Loretta Courtney v. Clay County Health Center

(Affirming Award and Decision of Administrative Law Judge)

Injury No.: 11-099024

Employee: Loretta Courtney

Employer: Clay County Health Center

Insurer: Accident Fund General Insurance Co.

Additional Party: Treasurer of Missouri as Custodian of Second Injury Fund (Open)

This workers' compensation case is pending before the Labor and Industrial Relations Commission on employer/insurer's Application for Review of the administrative law judge's Temporary or Partial Award. We have read the briefs, reviewed the evidence, and considered the whole record. We find that the award of the administrative law judge allowing compensation is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Law. Pursuant to § 286.090 RSMo ${ }^{1}$, we affirm the award and decision of the administrative law judge by this supplemental opinion.

The administrative law judge issued a temporary award of temporary total disability benefits and medical treatment. Employer/insurer challenges the administrative law judge's award. One ground for its challenge is that the "ALJ simply signed a proposed Temporary Award prepared and submitted by the Claimant's attorney." We have reviewed the Temporary Award in light of the record before us. All of the facts found by the administrative law judge are fully supported by the record. However, since the employer/insurer has questioned the impartiality of the administrative law judge, we make our own specific findings on the two critical issues.

We address employer/insurer's argument that the accident described by employee never occurred. As support, employer/insurer points to the seemingly crystal clear memories of two co-workers who purport to have mentally processed and stored minute details of what the co-workers describe as a non-event. Experience tells us that individuals seldom recall insignificant events in such great detail. There are no contemporaneous records to support the version of events relayed by the co-workers.

On the other hand, employee's testimony about the manner in which the accident occurred is supported by medical records made at or around the time of the alleged accident. Employee's description of her injury at trial is consistent with the history employee gave to Dr. Scott Steelman. We find employee's testimony to be the most credible regarding the events of December 9, 2011, and we believe the accident occurred as described by employee.

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[^0]: ${ }^{1}$ Statutory references are to the Revised Statutes of Missouri 2011, unless otherwise indicated.

Upon first examining employee, Dr. Steelman took employee off work and immediately requested an MRI. The December 16, 2011, MRI clearly showed a disc herniation at C5-6. The MRI is objectively different than the CT scan performed on January 9, 2010. The January 2010 scan revealed degenerative changes but did not show a herniated disc. Dr. Steelman diagnosed a disc herniation with radiculopathy.

Dr. Steelman referred employee to neurosurgeon Steven Reintjes. Somehow, Dr. Reintjes recorded that employee reported to him that a 50-pound box fell on her head. Employee credibly testified that she did not report that a box fell on her head and we believe her. We believe Dr. Reintjes inadvertently recorded the inaccurate history of a falling box. Dr. Reintjes' ultimate opinion is based upon the inaccurate history. For that reason, we disregard Dr. Reintjes' opinions.

Instead, we look to the testimony of Dr. Hopkins. Dr. Hopkins cogently explained why he believed the December 16, 2011, MRI of employee's C5-6 herniated disc showed a recent injury; there was fluid in the annulus of the disc. Dr. Hopkins acknowledged that the May 12, 2012, MRI was different from the December 2011 MRI. Dr. Hopkins believed that the changes were due to the progression of the herniation seen in the December 16, 2011, MRI. Dr. Hopkins did not believe the May 12, 2012, MRI showed a new disc herniation. We find credible the testimony of Dr. Hopkins.

We affirm and adopt the temporary award of the administrative law judge, as supplemented herein.

This award is only temporary or partial, is subject to further order and the proceedings are hereby continued and kept open until a final award can be made. All parties should be aware of the provisions of $\S 287.510$ RSMo.

The temporary or partial award and decision of Administrative Law Judge Lisa Meiners, issued May 6, 2013, is attached and incorporated by this reference, to the extent it is not inconsistent with our findings and conclusions herein.

Given at Jefferson City, State of Missouri, this $11^{\text {th }}$ day of December 2013.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

John J. Larsen, Jr., Chairman

James G. Avery, Jr., Member

Curtis E. Chick, Jr., Member

Attest:

Employee: Loretta Courtney

Injury No: 11-099024

Employer: Clay County Health Center

Insurer: Accident Fund General Insurance Co.

Hearing Date: April 5, 2013

Checked by: LM/cy

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law? Yes
4. Date of accident or onset of occupational disease: December 9, 2011
5. Location where accident occurred or occupational disease was contracted: Clay County Health Center, Liberty, Clay County, Missouri
6. Was the above employee in the employ of the above employer at time of alleged accident or occupational disease? Yes
7. Did the employer receive proper notice? Yes
8. Did the accident or occupational disease arise out of and in the course of employment? Yes
9. Was the claim for compensation filed within time required by Law? Yes
10. Was the employer insured by the above insurer? Yes
11. Describe the work employee was doing and how the accident occurred or the occupational disease contracted: Employee was taking a 35 -pound box off a shelf while standing on a stepstool when she lost her balance, causing her neck to jerk.
12. Did the accident or occupational disease cause death? No
13. Part(s) of body injured by accident or occupational disease: Neck

1. Nature and extent of any permanent disability: N/A
2. Compensation paid to-date for temporary disability: $\ 4,785.48
3. Value of necessary medical aid paid to date by employer? $\ 7,569.12
4. Value of necessary medical aid not furnished by employer? 0
5. Employee's average weekly wages: $\ 797.58
6. Weekly compensation rate: $\$ 531.72 / \ 425.19
7. Method of wages computation: By agreement

1. Amount of Compensation payable from the Employer:

Temporary total disability at the rate of $\ 531.72 per week from February 16, 2012, and ongoing until Employee reached maximum medical improvement.

Further medical care and treatment to cure and relieve claimant from this injury as it casually relates to her December 9, 2011, injuries.

1. Second Injury Fund Liability: None.
2. Future requirements awarded:

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 percent of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant: Mark E. Kelly

Employee: Loretta Courtney

Injury No: 11-099024

Employer: Clay County Health Center

Insurer: Accident Fund General Insurance Co.

Hearing Date: April 5, 2013

Checked by: LM/cy

A hearing was held on April 5, 2013, before the Honorable Lisa Meiners. Claimant appeared in person and was represented by Mark E. Kelly. Employer and Insurer were represented by Bill Richerson.

1. That the Employer, Clay County Health Center, was an employer operating under and subject to the provisions of Missouri Workers' Compensation Law on December 9, 2011, and was fully insured by Accident Fund General Insurance Co.;
2. that Loretta Courtney was its employee and working subject to the law in Liberty, Clay County, Missouri;
3. that Employee notified the Employer of her injuries as required by law and her claim was filed within the time allowed by law;
4. that Employee's average weekly wage was $\ 797.58, resulting in a compensation rate of $\ 531.72 for temporary total disability and $\ 425.19 for permanent partial disability compensation; and
5. that the Employer has paid temporary total disability compensation in the amount of $\ 4,785.48, and medical care costing $\ 7,569.12.

The issues to be determined by the hearing are as follows:

1. Whether Ms. Courtney suffered an injury by accident on December 9, 2011;

Issued by DIVISION OF WORKERS' COMPENSATION

Employee: Loretta Courtney

Injury No. 11-099024

1. Whether Ms. Courtney's injuries are casually related to the accident;
2. Whether Ms. Courtney requires further medical care and treatment to relieve her of her injuries from the December 9, 2011, accident; and
3. Whether Employer is liable for temporary total disability benefits from February 16, 2012, through the present date and ongoing until she reaches maximum medical improvement.

The following exhibits were presented at trial:

A. Deposition of Dr. William Hopkins

B. Employee's Report of Injury

C. December 14, 2011, letter from Accident Fund

D. January 27, 2012, check from Accident Fund

E. December 16, 2011, MRI report from Northland Imaging

F. May 1, 2012, MRI report from Diagnostic Imaging

G. January 9, 2010, CT Cervical Spine from Liberty Hospital

H. Medical Records of Work Health Solutions

I. Medical Records of KC Neurosurgery Group/Dr. Reintjes

J. Medical Records of Kearney Family Medicine

K. Medical Records of Liberty Hospital

L. Medical Records of University of Toledo Medical Center

M. Photograph \#1 - Place of Accident

N. Photograph \#2 - Place of Accident

O. Photograph \#3 - Place of Accident

P. Photograph \#1 - Demonstration

Q. Photograph \#2 - Demonstration

R. Photograph \#3 - Demonstration

S. Photograph \#4 - Demonstration

1. Deposition of Dr. Stephen Reintjes
2. MRI report dated December 16, 2011
3. MRI report dated May 1, 2012
4. Dr. Reintjes record dated January 16, 2012
5. Dr. Reintjes record dated April 8, 2012
6. Dr. Reintjes record dated May 16, 2012
7. Dr. Reintjes record dated June 20, 2012

Ms. Courtney was standing on a stepladder pulling on a box weighing approximately 35 pounds and lost her balance with the box in her arms and whipped her head backward to catch her balance. This injury happened on a Friday afternoon and Ms. Courtney's neck began to tighten later in the day and by the following morning was suffering a severe headache. The following Monday she reported the injury and was directed to see Dr. Scott Steelman at Work Health Solutions.

The demographic information sheet in Dr. Steelman's file lists the description of accident as; "lifting box of files off top file cabinet standing on stepladder. Box heavy started to slip/jerked to catch box of files." Dr. Steelman saw Ms. Courtney on December 13, 2011, and reported she had pain located in her neck, upper back, and left shoulder which she described as aching beginning three days prior remained constant. The pain was made worse by moving her head forward and backwards and noted it is accompanied by pain that shot down both arms. Ms. Courtney reported she was lifting a box of files off the top of a file cabinet while on a ladder and started to lose her balance and jerked her neck backwards and forwards. Dr. Steelman's physical examination revealed radicular pain and weakness of her grip, Spurling's maneuver was positive causing symptoms in both arms. Dr. Steelman diagnosed a neck strain, thoracic paraspinatous muscle spasm and cervical radiculopathy. He felt she suffered a whiplash injury to her cervical spine at work and had felt a burning sensation that had become worse. He requested an MRI of the cervical spine and then to return for follow up. Dr. Steelman took Ms. Courtney off work and on the off work status sheet, he listed acute c-spine strain with radic