FILED Aug 09, 2019 10:19 AM(CT)
TENNESSEE COURT OF WORKERS' COMPENSATION CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT GRAY CHRISTOPHER TILSON, ) Docket No.: 2018-02-0062 Employee, ) Vv. ) State File No.: 7426-2018 HAYWORTH TIRE and AUTO ) SERVICE, ) Judge Brian K. Addington Uninsured Employer. )
EXPEDITED HEARING ORDER
The Court held an Expedited Hearing on August 8, 2019, on Mr. Tilson’s request for past, unpaid medical benefits. Before the hearing, the parties discussed the issues and announced to the Court that they would state their stipulations on the record.
The parties stipulated that Mr. Tilson’s evidence was sufficient to prove he sustained a right-knee injury and is entitled to past medical benefits. Further, the parties stipulated Hayworth Tire and Auto Service (Hayworth) agreed to pay $13,761.19 in medical expenses related to his injury incurred to date.
Based on the parties’ stipulations, the Court holds Mr. Tilson is likely to succeed at a hearing on the merits in proving entitlement to medical benefits and orders Hayworth to pay the incurred medical bills associated with Mr. Tilson’s work injury according to the fee schedule.
The parties further agreed to continue this matter for two weeks to allow Hayworth to obtain a medical records review. Following the records review, the parties will determine whether Dr. Michael Wells will be designated the authorized treating physician or if a panel would be appropriate. The parties agreed to file a new Request for Expedited Hearing if they are unable to agree on continued medical treatment or an agreed order if they reach an agreement on this issue. IT IS, THEREFORE, ORDERED as follows:
1.
Hayworth shall pay the providers $13,761.19 for medical services incurred to date for treatment of Mr. Tilson’s work injury.
. This case is set for a Status Hearing on October 22, 2019, at 2:00 p.m. Eastern
Time. You must call 855-543-5044 to participate. Failure to call may result in a determination of the issues without your participation.
. Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance
with this Order must occur no later than seven business days from the date of entry of this Order as required by Tennessee Code Annotated section 50-6-239(d)(3). The Insurer or Self-Insured Employer must submit confirmation of compliance with this Order to the Bureau by email to WCCompliance.Program@tn.gov no later than the seventh business day after entry of this Order. Failure to submit the necessary confirmation within the period of compliance may result in a penalty assessment for non-compliance.
. For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit via email at WCCompliance.Program(@tn.gov.
ENTERED August 9, 2019.
/S/ Brian K. Addington Judge Brian K. Addington Court of Workers’ Compensation Claims
APPENDIX
Exhibits:
1. me
Affidavit of Josh Hoeppner (Collective) Medical Bills
Technical record:
1. 2.
Petition for Benefit Determination Dispute Certification Notice
3. Notice of Filing 4. Request for Expedited Hearing 5. Pre-Hearing Brief
CERTIFICATE OF SERVICE
I certify that a correct copy of this Order was sent as indicated on August 9, 2019.
Name Certified Email | Service sent to: Mail Josh Hoeppner, x josh@hoeppnerlaw.com Employee’s Attorney Jeff Luethke, x jeffluethke@gmail.com Employer’s Attorney
F f
J NAL Ati Linny Wu
Penny Shru/} Clerk of Court
Court of Wo/kers’ Compensation Claims WC.CourtClerk@tn.gov
Expedited Hearing Order Right to Appeal:
If you disagree with this Expedited Hearing Order, you may appeal to the Workers’ Compensation Appeals Board. To appeal an expedited hearing order, you must:
1. Complete the enclosed form entitled: “Expedited Hearing Notice of Appeal,” and file the form with the Clerk of the Court of Workers’ Compensation Claims within seven business days of the date the expedited hearing order was filed. When filing the Notice of Appeal, you must serve a copy upon all parties.
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten calendar days after filing of the Notice of Appeal. Payments can be made in-person at any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the alternative, you may file an Affidavit of Indigency (form available on the Bureau’s website or any Bureau office) seeking a waiver of the fee. You must file the fully- completed Affidavit of Indigency within ten calendar days of filing the Notice of Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will result in dismissal of the appeal.
3. You bear the responsibility of ensuring a complete record on appeal. You may request from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of the proceedings is to be filed, a licensed court reporter must prepare the transcript and file it with the court clerk within ten business days of the filing the Notice of Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both parties within ten business days of the filing of the Notice of Appeal. The statement of the evidence must convey a complete and accurate account of the hearing. The Workers’ Compensation Judge must approve the statement before the record is submitted to the Appeals Board. If the Appeals Board is called upon to review testimony or other proof concerning factual matters, the absence of a transcript or statement of the evidence can be a significant obstacle to meaningful appellate review.
4. If you wish to file a position statement, you must file it with the court clerk within ten business days after the deadline to file a transcript or statement of the evidence. The party opposing the appeal may file a response with the court clerk within ten business days after you file your position statement. All position statements should include: (1) a statement summarizing the facts of the case from the evidence admitted during the expedited hearing; (2) a statement summarizing the disposition of the case as a result of the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an argument, citing appropriate statutes, case law, or other authority.
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667. LB-1099
EXPEDITED HEARING NOTICE OF APPEAL Tennessee Division of Workers’ Compensation www. tn.gov/labor-wid/weomp.shtml wce.courtclerk@tn.gov 1-800-332-2667
Docket #: State File #/YR:
Employee
Vv.
Employer Notice Notice is given that
[List name(s) of all appealing party(ies) on separate sheet if necessary]
appeals the order(s) of the Court of Workers’ Compensation Claims at
to the Workers’ Compensation Appeals
Board. [List the date(s) the order(s) was filed in the court clerk’s office]
Judge
Statement of the Issues Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
Additional Information Type of Case [Check the most appropriate item]
L] Temporary disability benefits L] Medical benefits for current injury LC Medical benefits under prior order issued by the Court
List of Parties Appellant (Requesting Party): At Hearing: LJEmployer LJEmployee
Address:
Party’s Phone: Email: Attorney's Name: BPR#: Attorney’s Address: Phone:
Attorney's City, State & Zip code:
Attorney’s Email:
* Attach an additional sheet for each additional Appellant *
rev. 10/18 Page 1 of 2 RDA 11082 Employee Name: SF#: DOI:
Appellee(s)
Free access — add to your briefcase to read the full text and ask questions with AI
FILED Aug 09, 2019 10:19 AM(CT)
TENNESSEE COURT OF WORKERS' COMPENSATION CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT GRAY CHRISTOPHER TILSON, ) Docket No.: 2018-02-0062 Employee, ) Vv. ) State File No.: 7426-2018 HAYWORTH TIRE and AUTO ) SERVICE, ) Judge Brian K. Addington Uninsured Employer. )
EXPEDITED HEARING ORDER
The Court held an Expedited Hearing on August 8, 2019, on Mr. Tilson’s request for past, unpaid medical benefits. Before the hearing, the parties discussed the issues and announced to the Court that they would state their stipulations on the record.
The parties stipulated that Mr. Tilson’s evidence was sufficient to prove he sustained a right-knee injury and is entitled to past medical benefits. Further, the parties stipulated Hayworth Tire and Auto Service (Hayworth) agreed to pay $13,761.19 in medical expenses related to his injury incurred to date.
Based on the parties’ stipulations, the Court holds Mr. Tilson is likely to succeed at a hearing on the merits in proving entitlement to medical benefits and orders Hayworth to pay the incurred medical bills associated with Mr. Tilson’s work injury according to the fee schedule.
The parties further agreed to continue this matter for two weeks to allow Hayworth to obtain a medical records review. Following the records review, the parties will determine whether Dr. Michael Wells will be designated the authorized treating physician or if a panel would be appropriate. The parties agreed to file a new Request for Expedited Hearing if they are unable to agree on continued medical treatment or an agreed order if they reach an agreement on this issue. IT IS, THEREFORE, ORDERED as follows:
1.
Hayworth shall pay the providers $13,761.19 for medical services incurred to date for treatment of Mr. Tilson’s work injury.
. This case is set for a Status Hearing on October 22, 2019, at 2:00 p.m. Eastern
Time. You must call 855-543-5044 to participate. Failure to call may result in a determination of the issues without your participation.
. Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance
with this Order must occur no later than seven business days from the date of entry of this Order as required by Tennessee Code Annotated section 50-6-239(d)(3). The Insurer or Self-Insured Employer must submit confirmation of compliance with this Order to the Bureau by email to WCCompliance.Program@tn.gov no later than the seventh business day after entry of this Order. Failure to submit the necessary confirmation within the period of compliance may result in a penalty assessment for non-compliance.
. For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit via email at WCCompliance.Program(@tn.gov.
ENTERED August 9, 2019.
/S/ Brian K. Addington Judge Brian K. Addington Court of Workers’ Compensation Claims
APPENDIX
Exhibits:
1. me
Affidavit of Josh Hoeppner (Collective) Medical Bills
Technical record:
1. 2.
Petition for Benefit Determination Dispute Certification Notice
3. Notice of Filing 4. Request for Expedited Hearing 5. Pre-Hearing Brief
CERTIFICATE OF SERVICE
I certify that a correct copy of this Order was sent as indicated on August 9, 2019.
Name Certified Email | Service sent to: Mail Josh Hoeppner, x josh@hoeppnerlaw.com Employee’s Attorney Jeff Luethke, x jeffluethke@gmail.com Employer’s Attorney
F f
J NAL Ati Linny Wu
Penny Shru/} Clerk of Court
Court of Wo/kers’ Compensation Claims WC.CourtClerk@tn.gov
Expedited Hearing Order Right to Appeal:
If you disagree with this Expedited Hearing Order, you may appeal to the Workers’ Compensation Appeals Board. To appeal an expedited hearing order, you must:
1. Complete the enclosed form entitled: “Expedited Hearing Notice of Appeal,” and file the form with the Clerk of the Court of Workers’ Compensation Claims within seven business days of the date the expedited hearing order was filed. When filing the Notice of Appeal, you must serve a copy upon all parties.
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten calendar days after filing of the Notice of Appeal. Payments can be made in-person at any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the alternative, you may file an Affidavit of Indigency (form available on the Bureau’s website or any Bureau office) seeking a waiver of the fee. You must file the fully- completed Affidavit of Indigency within ten calendar days of filing the Notice of Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will result in dismissal of the appeal.
3. You bear the responsibility of ensuring a complete record on appeal. You may request from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of the proceedings is to be filed, a licensed court reporter must prepare the transcript and file it with the court clerk within ten business days of the filing the Notice of Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both parties within ten business days of the filing of the Notice of Appeal. The statement of the evidence must convey a complete and accurate account of the hearing. The Workers’ Compensation Judge must approve the statement before the record is submitted to the Appeals Board. If the Appeals Board is called upon to review testimony or other proof concerning factual matters, the absence of a transcript or statement of the evidence can be a significant obstacle to meaningful appellate review.
4. If you wish to file a position statement, you must file it with the court clerk within ten business days after the deadline to file a transcript or statement of the evidence. The party opposing the appeal may file a response with the court clerk within ten business days after you file your position statement. All position statements should include: (1) a statement summarizing the facts of the case from the evidence admitted during the expedited hearing; (2) a statement summarizing the disposition of the case as a result of the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an argument, citing appropriate statutes, case law, or other authority.
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667. LB-1099
EXPEDITED HEARING NOTICE OF APPEAL Tennessee Division of Workers’ Compensation www. tn.gov/labor-wid/weomp.shtml wce.courtclerk@tn.gov 1-800-332-2667
Docket #: State File #/YR:
Employee
Vv.
Employer Notice Notice is given that
[List name(s) of all appealing party(ies) on separate sheet if necessary]
appeals the order(s) of the Court of Workers’ Compensation Claims at
to the Workers’ Compensation Appeals
Board. [List the date(s) the order(s) was filed in the court clerk’s office]
Judge
Statement of the Issues Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
Additional Information Type of Case [Check the most appropriate item]
L] Temporary disability benefits L] Medical benefits for current injury LC Medical benefits under prior order issued by the Court
List of Parties Appellant (Requesting Party): At Hearing: LJEmployer LJEmployee
Address:
Party’s Phone: Email: Attorney's Name: BPR#: Attorney’s Address: Phone:
Attorney's City, State & Zip code:
Attorney’s Email:
* Attach an additional sheet for each additional Appellant *
rev. 10/18 Page 1 of 2 RDA 11082 Employee Name: SF#: DOI:
Appellee(s)
Appellee (Opposing Party): At Hearing: L]JEmployer LJEmployee
Appellee’s Address:
Appellee’s Phone: Email: Attorney’s Name: BPR#: Attorney’s Address: Phone:
Attorney’s City, State & Zip code:
* Attach an additional sheet for each additional Appellee *
I, Expedited Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all parties
and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee Rules of Board of Workers’ Compensation Appeals on this the day of , 20
, certify that | have forwarded a true and exact copy of this
[Signature of appellant or attorney for appellant]
LB-1099 rev. 10/18 Page 2 of 2 RDA 11082
Tennessee Bureau of Workers’ Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667
AFFIDAVIT OF INDIGENCY
I, , having been duly sworn according to law, make oath that because of my poverty, | am unable to bear the costs of this appeal and request that the filing fee to appeal be waived. The following facts support my poverty.
1. Full Name: 2. Address:
3. Telephone Number: 4. Date of Birth: 5. Names and Ages of Ail Dependents:
Relationship:
6. lam employed by:
My employer’s address is:
My employer’s phone number is:
7. My present monthly household income, after federal income and social security taxes are deducted, is:
$
8. | receive or expect to receive money from the following sources:
AFDC $ per month beginning ssl $ per month beginning Retirement $ per month beginning Disability $ per month beginning Unemployment $ per month beginning Worker's Comp.$ per month beginning Other $ per month beginning
LB-1108 (REV 11/15) RDA 11082 9. My expenses are:
Rent/House Payment $ permonth Medical/Dental $ per month
Groceries $ per month Telephone $ per month
Electricity $ per month School Supplies $ per month
Water $ per month Clothing $ per month
Gas $ per month Child Care $ per month
Transportation $ per month Child Support $ per month
Car $ per month
Other $ per month (describe: ) 10. Assets:
Automobile $ (FMV)
Checking/Savings Acct. $
House $ __ (FMV)
Other $ Describe:
11. My debts are:
Amount Owed To Whom
| hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete and that I am financially unable to pay the costs of this appeal.
APPELLANT
Sworn and subscribed before me, a notary public, this
day of , 20
NOTARY PUBLIC
My Commission Expires:
LB-1108 (REV 11/15) RDA 11082