Stewart v. Self-Insurer's Bureau

626 So. 2d 34, 1993 La. App. LEXIS 3270, 1993 WL 429680
CourtLouisiana Court of Appeal
DecidedOctober 15, 1993
Docket92 CA 1881
StatusPublished
Cited by5 cases

This text of 626 So. 2d 34 (Stewart v. Self-Insurer's Bureau) 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
Stewart v. Self-Insurer's Bureau, 626 So. 2d 34, 1993 La. App. LEXIS 3270, 1993 WL 429680 (La. Ct. App. 1993).

Opinion

626 So.2d 34 (1993)

Dr. Luther STEWART
v.
SELF-INSURER'S BUREAU.

No. 92 CA 1881.

Court of Appeal of Louisiana, First Circuit.

October 15, 1993.

*35 Robert Hill, Baton Rouge, for plaintiff-appellee Dr. Luther Stewart.

F. Scott Kaiser, Patricia Wilton, Baton Rouge, for defendant-appellant Self Insurer's Bureau.

Before CARTER, GONZALES and WHIPPLE, JJ.

CARTER, Judge.

This is an appeal from a judgment of the Office of Worker's Compensation in favor of a medical provider.

FACTS

On or about October 3, 1989, Lucy Mae Hammond, while in the course and scope of her employment with Fast Track U.S.A., Inc., allegedly suffered injuries in a slip and fall accident. Fast Track was self insured for workers' compensation claims at the time of the alleged incident, and its claims were administered through, defendant, Self Insurors Service Bureau, Inc.[1]

From October 3, 1989, to October 24, 1989, Ms. Hammond was seen by several physicians at Self Insurors' expense regarding her complaints of injury. However, on October 31, 1989, without notice to or prior approval from Self Insurors, Ms. Hammond consulted plaintiff, Dr. Luther Stewart, for evaluation and treatment. Ms. Hammond was seen by Dr. Stewart nineteen times between October 31 and December 8, 1989.

In March of 1990, Dr. Stewart forwarded to Self Insurors all bills for Ms. Hammond's treatment, totaling over $4,000.00. After reviewing the bills and Ms. Hammond's medical records, Self Insurors submitted the documents to Intracorp, an independent medical review firm, for an audit.

Dr. David Zelman, a physician who serves as an independent auditor for Intracorp, reviewed Dr. Stewart's bills and treatment records for Ms. Hammond. Based on Dr. Zelman's findings, Intracorp concluded that none of the treatment was "emergency treatment." Furthermore, Dr. Zelman determined that no more than $703.33 of Dr. Stewart's charges could be considered "reasonable and necessary" medical treatment.

Based on the audit report and the medical evidence, Self Insurors paid Dr. Stewart $703.33, but declined to pay the remainder of his charges. Dr. Stewart then filed a request for review of physician's fees for services and treatment with the Office of Worker's Compensation, seeking payment for the balance of his charges. Dr. Stewart claimed that Ms. Hammond's treatment was exclusively emergency treatment and that, therefore, the treatment was not subject to the statutory limit of $750.00, which is set forth in LSA-R.S. 23:1142.

On December 6, 1991, the matter proceeded to trial before a workers' compensation hearing officer who rendered judgment on April 30, 1992. The hearing officer determined *36 that Dr. Stewart's treatment was non-emergency treatment and that consent for treatment had not been obtained from Self Insurors. However, the hearing officer awarded Dr. Stewart the statutory limit of $750.00 for non-approved, non-emergency service, subject to a credit of $703.33 previously paid by Self Insurors, plus interest, costs, and $500.00 in attorney's fees.[2]

Self Insurors appealed from the judgment, contending that it was error for the trial court to award additional reimbursement of medical expenses and attorney's fees to Dr. Stewart.

REIMBURSEMENT FOR MEDICAL EXPENSES

Self Insurors contends that the trial court erred in awarding Dr. Stewart reimbursement beyond the $703.33, which Self Insurors had paid to Dr. Stewart.

LSA-R.S. 23:1203 A, provides that:

In every case coming under this Chapter, the employer shall furnish all necessary drugs, supplies, hospital care and services, medical and surgical treatment, and any nonmedical treatment recognized by the laws of this state as legal.... The obligation of the employer to furnish such care, services, treatment, drugs, and supplies, is limited to the reimbursement determined to be the mean of the usual and customary charges for such care, services, treatment, drugs, and supplies, as determined under the reimbursement schedule annually published pursuant to R.S. 23:1034.2 or the actual charge made for the service, whichever is less.[3] (Emphasis added).

LSA-R.S. 23:1142 C addresses emergency care and provides that no consent is required for an emergency procedure or treatment deemed immediately necessary by the treating health care provider. Any health care provider who authorizes or orders emergency diagnostic testing or treatment when diagnostic testing or treatment is not of an emergency nature shall be responsible for all charges incurred in the diagnostic testing or treatment. LSA-R.S. 23:1142 B addresses non-emergency care and provides as follows:

Except as provided herein, each health care provider may not incur more than a total of seven hundred fifty dollars in nonemergency diagnostic testing or treatment without the mutual consent of the payor and the employee. Except as provided herein, that portion of the fees for nonemergency services of each health care provider in excess of seven hundred fifty dollars shall not be an enforceable obligation against the employee or the employer or the employer's worker's compensation insurer unless the employee and the payor have agreed upon the diagnostic testing or treatment by the health care provider.

The statute requires that Self Insurors be notified as to the treatment and charges for it to be responsible for compensation over $750.00, unless the treatment was of an emergency nature. See Anesthesia East v. CIGNA Insurance Company, 598 So.2d 1253, 1254 (La.App. 4th Cir.1992). In the instant case, it is undisputed that Self Insurors did not consent to and was not notified of Dr. Stewart's treatment of Ms. Hammond. Moreover, despite Dr. Stewart's contentions at the hearing that his treatment of Ms. Hammond was in the nature of emergency care, the hearing officer determined that the treatment was not emergency treatment.[4]

Under LSA-R.S. 23:1142, if the health care provider's services are found to be of a non-emergency nature, the provider cannot be reimbursed for more than $750.00 of the provider's total charges. The burden of proof is on the claimant or, as in this case, the health care provider to show by a preponderance of the evidence that the medical services were necessary and to show the *37 value of those services. See Anesthesia East v. CIGNA Insurance Company, 598 So.2d at 1254; Williamson v. CIGNA/Insurance Company of North America, 595 So.2d 325, 328 (La.App. 3rd Cir.), writ denied, 596 So.2d 197 (La.1992); Lynn v. Berg Mechanical, Inc., 582 So.2d 902, 912 (La.App. 2nd Cir. 1991).

In the instant case, the trial judge made the following determination:

While the undersigned is in agreement with the actions of the defendants in this situation, it is decided that the preponderance of the evidence demonstrates that they should have paid the full statutory amount of $750.00, which occasioned the need of filing this action to rectify the case.

Although the trial judge did not make an express finding that the services Dr. Stewart rendered were "necessary" medical expenses, implicit in the award of $750.00 in medical expenses is a determination that $750.00 of the expenses incurred were necessary. After reviewing the testimony and medical evidence in the record, we disagree.

On October 5, 1989, Dr. Frederick E. Hackley saw Ms. Hammond for complaints of back and neck pain. When he entered his office, Ms.

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Cite This Page — Counsel Stack

Bluebook (online)
626 So. 2d 34, 1993 La. App. LEXIS 3270, 1993 WL 429680, Counsel Stack Legal Research, https://law.counselstack.com/opinion/stewart-v-self-insurers-bureau-lactapp-1993.