Ronald Malam v. State of Missouri/Dept. of Corrections

Injury No.: 11-062949

Medical Fee No.: 11-00127

Employee: Ronald Malam

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response to a question posed by his attorney, he agreed he may have experienced a bit of an adrenaline rush as a result of the event.

At some point after the takedown, employee experienced difficulty breathing. ${ }^{1}$ Employee felt as if his lungs were filling up with fluid. Employee tried to get a drink of water from a sink, but spit up blood instead. An on-site nurse saw this and suggested employee go to the hospital. Someone with employer called an ambulance, which took employee to Texas County Memorial Hospital. Employee woke up a week later at Lester E. Cox Medical Centers, where he received treatment for a hypertensive crisis.

Employee missed about six weeks of work ${ }^{2}$ but returned thereafter without any additional problems referable to the August 2011 takedown event. In fact, employee makes no claim for permanent partial disability benefits in this matter, as his medical expert, Dr. P. Brent Koprivica, specifically ruled out such in his evaluation. Instead, employee's sole claim for compensation is for unpaid past medical expenses.

Employee provided his unpaid medical bills and the treatment records corresponding to the bills, which suggest that he incurred $\ 138,010.15 in unpaid past medical expenses. Employee provided his uncontested testimony identifying the bills as incurred in connection with his treatment following the August 2011 takedown event; we credit employee in this regard, and find he incurred $\ 138,010.15 in unpaid past medical expenses for treatment reasonably required in connection with the August 2011 event.

Employer advances the expert medical opinion of Dr. Anne-Marie Puricelli, who believes employee's drinking excessive amounts of fluid per day exacerbated both his preexisting hypertension and his underlying cardiomyopathy, and that his hypertensive crisis of August 12, 2011, was the product of his severely compromised cardiopulmonary conditions, rather than his takedown of the inmate. In our award of October 10, 2014, we noted that Dr. Puricelli premised her causation opinion upon demonstrably incorrect facts with regard to the takedown event; she believed, for instance, that employee did not fall to the ground during the event, but instead remained standing.

Dr. Puricelli also based her opinion, in part, on a purely conclusory determination that employee's preexisting hypertension was inadequately treated before August 12, 2011, but we found no clear indication in the record that this was the case, and Dr. Puricelli failed to explain how or why she believed employee's hypertension was inadequately treated. For these reasons, we have already found that Dr. Puricelli's opinions lack persuasive force in this case.

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[^0]: ${ }^{1}$ Employee initially testified he experienced difficulty breathing less than 2 minutes after the takedown; on cross-examination, however, he conceded he was only guessing in this regard, and agreed it could have been any time within a 40 minute window after the event.

${ }^{2}$ The parties stipulated that employer paid temporary total disability benefits in the amount of $\ 2,284.95 for the period August 13, 2011, through September 21, 2011.

Likewise, we noted in our award of October 10, 2014, that employee's medical expert, Dr. Koprivica, appeared to rely upon a somewhat inaccurate history with regard to the circumstances of the accident. However, we accept Dr. Koprivica's causation opinion in this case. We find that the accident of August 12, 2011, was the prevailing factor precipitating employee's hypertensive crisis.

Lester E. Cox Medical Centers filed an Application for Direct Payment in this case alleging it is entitled under $\S 287.140 .13(6) RSMo to direct payment of \ 130,575.15 for medical services provided to employee to cure and relieve the effects of the claimed work injury. On its Application, Lester E. Cox Medical Centers checked the box indicating "[a]uthorization potentially in dispute." On its Application, Lester E. Cox Medical Centers also left blank the portions wherein it was directed to provide the name and title of the person who authorized the services, and the date such authorization was given.

At the hearing before the administrative law judge, Lester E. Cox Medical Centers did not present any witnesses or documentary evidence to prove up its assertion that employer authorized in advance the medical treatment resulting in charges of $\ 130,575.15. Instead, Lester E. Cox Medical Centers relied solely upon its crossexamination of employee, wherein he agreed that he did not call an ambulance for himself, and so someone with employer must have done this. Employee also testified, however, that employer never did or said anything that led him to believe employer would pay any of the bills he incurred for treatment provided by Lester E. Cox Medical Centers.

We acknowledge the parties' stipulation that employer did pay $\ 6,085.46 in medical expenses; however, the parties did not specify to which providers or for what medical treatments or procedures these amounts were paid. Employer's payment of this amount would tend to suggest that employer authorized at least some treatment that employee underwent, but it is not clear which providers or which treatments were authorized. ${ }^{3}$ Nor is it clear that such providers received authorization in advance of providing treatment to employee, in any event. Lester E. Cox Medical Centers has failed to present any evidence to clear up this ambiguity, or to otherwise demonstrate why employer's (apparent) authorization of some of employee's medical expenses should extend to the amount which it claims in its Application for Direct Payment.

What is clear is that employer has disputed employee's unpaid medical expenses in the amount of $\ 138,010.15, which includes the charges from Lester E. Cox Medical Centers. We find that employer did not authorize, in advance, the treatment employee underwent with Lester E. Cox Medical Centers for which it seeks the claimed amount of $\ 138,010.15 in its Application for Direct Payment.

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[^0]: ${ }^{3}$ Employee also received initial treatment at Texas County Memorial Hospital, and he testified that he received a bill for the ambulance services that transported him there.

Accident $^{4}$

On August 12, 2011, employee, who worked as a prison guard for employer, took down an uncooperative inmate. Section 287.020.2 RSMo provides, in relevant part, as follows:

The word "accident" as used in this chapter shall mean an unexpected traumatic event or unusual strain identifiable by time and place of occurrence and producing at the time objective symptoms of an injury caused by a specific event during a single work shift. An injury is not compensable because work was a triggering or precipitating factor.

The first sentence of the foregoing section constitutes the exclusive definition of "accident" for purposes of Chapter 287. The second sentence is a legislative directive telling us what type of "injury" is compensable. We do not deem the second sentence to modify the definition of what constitutes an "accident," because the plain language of the statute provides no indication that we should do so.

We note that the term "injury" is separately defined in the next numbered paragraph of the statute at $\S 287.020 .3(1)$ RSMo. It is, of course, somewhat unclear why the legislature chose to discuss the concept of "injury" in the numbered paragraph containing the definition of "accident," but we discern a need to avoid conflating the two concepts where the legislature has provided separate and specific definitions for each. Nor can we import a legislative directive regarding what "injuries" are compensable into the definition of "accident" where the legislature has mandated that we must strictly construe the provisions of Chapter 287. See § 287.800.1 RSMo.

We conclude that the incident on August 12, 2011, was (1) unexpected, (2) traumatic, (3) identifiable by time and place of occurrence, and (4) produced at the time objective symptoms of an injury caused by a specific event during a single work shift-namely, employee's difficulty breathing and his spitting up blood. We conclude, therefore, that employee suffered an accident.

Section 287.020.3(1) RSMo sets forth the statutory test for medical causation applicable to this claim, and provides, in relevant part, as follows:

An injury by accident is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and disability. "The prevailing factor" is defined to be the primary factor, in relation to any other factor, causing both the resulting medical condition and disability.

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[^0]: ${ }^{4}$ The parties did not challenge, before the Court, our determination with respect to the issue of "accident"; accordingly, for the convenience of the parties, our previous analysis and conclusions with respect to this issue are reproduced herein.

We have accepted Dr. Koprivica's causation opinion in this case. Accordingly, we have found that the accident of August 12, 2011, was the prevailing factor precip