Although the administrative law judge found employee sustained an injury by accident arising out of and in the course of employment, the administrative law judge denied compensation for medical expenses. The administrative law judge's denial was based upon his erroneous belief that the statute requires employee to prove that the accident was the prevailing factor in causing her need for a total knee replacement (TKR). I have highlighted the erroneous standard as it appears in the following administrative law judge's findings.
- Ms. Tillotson's arthritis present at the time of her accident was the prevailing factor in causing her need for her TKR. Employer's Exhibit 2 at 17:5-22, and Employer's Exhibit 1 at 10:12-14.
- While Dr. Koprivica is a well-qualified rating doctor, I find that he does not possess the expertise necessary to offer credible conclusive opinions regarding the cause of precise orthopedic conditions. When presented with the opinions of board certified and board eligible orthopedic surgeons whose practices are predominantly centered on treating patients, such as Drs. Van Den Berghe and Stechschulte, I will defer - and give greater weight - to their medical causation opinions instead of Dr. Koprivica's opinions. I do not find Dr. Koprivica's opinion that Ms. Tillotson's January 7, 2006 accident was the prevailing factor in causing her need for a TKR credible and I disbelieve this opinion. While interesting, Dr. Koprivica's "torn rag" analogy misrepresents the medical condition and effects of Ms. Tillotson's arthritis that was diagnosed by Drs. Van Den Berghe and Stechschulte. See, Claimant's Exhibit A at 24:11-25:6. More accurately, at the time of Ms. Tillotson's accident, the "rag" already was worn so thin that it required being replaced before it "tore"; the "tear" simply brought attention to a fact that already existed at the time it occurred.
- I reject Dr. Koprivica's conclusion that the prevailing factor in causing Ms. Tillotson's need for a TKR was both her tri-compartmental arthritis and her January 7, 2006 injury. Id. at 45:2 - 46:5. Had Ms. Tillotson suffered only a meniscal tear, a TKR would not have been required. Employer's Exhibit 2 at 9:16 - 11:14, and Employer's Exhibit 1 at 16:7 - 19. Ms. Tillotson required a TKR because of her arthritis alone that existed at the time of her accident.
- Because I find that Ms. Tillotson's accident was not the prevailing factor in causing her TKR I deny her request for future medical care. Neither Drs. Van Den Berghe nor Stechschulte testified that Ms. Tillotson required additional medical care, and Dr. Koprivica only testified that she required testing for deep venous thrombosis related to her TKR. Id. at 54:12-22.
- Ms. Tillotson requested reimbursement for medical expenses totaling $\ 4,646.21 related to her TKR. Because I find that the TKR was not due to her accident, I deny her request for reimbursement of these expenses.
The primary problem with the administrative law judge's analysis is that the Workers' Compensation Law does not impose upon employee the burden to prove that her accident was the prevailing factor in causing her need for medical treatment. The text of $\S 287.140 .1$ bears repeating.
In addition to all other compensation paid to the employee under this section, the employee shall receive and the employer shall provide such medical, surgical, chiropractic, and hospital treatment, including nursing, custodial, ambulance and medicines, as may reasonably be required after the injury or disability, to cure and relieve from the effects of the injury.
The statute does not recite a prevailing factor standard and, under a strict construction, the operation of the statute is confined to matters affirmatively pointed out by its terms. Id.
The administrative law judge correctly determined that employee sustained a compensable injury. Under § 287.140.1, we are called upon to determine if the TKR was reasonably required to cure and relieve employee from the effects of the work injury. If the TKR was reasonably required to cure or relieve employee of the effects of the work injury, employer should have provided the TKR and is now required to reimburse employee for the expenses of the TKR.
So what were the effects of employee's work injury? Employee sustained a torn lateral meniscus. Dr. Van den Berghe removed employee's menisci, so the TKR undoubtedly cured the tear. As a result of the work injury, employee suffered pain due to the swelling, tear, and rapid progression of her arthritis. Dr. Van den Berghe removed employee's knee structures, thereby reducing the pain. The TKR clearly relieved employee of the pain in her knee. The TKR cured and relieved employee of the effects of her injury. Dr. Van den Berghe testified he would not have performed the surgery if employee was not suffering pain. Clearly, the surgery was reasonably required to eliminate the lateral meniscus tear and to alleviate employee's pain.
We are not charged with considering whether the TKR also cured or relieved employee of the effects of other conditions. "[T]he need for the treatment must flow from the work injury, the fact that it also benefits a noncompensable condition is irrelevant." Bowers v. Hiland Dairy Co., 132 S.W.3d 260, 268 (Mo. App. 2004).
Employee is entitled to reimbursement of her medical expenses.
Dr. Koprivica testified that employee suffers from continued swelling of her right lower extremity, which exposes her to a greater risk of deep venous thrombosis. Dr. Koprivica believes employee should be medically monitored for this risk. Dr. Koprivica also believes employee may need another TKR in the future because the life expectancy of a TKR is 10-15 years.
Employee is entitled to an award of future medical care.