. This doctor examined him and concluded that not only should Smalley not be working, but he needed a second surgery, an L5 laminectomy with possible L4-5 fusion. Smalley saw Dr. Goodman two more times, but by August 1996 he notified the Office of Workers Compensation ("OWC") that Dr. Gleason would be his primary physician.

Because of the conflicting reports from Drs. Goodman and Gleason, the OWC ordered an independent medical examination from Dr. James Zum Brunnen, but this was not performed until November 1996. Dr. Zum Brunnen ultimately agreed with Dr. Gleason that Smalley should not be working and should have the second surgery. This was ultimately authorized and performed on March 6, 1997.

Meanwhile, Smalley faced financial problems involving a divorce and custody dispute (his comp check was already being reduced for a child support assignment), his father's medical bills and various other debts. Uncertain that the OWC would ever approve the surgery, Smalley went to work for a friend of his, John Sipes, starting in October 1996. His work for Sipes was part-time residential carpentry.[1] Smalley, however, did not report this income to the OWC, Integrity or its comp carrier, or to Drs. Zum Brunnen or Gleason, whom he saw while working for Sipes. He merely continued to receive, indorse and deposit his comp checks.

In the first week of January 1997, Smalley's comp check was late. He phoned Integrity to ask why, and learned his benefits had been terminated because the company had documentation that he was working for wages. Smalley quit working for Sipes on January 8. He then underwent the second surgery in March 1997; Integrity covered it.

Smalley filed this disputed claim in May 1997. Integrity and its comp carrier, the Louisiana Home Builders Association Self-Insurance Fund, defended on grounds that Smalley willfully made a false statement or representation for the purpose of obtaining benefits. La. R.S. 23:1208. Alternatively they sought credit for the wages Smalley earned, R.S. 23:1206, as well as a reduction of comp benefits for disability benefits under R.S. 23:1225 C.

Trial was held in December 1997. In support of its § 1208 defense, Integrity and its carrier cited a December 18, 1996 note from Dr. Gleason's office which stated, "Working/No," the indorsement of comp checks while he was working, and the failure to tell Dr. Zum Brunnen, Integrity or the OWC that he was working. Smalley denied giving anyone false information, insisting that no one asked about his work status during the period in question. In support of its § 1225 reduction claim, Integrity showed that it provided its employees a long-term disability policy through UNUM Life Insurance Company and paid 70% of the premiums. Because of his injury, Smalley qualified for benefits totaling $15,466.88 under this policy; Integrity sought credit for 70% of this amount. However, UNUM's policy *335 provided for the reduction of disability benefits if the employee was also drawing workers comp; for this reason, Smalley actually received only $1,649.95. Smalley requested that Integrity's credit be based on the reduced amount.

The WCJ ruled from the bench that Smalley did not falsely represent to anyone that he was not working when he really was. She further ruled that his failure to report income did not warrant forfeiture of benefits under § 1208 E. She noted that § 1208 had been amended in 1995, prior to Smalley's injury, to require that each claimant receive a form summarizing the fines and penalties for comp fraud, with notice of the duty to report wages to his insurer. She took judicial notice, however, that the OWC did not publish the necessary form and notice until after Smalley's injury, and found that Smalley had never in fact received this information. She therefore declined to hold that the failure to report other income required a forfeiture of benefits. She awarded supplemental earnings benefits from October 7, 1996 (the date Smalley went to work for Sipes) through March 6, 1997 (the date of the second surgery); then temporary, total benefits from March 7 through September 5, 1997; then SEB thereafter. She awarded a credit for temporary total benefit overpayments made while Smalley was working.

Addressing the reduction for disability benefits, the WCJ stated that R.S. 23:1225 C(3) was ambiguous and confusing, and that the "basic benefit" amount of $15,466.88 was a "fictitious figure" which Smalley never received. She stated that the spirit of the statute was to avoid duplicate recovery, and that reduction based on the actual amount received, $1,649.86, better served that objective. She therefore ordered a reduction of $1,154.90, or 70% of the benefits received.

Discussion: Forfeiture of benefits

By its first assignment Integrity urges the WCJ erred in failing to order the forfeiture of benefits. In support it reiterates that the office note of December 18, 1996 from Dr. Gleason's office, "Working/No," was a false statement; that Smalley's indorsement of comp checks while he was earning other wages was a recurrent false statement; and that the failure to advise Dr. Zum Brunnen or Integrity's comp carrier of his work status was a misrepresentation.

Forfeiture of comp benefits for misrepresentation is governed by La. R.S. 23:1208, which provides in part:

§ 1208. Misrepresentations concerning benefit payments; penalty
A.

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722 So. 2d 332, 1998 WL 847665, Counsel Stack Legal Research, https://law.counselstack.com/opinion/smalley-v-integrity-inc-lactapp-1998.