Smith v. Highlines Construction Co.

198 So. 3d 210, 2016 La. App. LEXIS 1337, 2016 WL 3609060
CourtLouisiana Court of Appeal
DecidedJuly 6, 2016
DocketNo. 50,636-WCA
StatusPublished
Cited by1 cases

This text of 198 So. 3d 210 (Smith v. Highlines Construction 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
Smith v. Highlines Construction Co., 198 So. 3d 210, 2016 La. App. LEXIS 1337, 2016 WL 3609060 (La. Ct. App. 2016).

Opinion

DREW, J.

|,In this workers’ compensation proceeding, Highlines Construction Company (“Highlines”) appeals a judgment ordering it to pay $34,314.42 together with interest to claimant John Smith for prescription drugs that he obtained from Injured Workers Pharmacy (“IWP”), as well as a penalty of $2,000 and attorney fees of $5,000. Smith has answered the appeal, seeking reversal of that part of the judgment denying his claim of entitlement to permanent total disability (“PTD”) . benefits.

We affirm the denial of Smith’s claim of entitlement to PTD benefits, and we also affirm the award of the penalty and attorney fees. We revérse the judgment insofar as it ordered Highlines to pay' for prescription drugs provided by IWP.

FACTS

On August 7, 2003, John Smith was injured while moving steel panels at work for Highlines. Smith felt immediate neck and left upper extremity pain.

Smith received workers’ compensation indemnity payments for 520 weeks. He also received medical benefits, including prescription drug coverage. Gray Insurance Company (“Gray”), the workers’ compensation insurer .of Highlines, provided Smith with a TMESYS .pharmacy card [212]*212that Smith was to use to have his prescriptions filled at participating pharmacies.

In May of 2013, Smith encountered difficulty in filling his prescriptions using the TMESYS card at a Walgreens pharmacy. Smith’s wife, Faye, alleged that she was told by Walgreens employees that she would have to pay for his drugs because his case had been closed. Faye, |2who usually handled getting the prescriptions filled, then contacted Smith’s attorney, C. Daniel Street, who directed her to IWP.

When IWP sought pre-authorization in May of 2013, Gray declined coverage and informed IWP that it would not pay its invoices and that Smith would have to obtain his drugs through Gray’s “process.” IWP continued to fill Smith’s prescriptions despite receiving repeated notices from Gray that it would not pay for the drugs provided by IWP.

Smith filed this disputed claim for compensation against Highlines and Gray on July 15, 2013, contesting Gray’s refusal to pay for his prescriptions filled by IWP. Smith sought attorney fees, penalties, and the amount owed at the time to IWP,

On September 5, 2013, Gray gave notice of termination of benefits because Smith had received 520 weeks of indemnity benefits. Smith disagreed with the termination, arguing that he was totally and permanently disabled and entitled to medical and indemnity benefits. Smith amended his claim on September 25, 2013, to allege entitlement to permanent total disability benefits of $394.71 per week from August 9, 2013, along with penalties and attorney fees-.

Following a trial, the WCJ ordered Highlines and Gray to pay $34,314.42 and interest to Smith for the IWP bill. High-lines and Gray were also ordered to pay a penalty of $2,000, and attorney fees of $5,000. Smith’s claim for permanent total disability benefits was rejected. Each party was ordered to bear its own costs.

| «DISCUSSION

Permanent total disability

Smith contends that he is entitled to designation as being permanently totally disabled. La. R.S. 23:1221(2), which governs claims for PTD, states, in part:

(a) For any injury producing permanent total disability of an employee to engage in any self-employment or occupation for wages, whether or not the same or a similar occupation as that in which the employee was customarily engaged when injured, and whether or not an occupation for which the employee at the time of injury was particularly fitted by reason of education, training, and experience, sixty-six and two-thirds percent of wages during the period of such disability.
(b) For purposes of Subparagraph (2)(a) of this Paragraph, compensation for permanent total disability shall not be awarded if the employee is engaged in any employment or self-employment regardless of the nature or character of the employment or self-employment including but not limited to any and all odd-lot employment, sheltered employment, or employment while working in any pain.
(c) For purposes of Subparagraph (2)(a) of this Paragraph, whenever the employee is not engaged in any employment or self-employment as described in Subpar-agraph (2)(b) of this Paragraph, compensation for permanent total disability shall be awarded only if the employee proves by clear and convincing evidence, unaided by any presumption of disability, that the employee is physically unable to engage, in any employment or self-employment, regardless of the nature or character of the employment or [213]*213self-employment, including, but not limited to, any and all odd-lot employment, sheltered employment, or employment while working in any pain, notwithstanding the location or availability of any such employment or self-employment.

A claimant seeking PTD benefits bears the burden of proving, by clear and convincing evidence, his inability to engage in any type of employment. Harris v. City of Bastrop, 49,534 (La.App.2d Cir.1/14/15), 161 So.3d 948; State, DOTD v. Berry, 49,186 (La.App.2d Cir.8/13/14), 147 So.3d 270. The clear and convincing standard in a workers’ compensation' case is an intermediate standard falling somewhere between the ordinary preponderance of the evidence civil standard and the beyond a reasonable doubt criminal standard. To prove a matter by clear and convincing evidence means to demonstrate that the existence of the disputed fact is highly probable, or much more probable than its nonexistence. Hollingsworth v. Steven Garr Logging, 47,884 (La.App.2d Cir.2/27/13), 110 So.3d 1219; Young v. Physicians & Surgeons Hosp., 39,348 (La.App.2d Cir.3/2/05), 895 So.2d 723.

Following the 1983 améndments to.the workers’ compensation statute, evidence that an employee could not return to any gainful employment without suffering substantial pain is no longer sufficient to support an award of permanent total disability benefits. Morgan v. Glazers Wholesale Drug Co., 46,692 (La.App.2d Cir.11/2/11), 79 So.3d 417; Bank of Winnfield & Trust Co. v. Collins, 31,473 (La.App.2d Cir.2/24/99), 736 So.2d 263.

A left shoulder MRI taken a few days after the accident showed injury-to that area. The next month, Dr. Douglas Liles performed surgery to repair Smith’s torn left rotator cuff.

Dr. Bernie McHugh, a neurosurgeon, examined Smith on January 4, 2005, on a workers’ ■ compensation consultation. Smith complained of increasing cervical pain- along with left upper extremity pain and radicular symptoms. He told Dr. McHugh that' he was now retired from doing construction- work. Dr. McHugh noted that a cervical MRI from October of 2004 showed severe spondylosis from C4 to C7. Dr. McHugh | ^recommended that Smith receive epidural steroid injections, and if. Smith saw no relief from that, then they would discuss surgical decompression. Dr. McHugh referred Smith to Dr. John Ledbetter, who specialized in pain management. Dr. McHugh believed that he did not examine Smith again until April of 2014, a period of nine years.

Smith first saw Dr. Ledbetter on March 16, 2005, telling him that he had retired on workers’ compensation. His chief complaints were neck pain and left arm numbness. Smith reported an intermittent pain that was worse when he was moving or twisting his neck. Dr. Ledbetter noted unintentional tremors in Smith’s left upper extremity. Dr.

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Bluebook (online)
198 So. 3d 210, 2016 La. App. LEXIS 1337, 2016 WL 3609060, Counsel Stack Legal Research, https://law.counselstack.com/opinion/smith-v-highlines-construction-co-lactapp-2016.