This and That Services Co. Inc. v. Nieves

CourtSupreme Court of Delaware
DecidedAugust 17, 2023
Docket441, 2022
StatusPublished

This text of This and That Services Co. Inc. v. Nieves (This and That Services Co. Inc. v. Nieves) is published on Counsel Stack Legal Research, covering Supreme Court of Delaware primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
This and That Services Co. Inc. v. Nieves, (Del. 2023).

Opinion

IN THE SUPREME COURT OF THE STATE OF DELAWARE

THIS AND THAT § SERVICES CO. INC., § § No. 441, 2022 Employer Below, § Appellant, § Court Below: Superior Court § of the State of Delaware v. § § C.A. No. S21A-11-004 RAYMOND NIEVES, § § Claimant Below, § Appellee. §

Submitted: June 28, 2023 Decided: August 17, 2023

Before VALIHURA, TRAYNOR, and LEGROW, Justices.

Upon appeal from the Superior Court of the State of Delaware: REVERSED.

John J. Ellis, Esquire, HECKLER & FRABIZZIO, Wilmington, Delaware, for Appellant This and That Services Co. Inc.

Walt F. Schmittinger, Esquire, SCHMITTINGER AND RODRIGUEZ, P.A., Dover, Delaware, for Appellee Raymond Nieves.

LEGROW, Justice: An employer seeks review of a Superior Court Opinion1 reversing a decision

by the Industrial Accident Board (the “IAB” or “Board”) regarding the

reasonableness of a prescribed course of treatment. This case has a protracted

procedural history despite the dispute’s limited scope. The IAB initially dismissed

this case as moot, but the Superior Court reversed and remanded that decision in

2019. On remand, the IAB held that the claimant employee’s ongoing narcotics

treatment after June 2017 was unreasonable, unnecessary, and therefore not

compensable under the Workers’ Compensation Act. The Superior Court then

reversed the IAB again, holding there was no justiciable issue before the Board

because the claimant employee had not submitted any medical claims to his

employer for ongoing treatment.

The statute at issue in this appeal, 19 Del. C. § 2322F, provides a mechanism

for employers and their workers’ compensation carriers to challenge proposed or

provided health care services relating to compensable work injuries. On appeal, the

employer argues that the Superior Court erred as a matter of law in concluding that

the IAB could not consider the compensability of an employee’s ongoing narcotics

treatment until the employee submitted invoices for payment to the employer and

the employer disputed those invoices in the statutory review process. Because the

1 Nieves v. This & That Servs. Co., 2022 WL 3225283 (Del. Super. Aug. 10, 2022) [hereinafter “Nieves II”]. Superior Court incorrectly interpreted 19 Del. C. § 2322F with respect to the

justiciability of the employer’s petition, we reverse the Superior Court’s decision,

vacate the attorneys’ fees award, and reinstate the IAB’s determination.

I. RELEVANT FACTS AND PROCEDURAL BACKGROUND

A. The work injury and the utilization review

On July 29, 2014, Raymond Nieves (“Mr. Nieves”), an employee of This and

That Services Co., Inc. (“This and That Services”), sustained a back injury while

working on a construction project.2 On December 17, 2015, Mr. Nieves sought pain

management treatment from Dr. Ganesh Balu (“Dr. Balu”), a board-certified

physician.3 Dr. Balu prescribed Mr. Nieves both opiate and non-opiate pain

medication, physical therapy, and two epidural injections.4 Dr. Balu also ordered a

discogram which showed a herniated disc and annular tear. As of June 13, 2017,

Mr. Nieves continued to complain of back pain and limited range of motion due to

pain and stiffness.5 To reduce the pain, Dr. Balu prescribed a mild opiate along with

Ibuprofen.6 After the June 13, 2017 visit, Mr. Nieves did not see Dr. Balu again until

2 See App. to Opening Br. at A19 (2021 IAB Decision). 3 See id. at A26. 4 Id. 5 Id. at A26–27. 6 Id. at A27. 2 April 10, 2018.7 Between those visits, Mr. Nieves underwent disc replacement

surgery on August 23, 2017.8

This and That Services submitted Dr. Balu’s pain management treatment from

June 13, 2017 onward to utilization review in accordance with 19 Del. C. § 2322F.

Utilization review provides a mechanism for employers and their workers’

compensation carriers to challenge proposed and provided health care services

relating to compensable work injuries.9 On August 15, 2017, the utilization reviewer

certified Dr. Balu’s treatment as compliant with the Workers’ Compensation

Practice Guidelines and found all the treatment at issue was reasonable and

necessary.10

B. The IAB proceedings begin

This and That Services disagreed with the utilization reviewer’s determination

and filed a petition (the “Petition”) with the IAB for de novo review of the utilization

reviewer’s conclusion that Dr. Balu’s pain management treatment was reasonable

and necessary.11 The parties filed a pre-hearing stipulation with the IAB in

7 Id. at A28. 8 Id. at A27. 9 19 Del. C. § 2322F. Under Section 2322F(j), the “Workers’ Compensation Oversight Panel shall approve, propose, and maintain a utilization review program for any health-care provider providing services to injured workers. . .The intent is to provide reference for employers, insurance carriers, and health-care providers for evaluation of health care and charges.” Id. § 2322F(j); A- 497 (Utilization Review Appeal). 10 App. to Opening Br. at A502–07 (Utilization Review Determination). 11 See id. at A497 (Utilization Review Appeal). 3 September 2018, narrowing the issues to whether Dr. Balu’s narcotic prescriptions

from June 13, 2017 forward were reasonable and necessary.12

On September 14, 2018, Mr. Nieves filed a motion in limine with the IAB to

limit the Petition’s relevant time period to June 13, 2017 through August 23, 2017,

and to exclude all challenges to treatment after August 2017, when Mr. Nieves

underwent disc replacement surgery.13 Mr. Nieves argued that the circumstances of

his treatment changed as a result of the surgery.14 Mr. Nieves also moved to dismiss

the Petition, contending the remaining issues before the IAB were moot.15 The IAB

held a hearing to consider the Petition on September 20, 2018.16 At that hearing, the

IAB granted the motion in limine and limited the treatment period in dispute to June

13, 2017 through August 23, 2017, when Mr. Nieves had surgery.17 The IAB then

dismissed the Petition for mootness because This and That Services already had paid

for Mr. Nieves’ narcotics treatment from June 13, 2017 to August 23, 2017, and

nothing else remained in dispute (the “2018 IAB Decision”).18

12 Id. at A5 (Stipulation of Facts). 13 Id. at A524. 14 Id. 15 Id. 16 Id. at A6 (2018 IAB Decision). 17 Id. at A7. 18 Id.; See also id. at A18 (2021 IAB Decision). 4 C. The first appeal to the Superior Court

This and That Services then appealed the 2018 IAB Decision to the Superior

Court.19 The Superior Court issued a decision dated June 7, 2019 (“Nieves I”),

reversing and remanding the IAB’s decision.20 The Superior Court held that the IAB

erred in dismissing the Petition as moot because there was no evidence that This and

That Services had paid for the medication at issue, so there was still “a real, albeit

narrow, issue” for the IAB to decide.21 Mr. Nieves moved for reargument, seeking

to clarify whether the Superior Court was reversing the IAB’s holding that the

Petition was limited to the June to August 2017 period. The Superior Court denied

reargument, holding that “[a] full review of the evidence is needed. The Board

should make its decision after the review. My decision necessarily overrules the

limitations placed upon the parties by granting the motion in limine.”22

D. The IAB remand hearings The IAB conducted remand hearings on June 3, 2021, and October 8, 2021,

and issued a decision on October 18, 2021 (the “2021 IAB Decision”).23 During the

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This and That Services Co. Inc. v. Nieves, Counsel Stack Legal Research, https://law.counselstack.com/opinion/this-and-that-services-co-inc-v-nieves-del-2023.