Decision date: March 23, 200631 pages
Summary
The Labor and Industrial Relations Commission affirmed its temporary award finding the Second Injury Fund liable for medical expenses related to the employee's work-related injury from September 18, 1993. The Commission determined that sufficient factual basis existed to award compensation for medical bills when the employee testified the visits and treatments were products of the work-related accident and submitted supporting medical records.
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| Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION | |
| FINAL AWARD ALLOWING COMPENSATION(Based on Remand Hearing Subsequent to Temporary AwardIssued by the Labor and Industrial Relations Commission) | |
| Injury No.: 93-173447 | |
| Employee: | James H. Metts |
| Employer: | Fantasy Bus Limousine Service |
| Insurer: | None |
| Additional Party: | Treasurer of Missouri as Custodianof Second Injury Fund |
| Date of Accident: | September 18, 1993 |
| Place and County of Accident: | Jefferson County, Missouri |
| The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review subsequent to a remand hearing ordered by the Commission in a temporary award issued on September 2, 2004. The issue on remand was for the Division of Workers’ Compensation (Division) to take additional evidence concerning all medical bills claimed, allowing the Commission to ascertain the validity of all the medical bills claimed, whether or not the employee is legally subject to liability for the medical bills claimed and consequently, the resultant liability of the Second Injury Fund.Subsequent to the issuance of the temporary award, the Second Injury Fund perfected an appeal to the Missouri Court of Appeals, Eastern District, claiming the Commission erred in finding Second Injury Fund liability for medical expenses due to this workers’ compensation injury. The Commission received the mandate from the Missouri Court of Appeals, Eastern District, dated June 23, 2005, in which, the temporary award issued by the Commission was affirmed. Consequently, the Division scheduled the remand hearing February 23, 2006, in which all parties participated and upon conclusion of the hearing, the transcript has been forwarded to the Commission for its review and issuance of its final order. | |
| Issue: Liability of Second Injury Fund for Medical Bills | |
| At the remand hearing, employee testified as to certain visits, treatment and services rendered from various physicians and health care providers, on account of his injury. Employee further testified that the bills he received were the results of these various visits, treatments and services rendered. The treating medical records and/or medical records pertaining to the services rendered for these several visits were all submitted into evidence accompanying the various bills. The employee identified all of the medical bills as being related to and the product of his work related injury. The medical bills were shown to relate to the professional services rendered by various exhibits submitted into evidence in behalf of employee.When an employee testifies that his visits, treatment and services rendered at hospitals, health care providers and various doctors were the product of a work-related accident, and the employee further states that the medical bills received were the results of these visits, treatment and services rendered, and when such testimony accompanies the bills, which the employee identifies as being related to and the product of his injury, and when the bills relate to professional services rendered as shown by the medical records in evidence, a sufficient factual basis exists for the Commission to award compensation. *Martin v. Mid-America Farm Lines, Inc.,* 769 S.W.2d 105 (Mo. banc 1989). |
| The employer may challenge the reasonableness or fairness of these bills or may show that the medical expenses incurred were not related to the injury in question. *Martin v. Mid-America Farm Lines, Inc., supra.* | |
| If the employee remains personally liable for any of the medical bills, the employee is entitled to recover them as fees and charges pursuant to section 287.140 RSMo. However, if the employer establishes by a preponderance of the evidence that the health care providers allowed write offs and reductions for their own purposes and the employee is not legally subject to further liability, the employee is not entitled to any windfall recovery. *Farmer-Cummings v. Personnel Pool of Platt County* , 110 S.W.3d 818 (Mo. banc 2003). | |
| At the remand hearing, the following medical bills were submitted into evidence in behalf of the employee; employee stated that said bills received were attributable to his accident and were related to visits to various health care providers, physicians and or entities providing treatment on account of his injury; and the bills related to the professional services rendered: | |
| Exhibit | Amount |
| B. Logan Chiropractic | $100.00 |
| D. Deaconess West MRI | $893.00 |
| E. St. Mary’s Hospital | $4,936.93 |
| F. St. Louis Rehab Inst. | $1,172.00 |
| G. Dr. Bailey | $10,315.00 |
| H. St. Anthony’s | $180.00 |
| $26,342.50 | |
| $2,301.00 | |
| $1,380.00 | |
| I. South County Anesthesiology | $700.00 |
| $645.00 | |
| $1,155.00 | |
| J. South County Radiology | $551.00 |
| $47.00 | |
| K. Dr. Mirkin | $17,536.00 |
| TOTAL | $68,254.43 |
| The employee testified that to the best of his knowledge these outstanding medical bills were valid; had not been written off; and he was subject to payment to these various health care providers for the amounts itemized. | |
| Pursuant to *Martin, supra* , the employee satisfied his burden of proof, and produced documentation detailing his past medical expenses and testified to the relationship of said expenses to his compensable work place injury. | |
| Based on the record, the Second Injury Fund did not produce evidence challenging the reasonableness or fairness of the medical bills or show that the medical expenses incurred were not related to the injury in question. Furthermore, there is no competent and substantial evidence in the record on which the Commission could base a finding that the employee is not legally subject to further liability; i.e., that these medical bills were written off, or were reduced by the health care providers. | |
| Consequently, the Commission awards employee the claimed medical expenses in the total amount of $68,254.43. The temporary award of the Commission dated September 2, 2004, is attached and incorporated by reference. | |
| The Commission further approves and affirms the administrative law judge’s allowance of attorney’s fee herein as being fair and reasonable. | |
| Any past due compensation shall bear interest as provided by law. | |
| Given at Jefferson City, State of Missouri, this 23rd day of March 2006. |
William F. Ringer, Chairman
Alice A. Bartlett, Member
John J. Hickey, Member
Attest:
Secretary
Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION
TEMPORARY AWARD
(Modifying Award and Decision of Administrative Law Judge)
Injury No.: 93-173447
Employee: James Metts
Employer: Fantasy Bus Limousine
Additional Party: Treasurer of Missouri as Custodian of Second Injury Fund
Date of Accident: September 18, 1993
Place and County of Accident: Jefferson County, Missouri
The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by section 287.480 RSMo. Having reviewed the evidence and considered the whole record, the Commission finds that the award of the administrative law judge (ALJ), as modified, is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Act. Pursuant to section 286.090 RSMo, the Commission affirms the award and decision of the administrative law judge dated December 31, 2003, as modified. The award and decision of Administrative Law Judge Leslie E. H. Brown, is attached and incorporated by this reference.
The Commission affirms the award of the ALJ insofar as the compensability of the injury and the liability of the Second Injury Fund (Fund) has been established under the law. However, we find that there is insufficient evidence to establish the liability of the Fund and/or Employee for the medical charges.
The Commission would evaluate the testimony of Dr. Musich to establish the liability of the Fund for the charges of St. Anthony's Medical Center in the amount of $\ 26,342.50. The ALJ was of the opinion that the substantial weight of the medical evidence did not establish that the work injury was a substantial factor in Employee's low back complaints and treatment subsequent to March 14, 1994. We disagree.
The Commission adopts the expert opinion of Dr. Musich that Employee continued to experience low back pain
and radicular symptoms after his first surgery. These complaints continued and led to the second surgical intervention in 1999. Dr. Musich found the charges of St. Anthony's Medical Center, South County Radiologists, Inc., South County Anesthesiology and Dr. Peter Mirkin to be reasonable and necessary to cure and relieve and necessitates as a sequela of the 1993 injury. We adopt the opinion of Dr. Musich in this regard. Sullivan v. Masters Jackson Paving Co., 35 S.W.3d 879 (Mo. App. 2001); Palmer v. Kansas City Football Club, 621 S.W.2d 350 (Mo. App. 1981).
The Commission finds that Employee's complaints to Dr. Mirkin verify his testimony that he experienced low back pain with radiating pain down his legs for many years prior to the medical consultations of 1999. We find Employee credible. Shaw v. Scott, 49 S.W.3d 720 (Mo. App. 2001).
The Commission finds the evidence insufficient to determine responsibility for all the medical charges in question. The Fund is quoted in the award as relying on Mann v. Varney Construction, 23 S.W.3d 231 (Mo. App. E.D. 2000), for the proposition that Fund liability for medical expenses does not extend to the full amount of the bills but, rather, is limited only to the amount of the Medicare lien. This is only true if the payment made by Medicare has extinguished all other liability for payment of the bill. To the extent that any additional sum could be owed by Employee the Fund would have additional liability.
The Commission remands this case to the Division of Workers' Compensation to take additional evidence concerning the medical bills. Such evidence shall include: 1) the total amount of all bills claimed; 2) the amount of payments made by Medicaid or other providers and whether such amount must be repaid by Employee; and, 3) the amount due and owing which is the responsibility of Employee.
The Commission further approves and affirms the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.
Any past due compensation shall bear interest as provided by law.
Given at Jefferson City, State of Missouri, this $\qquad 2nd \qquad$ day of September 2004.
LABOR AND INDUSTRIAL RELATIONS COMMISSION
Ken Jacob, Chairman
Ken Legan, Member
Attest:
John J. Hickey, Member
Secretary
| Dependents: | Before the | |
| Employer: | Fantasy Bus Limousine | DIVISION OF WORKERS' COMPENSATION Department of Labor and Industrial |
| Additional Party: | State Treasurer, as custodian of Second Injury Fund | Relations of Missouri Jefferson City, Missouri |
| Insurer: | ---- | |
| Hearing Date: | July 24, 2003 (finally submitted 8/25/03) | Checked by: LEHB/bfb |
Full decision text continues in the plain-text archive copy.
March 22, 2011
The LIRC modified the ALJ's April 15, 2010 award, agreeing that the employee is entitled to future medical care but disagreeing with the directive that it be provided by a specific physician. The Commission also reversed the ALJ's evidentiary rulings regarding Social Security Administration records, finding them relevant to establishing the disabling nature of the work-related injury.
October 29, 2010
The Commission modified the administrative law judge's award, affirming that the employee is permanently and totally disabled due to a combination of his work injury and preexisting conditions, but disagreeing with the timing of when Second Injury Fund benefits should commence. The Commission addressed the proper legal framework for determining when temporary total disability ends and permanent total disability benefits should begin, focusing on the concept of maximum medical improvement.
April 7, 2010
The Commission affirmed the administrative law judge's award denying the widow of a deceased employee continuing permanent total disability benefits that would have accrued after the employee's death. The decision applies the 2008 Missouri statutory amendments that rejected the Schoemehl decision and terminated dependents' rights to unaccrued permanent total disability compensation upon the injured employee's death.