Kimberly Zachary Holland v. Expert Global Solutions

(Affirming Award and Decision of Administrative Law Judge)

**Injury No.:** 16-051694

**Employee:** Kimberly Zachary Holland

**Employer:** Expert Global Solutions

**Insurer:** Starr Indemnity & Liability Company

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by § 287.480 RSMo. Having reviewed the evidence and considered the whole record, the Commission finds that the award of the administrative law judge is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Law. Pursuant to § 286.090 RSMo, the Commission affirms the award and decision of the administrative law judge dated April 14, 2021. The award and decision of Administrative Law Judge, Kevin R. Thomas issued April 14, 2021, is attached and incorporated by this 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 **29th** day of November 2021.

**LABOR AND INDUSTRIAL RELATIONS COMMISSION**

Robert W. Cornejo, Chairman

Reid K. Forrester, Member

**DISSENTING OPINION FILED**

Shalonn K. Curls, Member

Attest:

Secretary

The administrative law judge (ALJ) erred in finding that employee's thoracic outlet syndrome (TOS) did not arise out of and in the course of her employment.

The parties stipulated that occupational disease (OD) culminated in disability on June 23, 2016. The employer accepted the compensability of the employee's bilateral tendinitis but denied her claim for disability related to TOS.

Four physicians offered their opinions on the issue of medical causation. The employer offered the opinions of Dr. Dennis Estep and Dr. Jeffrey Woodward. Dr. Estep is board certified in OD, but his resume indicated no specialized training in TOS evaluation and treatment. Dr. Woodward specializes in physical medicine and rehabilitation. His listed supplemental medical training appears limited to the treatment of the back.

Dr. Woodward also lacks specialized education or training in the evaluation of TOS.

In contrast to employer's experts' generalized qualifications, employee's medical expert Dr. Robert Thompson is an attending surgeon at Barnes-Jewish St. Peters Hospital and has been Director of the Multidisciplinary Center for Thoracic Outlet Syndrome since 2006. Dr. Thompson co-edited a textbook on TOS and has authored numerous chapters in other vascular and surgical textbooks on TOS. He has either lectured or provided presentations as a TOS expert over fifty times. For the last five years, Dr. Thompson has limited his medical practice to the evaluation and treatment of TOS. Dr. Thompson is a nationally recognized TOS expert.

Dr. Estep referred the employee to Dr. Thompson. As confirmed by Exhibit $3^{1}$ to his deposition, Dr. Thompson reviewed Dr. Estep's treatment records before authoring his narrative report. Although Dr. Thompson did not specifically recall reviewing these medical records when initially cross-examined, he later confirmed his review of the employee's past medical records.

Dr. Thompson did not ignore other doctors' opinions. Nor was he dismissive of other physicians' opinions by stating that he did not know the details or expertise of those who rendered them and considered his knowledge and training in evaluation and treating patients with TOS more significant.

Dr. Brent Koprivica is board-certified in occupational medicine and a member of the American Academy of Disability Evaluating Physicians. He is a recognized expert in evaluating causation, impairment, and disability under The Workers' Compensation Law. The fact Dr. Thompson and Dr. Koprivica were both subject to cross-examination during their depositions also enhances their credibility.

Dr. Thompson and his team initially saw the employee on April 5, 2017. She gave a history of doing office-based work and developing weakness, numbness, and tingling in both hands. The employee had also developed intermittent bluish discoloration in the arms and hands.

[^0]

[^0]: ${ }^{1}$ Transcript, p. 418.

Dr. Thompson performed a physical examination, which, along with the employee's history of the onset of symptoms, led to his clinical diagnosis of neurogenic thoracic outlet syndrome. The employee met ten out of the fourteen published and validated clinical diagnostic criteria for neurogenic TOC syndrome in five categories, making a solid diagnosis. Dr. Thompson concluded,

It was my impression at that time that her current condition of neurogenic TOS was severely disabling, as reflected by history, description of symptoms, physical examination, and DASH score. I felt she was unable to work in her usual job due to the limitations and restrictions as a result of this condition. ${ }^{2}$

Dr. Thompson recommended a course of physical therapy directed toward TOS. He instructed the employee to continue taking NSAIDs for pain as needed. Dr. Thompson also recommended that the employee undergo an imaging-guided right anterior scalene and pectoralis minor muscle block with a local anesthetic to provide further information. The test resulted in ". . . substantial but temporary improvement in symptoms and was considered a positive block. This strongly confirmed the clinical diagnosis of neurogenic TOS . . ."3

When specifically asked about any causative relationship between employee's job duties for the employer and the development of neurogenic TOS, Dr. Thompson opined, "The symptoms and physical examination findings attributable to neurogenic TOS that she exhibited [on April 5, 2017] had started in 2016, when she was working for EGS as a customer service representative, in the absence of another specific injury, incident, or event, her work involved repetitive strain activity with both upper extremities that aggravated her symptoms and over time these symptoms progressed to limit her work activities. It is my opinion that her development of bilateral neurogenic thoracic outlet syndrome was directly and causally related to the work activities that Ms. Holland conducted while employed at EBS and that there activities were the primary or prevailing factor in her development of this condition [emphasis added]." ${ }^{4}$

After reviewing all relevant past medical records and taking an extensive history of the employee's past work and job duties for the employer, Dr. Koprivica gave a similar opinion on causation. He opined that positioning her shoulders forward and repetitively using them with her arm away from the torso was sufficient to narrow the thoracic outlet. Dr. Koprivica concluded that the type of job duties the employee performed was sufficient to produce her injury. The employee did not do this type of repetitive activity at home. The general public does not use upper extremities to the same extent as the employee's employment required. Dr. Koprivica stated, "Ms. Holland's described upper extremity use activities, in terms of the postures in doing her data entry tasks as well as the repetitiveness of those activities, are felt to represent the direct, proximate and

[^0]

[^0]: ${ }^{2} Transcript, p. 410.

{ }^{3} Id., 410-411.

{ }^{4}$ Id., p. 416, see also pp. 324-325.

Improve: Kimberly Zachary Holland

-3-

prevailing factor in the development of disabling bilateral neurogenic thoracic outlet syndromes.5

Employer's experts Dr. Estep and Dr. Woodward fail to correctly diagnose the employee's condition. Dr. Estep referred to the employee's condition as vascular TOS rather than neurogenic TOC. Dr. Woodward had no diagnosis for many of the employee's symptoms. Neither Dr. Estep nor Dr. Woodward mentioned whether either performed any nationally recognized clinical tests related to TOS. Dr. Estep found that TOS is based on "an anatomic variation" but gave no rationale for this opinion.6

Dr. Thompson testified certain conditions, such as the presence of a first cervical rib, make people more susceptible to TOS development but acknowledged that these variations are present in probably seventy to eighty percent of the population at large and are not causative.

Dr. Woodward seemed unsure of any diagnosis other than extensor tendonopathy. He referred to coldness and color changes in the employee's hands present at the time of her office visit when she had not been doing repetitive hand activities, which he felt made the diagnosis of "vascular thoracic outlet syndrome [emphasis added]" unlikely.7

Intermittent color changes in employee's bilateral forearms were also present in April 2017 when Dr. Thompson first evaluated the employee. Dr. Thompson found no evidence of arterial or venous forms of TOS but instead found "sympathetic-mediated vasospasm related to nerve irritation that explained the bilateral finger discoloration."8

Further, by the time Dr. Woodward evaluated the employee's condition, the changes in the nerves and fibers of the muscle had already occurred. Therefore, symptoms would be present due to these chronic changes even without performing the employee's injurious job duties.

The ALJ based his decision largely on the belief that the employee's symptoms must have started before her work for the employer. He stated, "The Claimant testified that she made certain ADA accommodation requests related to her alleged occupational disease one month after starting her employment. This represents compelling evidence that her symptoms began well prior to commencement of her employment at EGS."9 Whether the employee may have been exposed to repetitive motion in earlier employment is irrelevant. The parties stipulated that the employee was exposed to repetitive trauma in her work for the employer from February 2015 to June 23, 2016, a period of sixteen months. The provisions of § 287.067.8, proving for liability of the immediate prior employer where exposure which is found to be the cause of the injury is for a period of fewer than three months, therefore do not apply.

5 Id., p. 203.

6 Transcript, 461.

7 Id., 452.

8 Id., 410.

9 Award, p. 14.

More importantly, there is no testimony from any medical expert that the employee's TOS resulted from work at either of her two prior call center jobs. Simply because employee's symptoms began after approximately one month of employment does not alone-without other supporting evidence-lead to the conclusion that prior work duties are the prevailing factor in her development of TOS. The "exposure time" necessary for TOS development is not a matter of common knowledge but takes expert testimony. "Medical causation, which is not within common knowledge or experience, must be established by scientific or medical evidence showing the relationship between the complaint of condition and the asserted cause." Malam v. Department of Corrections, 492 S.W.3d 926,929 (2016), quoting Gordon v. City of Ellisville, 268 S.W.3d 454,461 (Mo. App. 2008).

Neither the ALJ nor the Commission may base findings on conjecture or their personal opinion unsupported by sufficient competent evidence. Gordon v. City of Ellisville, 268 S.W.3d 454,461 (Mo. App. 2008).

Employee's work for the employer had approximately five times more keyboard and mouse work than her previous call center jobs. Moreover, at the two prior call centers employee was not required to work with a defective keyboard and mouse, which required her to strike the keys forcefully-sometimes multiple times-to have them register.

Employer/insurer's Exhibit G, purports to be employer's Report of Injury. The unsigned injury report form, dated July 15, 2016, lists its preparer as "Michelle Sllvestre, Leaves Administration Analyst." The report cited employee's alleged reference to employee's delay in meeting her request for a specific mouse style "when she was first hired." 10 Employee denied this statement, testifying instead that she requested a new keyboard and mouse after her symptoms began-approximately five weeks after her employment. The employer produced no testimony to contradict the employee's statement at hearing, which represents the only first-hand evidence on this issue. I take administrative notice of Division records that show a substantially different Report of Injury, also dated July 15, 2016, that states that employee sustained "alleged carpal tunnel due to not meeting request for a specific mouse."

Neither Dr. Estep nor Dr. Woodward based their opinions on when symptoms began, which was one month after the employee's employment with the employer. Dr. Estep attributed the employee's TOS to an anatomic variation. As discussed, this theory is disproven by his admission that anatomic variations are predisposing but not causative.

The ALJ finds Dr. Thompson's opinion less credible because Dr. Thompson was unaware of the employee's preexisting conditions. However, the employee's preexisting conditions, outlined in Dr. Koprivica's report, are unrelated to her upper extremities. Employer emphasizes employee's prior diagnosis of post-traumatic stress syndrome (PTSD). PTSD is a mental or emotional condition triggered by experiencing or witnessing a terrifying event. As such, PTSD is entirely unrelated to an objectively

[^0]

[^0]: ${ }^{10}$ Transcript, 487.

and clinically proven diagnosis of neurogenic TOS. PTSD is not a condition that affects the honesty of the employee. Therefore, Dr. Thompson's lack of knowledge of prior health conditions unrelated to the employee's upper extremities should not impair his credibility.

Simply put, the ALJ did not believe that TOS could develop after one month of work, even if there were a defective keyboard and mouse. This statement is confusing in that the ALJ earlier specifically found that the employee does suffer from TOS. ${ }^{11}$

The ALJ based his findings on conjecture and his personal opinion, unsupported by sufficient competent evidence. Gordon, supra at 461. There is no medical opinion that work at prior call centers led to the development of employee's TOS. Instead, the overwhelming evidence, in this case, is that the employee developed TOS over sixteen months from February 23, 2015, when she started work for the employer, to June 23, 2016, when she took FMLA leave due to her inability to continue working for the employer because of symptoms in both upper extremities.

The employee is therefore entitled to an award of outstanding medical bills, temporary total benefits, permanent total benefits, and future medical from the employer related to her work-related occupational disease, TOS, resulting from repetitive job duties in her work for the employer. Because the majority finds otherwise, I respectfully dissent.

Shalonn K. Curls, Member

[^0]

[^0]: ${ }^{11}$ Award, p. 14.

Issued by Division of Workers' Compensation:

Employee: Kimberly Zachary Holland

Injury No. 16-051694

Employer: Expert Global Solutions

Insurer: Starr Indemnity \& Liability Company

Hearing Date: February 19, 2021

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease of thoracic outlet syndrome compensable under Chapter 287? No

Was the injury or occupational disease of bilateral tendintis compensable under Chapter 287? Yes

1. Was there an accident or incident of occupational disease under the Law? Yes
2. Date of accident or onset of occupational disease: June 23, 2016
3. State location where accident occurred or occupational disease was contracted: Greene County, Missouri
4. Was above Employee in employ of above Employer at time of alleged accident or occupational disease? Yes
5. Did Employer receive proper notice? Yes
6. Did accident or occupational disease of thoracic outlet syndrome arise out of and in the course of employment? No

Did accident or occupational disease of bilateral tendinitis arise out of and in the course of the employment? Yes

1. Was claim for compensation filed within time required by Law? Yes

1. Was Employer insured by above insurer? Yes
2. Describe work Employee was doing and how accident occurred or occupational disease contracted:

Employee alleges that she worked as a claims service representative. She alleges that this was a very fast-paced job that required the Employee to work with both a mouse and a keyboard while speaking with the customer by phone. The Employee alleges that she had to repetitively use her upper extremities (UE) away from her body to reach the keyboard and mouse.

As the Employee performed these repetitive job duties, she alleges injuries through repetitive trauma / occupational disease resulting in both bilateral tendinitis and bilateral neurogenic thoracic outlet syndrome (TOS).

1. Did accident or occupational disease cause death? No; Date of death? N/A
2. Part(s) of body injured by accident or occupational disease: Bilateral upper extremities
3. Nature and extent of any permanent disability: Claimant's permanent disability associated with her work at EGS and due to the compensable condition of bilateral tendonitis is permanent and partial in nature. The extent of the permanent and partial disability is assessed as follows: 5 % at the 200 week level with respect to the left UE and 10 % at the 200 week level with respect to the right UE.
4. Compensation paid to-date for temporary disability: $\ 2,181.76 representing 10.24 weeks of temporary total disability benefits.
5. Value necessary medical aid paid to date by Employer / insurer? $\ 30,017.96
6. Value necessary medical aid not furnished by Employer / insurer? $\ 54,457.00
7. Employee's average weekly wage: $\ 407.28
8. Weekly compensation rate: $\ 271.52
9. Method wages computation: By applicable statute, Section 287.250 RSMo., and by stipulation of the parties.

1. Amount of compensation payable:

a. Employee is awarded permanent partial disability compensation in the total amount of $\ 8,145.60, calculated as follows below:

c. Employee is awarded no additional benefits from the Employer - Expert Global Solutions - and its insurance carrier - Starr Indemnity \& Liability Company. 22. Future requirements awarded: None

The compensation awarded to the Employee shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the Employee: Jan L. Fisher, Esq.

Employee: Kimberly Zachary Holland

Injury No. 16-051694

Employer: Expert Global Solutions

Insurer: Starr Indemnity \& Liability Company

Hearing Date: February 19, 2021

Checked by KRT/bh

The above-referenced workers' compensation claim was heard before the undersigned Administrative Law Judge (ALJ) on February 19, 2021. The record was closed at the conclusion of the hearing. The parties, however, were afforded an opportunity to submit briefs or proposed Awards with the last such proposed Award being completed and submitted to the undersigned on or about March 5, 2021.

The Employee, Kimberly Zachary Holland (also referred to herein at various times as "Employee" or "Claimant") appeared personally and through her attorney - Jan L. Fisher, Esq. The Employer and insurance carrier appeared through their attorney - Clay Fielder, Esq.

The parties entered into a stipulation of facts. The stipulations are as follows:

(1) On or about June 23, 2016, Expert Global Solutions (EGS) was an Employer operating under and subject to The Missouri Workers' Compensation Law, and during this time was fully insured by Starr Indemnity \& Liability Company.

(2) On the alleged injury date of June 23, 2016, Kimberly Zachary-Holland was an Employee of the Employer, and was working under and subject to The Missouri Workers' Compensation Law.

(3) On or about June 23, 2016, the Employee Kimberly Zachary Holland sustained an incident of occupational disease, which arose out of and in the course of her employment with the Employer, i.e., bilateral tendinitis.

(4) The incident of occupational disease of June 23, 2016, occurred in Greene County, Missouri. The parties agree to venue lying in Greene County, Missouri. Venue is proper.

(5) The Employee notified the Employer of her injury as required by Section, 287.420, RSMo.

(6) The Claim for Compensation was filed within the time prescribed by Section 287.430, RSMo.

(7) At the time of the repetitive trauma/occupational disease the Employee's average weekly wage was 407.28 which is sufficient to allow a compensation rate of 271.52 for temporary total disability compensation / permanent total disability compensation, and a compensation rate of $271.52 for permanent partial disability compensation.

(8) Temporary disability benefits have been provided to the Employee in the amount of $2,181.76, representing 10.24 weeks of disability benefits.

(9) The Employer and insurer have provided medical treatment to the Employee - having paid $30,017.96 in medical expenses.

(10) The attorney's fee being sought is 25%.

**THE ISSUES TO BE RESOLVED BY HEARING INCLUDE:**

(1) Whether the Employee sustained an incident of occupational disease on or about June 23, 2016 - specifically thoracic outlet syndrome (TOS) - and - if so - whether the occupational disease arose out of and in the course of her employment with the Employer.

(2) Whether the alleged incident of occupational disease (TOS) caused the injuries and disabilities for which benefits are now being claimed.

(3) Whether the Employer and insurer are obligated to pay for certain past medical care and expenses in the amount of $54,457.00.

(4) Whether the Employee has sustained injuries that will require additional or future medical care in order to cure and relieve the Employee of the effects of the injuries.

(5) Whether the Employee is entitled to temporary disability benefits? (The employee seeks payment of $40,961.51 which represents 150.86 weeks of past temporary disability compensation payable at a rate of $271.52 for the period of December 3, 2016 to October 24, 2019.)

(6) Whether the Employee sustained any permanent disability as a consequence of the alleged incident of occupational disease; and, if so, what is the nature and extent of the disability.

(7) If the Court finds that the Claimant is permanently and totally disabled, is the Employer liable for such benefits or is the Employer only liable for permanent partial disability benefits as the Second Injury Fund would be

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liable for permanent total disability benefits had they been properly

impleaded in the claim.

EVIDENCE PRESENTED

The Employee testified at the hearing in support of her claim. While the attorney for

Employer/Insurer cross-examined Employee at the hearing, no witness testified live at the

hearing on behalf of Employer/Insurer.

In addition, the Employee offered for admission the following Exhibits:

Exhibit 1: Evidentiary deposition of Kimberly Lynn Zachary-Holland held on June 5,

2020.

Exhibit 2: Deposition of Dr. Preston Brent Koprivica held on June 24, 2020

including deposition Exhibits 1 and 2.

Exhibit 3: Deposition of Michael J. Dreiling held on September 1, 2020 including

deposition Exhibits 1 and 2.

Exhibit 4: Deposition of Dr. Robert Thompson held on October 29, 2020 including

deposition Exhibits 1 - 4.

Exhibit 5: Medical bill exhibit

The undersigned ALJ received and admitted into evidence the above exhibits.

Again, the Employer/Insurer presented no witnesses at the hearing of this case.

However, the Employer/Insurer offered for admission the following exhibits:

Exhibit A: Medical report of Dr. Jeffrey L. Woodward dated February 16, 2017.

Exhibit B: Dr. Jeffrey L. Woodward Curriculum Vitae.

Exhibit C: Medical reports of Dr. Dennis A. Estep.

Exhibit D: Dr. Dennis A. Estep Curriculum Vitae

Exhibit G: Report of Injury

The undersigned ALJ received and admitted into evidence the above exhibits.

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All exhibits appear in the record as the undersigned ALJ received and admitted into evidence the exhibits at the evidentiary hearing on February 19, 2021.

The Employee - Kimberly Zachary-Holland - is 50 years of age, having been born on January 6, 1971. Ms. Zachary- Holland resides in Ozawkie, Kansas.

Ms. Zachary-Holland graduated from high school in Blackwell, Oklahoma, in 1989, with reported average to above-average grades. She attended Northem Oklahoma College for three (3) semesters majoring in nursing, although she did not complete her degree. She has also participated in training - focusing on medical assistant work - at a vocational technical program although she never did work as a medical assistant. She acquired typing abilities and - at the time of her injuries in June of 2016 - was able to type 60 to 80 words per minute.

Ms. Zachary-Holland's work history includes: janitorial work, nursing aide work, working as a cashier, home health aide work, and office assistant work. In 2012, Ms. Zachary-Holland started working at call centers. She continued working at call centers in customer service roles for two different employers prior to starting her employment with Expert Global Solutions. Her duties while working for the two prior employers included repetitive use of her upper extremities while utilizing a mouse and keyboard and taking customer calls.

In February 2015, Ms. Zachary-Holland obtained employment with the employer - Expert Global Solutions (EGS) - working as a customer service representative. She continued in this employment through December 2, 2016, at which time she left this employment with EGS due to the effects of thoracic outlet syndrome.

Dr. Koprivica testified that Claimant has several preexisting conditions including her low back, ankle, and bilateral knees. All her preexisting conditions he believes place a hindrance or obstacle to her employment. Claimant had a severe back injury in 2005. An MRI was taken at that time which revealed significant central L5-S1 disc herniation with displacement of the bilateral S1 nerve root resulting in lower back pain. No surgery was performed. The doctor testified that disc herniations in some people can be reabsorbed and physically go away. Her ankle injury was diagnosed as chronic instability of her lateral ligamentous. Employee had unsuccessful surgery, remained symptomatic, and was recommended to wear an ankle brace. She also underwent bilateral partial meniscectomies of her knees in 2007. Lastly, Claimant had a preexisting psychological impairment. Her husband committed suicide in 2010. Prior to that, she had been

raped by her brother-in-law which resulted in a pregnancy that ultimately resulted in her having a total hysterectomy. She was hospitalized in a psychiatric facility and diagnosed with PTSD and amnesia. Dr. Koprivica testified that those psychological conditions could also be a hindrance or obstacle to employment, but he would need to defer to a mental health expert. All of Claimant's psychological conditions existed prior to her work injury. Claimant told Dr. Koprivica that her actual choice of employment was predicated on accommodations for those preexisting conditions, she took the job at the call center due to need for a sedentary job and her PTSD to avoid contact with the public. See, Employee's Exhibit 2, Deposition Transcript of Dr. Koprivica.

In addition, the Claimant testified at trial that she had severe PTSD prior to her employment with Expert Global Solutions. She testified that she had been advised that her PTSD tests had revealed that she had more severe PTSD than military veterans. This condition required that the Claimant undergo vocational rehabilitation to re-enter the workforce. This condition was clearly a hindrance or obstacle to her employment and should be considered in determining any liability for permanent total disability benefits. Additionally, the Claimant testified that she advised co-workers that she suffers from autism. This condition was not disclosed to any of the Claimant's experts and should have been considered by them from both a medical and vocational standpoint as it certainly has the potential to hinder an individual vocationally.

In short, the record shows that Claimant came to her employment with EGS with many substantial medical and health related issues in her history.

The Employer stipulated to the accident resulting in bilateral tendinitis. However, the Employer specifically reserved as an issue, "whether the Employee sustained any permanent disability as a consequence of the alleged incident of occupational disease culminating in disability on June 23, 2016 and - if so - what is the nature and extent of disability." As such, this issue will be addressed as the Claimant testified and provided competent evidence that her condition developed approximately thirty (30) days after she commenced work for the Employer. Therefore, this Court must analyze whether her employment with EGS was the prevailing factor in causing her injury and the need for treatment.

Claimant was treated and evaluated on multiple occasions by Dr. Dennis Estep at Freeman Health System, Joplin, Missouri. A review of Employer's Exhibit C indicates 28 pages of records from Freeman Health System that pertain to Employee and the evaluations and treatment she received there. The records indicate she was seen and treated there between August 24, 2016, and December 19, 2016, with a final written report dated January 9, 2017, at which time Dr. Estep referred Claimant for a second opinion.

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During the August 24, 2016, evaluation of Claimant, it is clear that Dr. Estep took a fairly extensive medical history from Claimant and it is indicated he had also reviewed records from a Dr. Wool who was Claimant's primary care physician. Among the subjective complaints noted, he said that Employee was complaining of difficulties associated with her bilateral upper extremities. Dr. Estep noted that Dr. Wool "was concerned of carpal tunnel versus thoracic outlet syndrome." His objective findings noted an impression of "Thoracic outlet syndrome [and] right greater than left forearm tendonitis (sic?) with intersection syndrome." The plan going forward involved conservative treatment and notably Dr. Estep stated: "It was discussed with her that thoracic outlet syndrome is not work related. That this is an anatomical variation. It is also noted that she does have a long history of having large breasts and having to wear special bras for a number of years." See, Exhibit C.¹

As a result of Dr. Estep's evaluation (apparently his last) of Employee on December 19, 2016, Dr. Estep stated that "She is reexamined for thoracic outlet syndrome and forearm tendonitis. (sic?)" He then noted that she was still reporting issues with her upper extremities and that she had undergone an EMG. Claimant brought with her a report from Dr. Uppal which Dr. Estep reviewed. He stated the report showed the right upper extremity was read as normal, no evidence of carpal tunnel, no evidence of cervical radiculopathy and no evidence of ulnar neuropathy. Notwithstanding the EMG results that apparently did not show any objective evidence to support the subjective complaints, Claimant told Dr. Estep that "her arms blew up."

Dr. Estep then stated: "Recommend that she can return to work with the use of the ergonomic keyboard and mouse, stretch breaks, may use heating pad, exercises, no overtime, as these were the limitations that she was on previously and functioning. At this time, recommend she be seen for an outside opinion, as I have nothing further to offer her. I feel at this time that work is not the prevailing factor of her underlying difficulty. It was discussed with her previously and again today that thoracic outlet work (sic) is not a prevailing factor of her underlying disease process which is causing her the most problem. I recommend that work comp no longer cover any other aspect of this and that she should seek treatment on her own for thoracic outlet. I recommend a second opinion because of her continued aggressiveness and continuing to accuse me of not taking care of her. It is my opinion that, from a work standpoint, we really have nothing more that we can offer her. Diagnosis and treatment were fully discussed with the patient. Did express full understanding and full agreement." See Exhibit C, Medical Reports of Dennis Estep, D.O., December 19, 2016 entry.

**Independent Medical Examination - Dr. Woodward**

Jeffrey Woodward, M.D. performed an independent medical examination of the Claimant on February 16, 2017. At the time of this examination, Dr. Woodward took a history from Ms.

---

¹ It should be noted that Claimant also testified during direct examination at the final hearing that she was unable to wear a bra due to, essentially, pain and discomfort that she clearly associated with her alleged work-related medical conditions. This testimony, together with Dr. Estep's observation that Claimant had a "long history" of this situation, indicates that Employee had these issues in her medical history prior to her employment with EGS.

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Zachary-Holland, reviewed various medical records, and performed a physical examination of her. Dr. Woodward determined that the Claimant had bilateral extensor tendonopathy which was related to her work duties.

Dr. Woodward's assessment of Employee is worthy of a full quote:

"The patient has a prevailing work related diagnosis of extensor tendonopathy in right>left forearm/wrist/hand regions. This diagnosis was the cause of the patient's initial work related right dorsal forearm pain and swelling. The patient continues to report intermittent bilateral dorsal forearm pain and symptoms now, I cannot identify any current objective physical abnormalities on exam today related to the UE extensor tendon diagnosis condition.

The patient has numerous other bilateral UE symptoms and signs that do not have a prevailing work related causation including: diffuse UE/hand skin discoloration with associated sensory and skin temperature abnormalities, possible thoracic outlet syndrome condition, cervical spine anterior muscle weakness/atrophy associated with initial onset dysphagia and drooling signs. The cause of the patient's bilateral hand discoloration may be due to a connective tissue disorder or Raynaud's type disorder. Today, her bilateral radial artery pulses are full and symmetric with arms at side, but patient developed obvious bilateral hand redness/coldness early in office visit without raising her arms above chest level at any time which makes vascular thoracic (sic) outlet syndrome as the only causation doubtful. Also, the patient reports daily UE pain and hand discoloration/coldness including today while not performing any work related keyboard activities lately which also supports a non-work-related condition.

Episodic hand vasopasm conditions are a known condition that can be difficult to diagnose underlying causation or cure. The patient should pursue further cranial/cervical disorder and EE vascular disorder care with her PCP outside work comp insurance coverage. Regarding the patient's work-related bilateral UE tendonopathy condition, she has reached MMI at this time. No additional or future work injury medical treatment is necessary." See, Employer's Exhibit A, page 5 of 6.

In short, Dr. Woodward stated that Claimant was at MMI, that no additional work injury medical treatment was necessary, and that she did not require any work restrictions as a result of her prevailing work injury conditions. Id.

In light of his examination and evaluation of the Claimant, Dr. Woodward opined that Ms. Zachary-Holland suffered a work injury related to the diagnosis of extensor tendonopathy in the right and left forearm, wrist, and hand regions. He assigned a 10% disability to the right upper extremity at the 200-week level and a 5% disability to the left upper extremity at the 200-week level. See Exhibit A, Report of Dr. Jeffrey Woodward, M.D.

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The undersigned ALJ has carefully reviewed and considered the deposition transcript and report of Dr. Koprivica. See, Employee's Exhibit 2. In summary, Dr. Koprivica reviewed medical records, took a medical history from Claimant, and examined her. Dr. Koprivica opined that Claimant suffered from TOS, that she developed this condition due to the repetitive nature of her job duties while working at EGS, placed her on certain work restrictions, and that she was permanently and totally disabled. He stated that the repetitive nature of the job was the prevailing factor in the development of the disease. See, Employee's Exhibit 2.

At the outset, the undersigned ALJ is fully aware of Dr. Thompson's very extensive resume and Curriculum Vitae that appears within Employee's Exhibit 4. See, Exhibit 4, Deposition transcript of the doctor, deposition taken October 29, 2020. Clearly, the doctor has an extensive background in TOS. Also, the undersigned ALJ has carefully reviewed the deposition transcript and the report authored by Dr. Thompson attached to the transcript. The following observations are gleaned from those documents:

During Attorney Fielder's cross examination of the doctor, Dr. Thompson stated that he could not recall whether he had reviewed any medical records from Dr. Estep or from Dr. Woodward relating to their examinations of Employee. Specifically, he stated that he was not aware that neither Dr. Estep nor Dr. Woodward believed that her work was the prevailing factor for the diagnosis of thoracic outlet syndrome. When Attorney Fielder asked the doctor if it would be helpful to have read the reports of physicians who had previously addressed the issues with Employee, Dr. Thompson was largely dismissive of such opinions stating that such reports "are often incorrect." See, deposition transcript of Dr. Thompson, Exhibit 4 pages 21-22 of the transcript.

He also stated that TOS "has always been considered somewhat controversial." Significantly, with respect to preparing his report that he authored, Dr. Thompson testified that he had reviewed two letters from Employee's attorney that described Employee's work activities and he believed that was the only additional information that he had reviewed - outside of his own office's records. Again, it was emphasized that he could not recall whether he had received and or reviewed any medical records outside of his own office's records. See Employee's Exhibit 4, deposition transcript of Dr. Thompson, pages 19-25.

In addition, Dr. Thompson testified that he gave no opinion on the level or extent of any permanent partial disability with respect to Employee. He also gave no opinion about the employability of Employee in the open labor market. Regarding the Employee's prior existing conditions, Dr. Thompson's testimony was uncertain as to what prior conditions could have been related to Employee's upper extremities. He also was not aware, or was unable to recall, that Employee had been treated for PTSD and hospitalized in a psychiatric facility. Finally, although Dr. Thompson opined that the work activity with Employer was the prevailing factor, he admitted that his diagnosis and opinion relied, in part, on the subjective complaints made by Employee. See,

Exhibit 4, pages 26-29, generally. Based on Dr. Thompson's responses and testimony during cross-examination, the undersigned judge finds that there are major questions about whether Dr. Thompson had a sufficiently complete history of Claimant's prior medical and health related history in rendering his opinions. Moreover, his apparent dismissiveness of the positions and opinions of Dr. Estep and Dr. Woodard is also perplexing. Both of these observations adversely impact the persuasiveness of his testimony and opinions in this matter.

Significantly, Mr. Dreiling testified he did not review any records from Dr. Woodward or Dr. Estep. He was not aware that neither doctor believed that Claimant's work was the prevailing factor in causing her thoracic outlet syndrome. He was not aware that both doctors believed the alleged work injury only resulted in tendinitis. He agreed with Dr. Koprivica's assessment that if the only compensable injury Claimant suffered was tendinitis, she would not be permanently and totally disabled. He testified that Claimant is currently on social security disability, but he is not aware what medical conditions were considered by the Social Security Administration in approving her for benefits. He does not believe Claimant applied for any jobs between the time of injury and her social security disability application being approved. He does not believe she participated in any vocational rehabilitation following her work injury. Mr. Dreiling agrees that Claimant's choice of employment was predicated on accommodating those disabilities.

He agrees her pre-existing conditions including PTSD, bilateral knees, the left ankle and the lower back all pre-date the date of her alleged injury. He testified that all the conditions just listed represent a hindrance or an obstacle to employment or reemployment. He agreed that for the preexisting conditions, Claimant went through vocational rehabilitation in 2012 to reenter the work force. Mr. Dreiling agreed that based on all the disabilities/restrictions she had prior to 2016, the market for jobs which would accommodate her was limited. See Exhibit 4, Deposition Transcript of Michael J. Dreiling. Given the above summary of portions of Mr. Dreiling's testimony the undersigned finds that Mr. Dreiling's opinion is not sufficiently persuasive, as offered by Claimant, to prove that she is totally and permanently disabled due to a work-related injury (TOS).

The parties have asked this ALJ to resolve, the first issue of whether the employee sustained an incident of occupational disease on or about June 23, 2016, i.e., thoracic outlet syndrome (TOS), and, if so, whether the disease arose out of and in the course of employment. The Claimant seeks a finding and ruling from this ALJ that she is permanently and totally disabled due to TOS and that this condition/occupational disease arose out of and in the course of her employment with EGS. Inter alia, Claimant seeks the sum of $\ 271.52 per week for the lifetime of Employee (This is the requested relief within her proposed Award). This first issue, therefore, is critical in the analysis of this matter.

"The burden of establishing any affirmative defense is on the Employer. The burden of proving an entitlement to compensation.......is on the Employee. In asserting any claim or defense based on a factual proposition, the party asserting such claim or defense must establish that such proposition is more likely to be true than not true." Section 287.808, RSMo. The Administrative Law Judges and the Labor and Industrial Relations Commission shall weigh the evidence impartially without giving the benefit of the doubt to any party when weighing evidence and resolving factual conflicts. Missouri Workers Compensation law provides that ALJs shall strictly construe the provisions of Chapter 287. Section 287.800 RSMo.

"The term 'total disability' as used in this chapter shall mean inability to return to any employment and not merely mean the inability to return to the employment in which the employee was engaged at the time of the accident (bolded within the statute)." Section 287.020.6 RSMo.

Missouri statute defines "occupational disease" as, "an identifiable disease arising with or without human fault out of and in the course of employment. Ordinary diseases of life to which the general public is exposed outside of employment shall not be compensable, except where the diseases follow as an incident of an occupational disease as defined in this section." Section 287.067.1 RSMo. "An injury due to repetitive motion is recognized as an occupational disease for purposes of this chapter. An occupational disease due to repetitive motion is compensable only if the occupational exposure 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 (bold within the statute)." Ordinary, gradual deterioration or progressive degeneration of the body caused by aging or by the normal day-to-day living shall not be compensable." Section 287.067.3 RSMo.

In a case reviewing a decision by the Labor and Industrial Relations Commission the Missouri Court of Appeals, Southern District, stated: "Here we review the ALJ's findings and decision because they were adopted by the Commission, and we defer to the ALJ's credibility determination, weighing of evidence, and decisions between competing medical theories." Parvin v. Camcorp Environmental, LLC et al., 597 S.W.3d 357, 360 (Mo.App. 2020) quoting Proffer v. Fed Mogul Corp., 341 S.W.3d 184, 187 (Mo.App. 2011). "It was Claimant's burden to prove all elements of his claim." Id. The Court further ruled: "It is well settled that weighing of conflicting medical testimony lies within the Commission's sole discretion and cannot be reviewed by this court." Id., at 362. Quoting the Proffer decision, the Parvin court then held: "We are bound, therefore, by the ALJ's decision as to which of the various medical experts to believe." Id.

The above statutes and case law principles, therefore, are instructional and binding on this ALJ with respect to conducting the following analysis in answering the issues below.

(1) Whether the Employee sustained an incident of occupational disease on or about June 23, 2016 - specifically thoracic outlet syndrome - and - if so - whether the occupational disease arose out of and in the course of her employment with the Employer.

The parties have asked the undersigned judge to decide the above, precise issue (as well as the other issues). Employee's claim for compensation rests on the assertion that Claimant suffers from TOS and that she developed this condition due to the repetitive nature of her job duties while working at EGS. The diagnosis of thoracic outlet syndrome (TOS) and that Employee has this diagnosis is apparent within the medical record. Doctors Estep, Thompson, and Koprivica are on record opining that Employee has TOS. Indeed, Dr. Estep stated "The patient has a well-documented vascular thoracic outlet abnormalities as noted by her previous vascular studies." Exhibit C. A careful review of Dr. Woodward's report reveals that he apparently did not diagnose TOS, definitely and specifically. Based on the following analysis and discussion, however, the undersigned ALJ determines that Employee's condition of thoracic outlet syndrome did not arise out of and in the course of her employment with Employer EGS.

Missouri statute provides: "An injury due to repetitive motion is recognized as an occupational disease for purposes of this chapter. An occupational disease due to repetitive motion is compensable only if the occupational exposure 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 (bold within the statute)." Ordinary, gradual deterioration or progressive degeneration of the body caused by aging or by the normal day-to-day living shall not be compensable." Section 287.067.3 RSMo.

Employee testified that her UE symptoms consistent with thoracic outlet syndrome first appeared within the first month of her employment with Employer EGS. Indeed, Employee testified to this fact on cross-examination, and by answering a question posed to Employee by the undersigned ALJ during the final hearing. Stated another way, Employee is alleging that she had no such symptoms prior to coming to the employ of EGS. Based on the record before this judge the undersigned does not find this portion of her testimony credible, and together with the following analysis, Employee has failed to meet her burden consistent with Section 287.800 RSMo.

Indeed, Claimant, by her own testimony, admitted that the symptoms of the alleged occupational disease began approximately one month after she commenced her employment with Employer. The Claimant further testified that she made certain ADA accommodation requests related to her alleged occupational disease one month after starting her employment. This represents compelling evidence that her symptoms began well prior to commencement of her employment with EGS.

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Additionally, Claimant testified that prior to beginning her employment with Employer, she performed the same or similar duties with her prior employers from 2012 through 2015. These prior employments were also customer service positions requiring the Claimant to repetitively use her upper extremities to perform computer work consisting of repetitive typing and utilizing a computer mouse. The persuasive weight of the medical evidence, other evidence, common sense, and simple logic indicate that the prevailing factor for the Claimant's symptoms were activities that pre-dated her employment with EGS. This is further evidenced by the report of injury admitted as Exhibit G which indicates that employee stated that the "delay in meeting her request for a specific mouse style when she first started" was the cause of her injury. If the Claimant did not have a pre-existing condition affecting her upper extremities, logic would suggest that no such request for specialized equipment would have been made at the outset of her employment. However, such request was made and further proof of her need for specialized equipment is found in her testimony that her symptoms were present within thirty (30) days of the date she commenced her employment.

In addressing this first issue that the parties have asked this judge to decide, this ALJ must weigh conflicting medical testimony/opinions within the record. The undersigned ALJ has carefully reviewed the records and the testimony of all four doctors, Woodward, Estep, Koprivica, and Thompson - as summarized and set forth above. Based on this review and careful consideration this ALJ finds that the assessments and opinions of Doctors Woodward and Estep are more persuasive than those of Doctors Koprivica and Thompson. This determination is also based on the testimony of Claimant herself, a significant aspect of which this judge did not find as credible, i.e., that she came to the employment at EGS with no symptoms consistent with a diagnosis of TOS but that such symptoms first occurred at the one month mark of her employment with EGS.

This ALJ accepts and agrees with the opinions of Dr. Estep and Dr. Woodward as stated within the record. Both doctors have opined that Employee's work at EGS was not the prevailing factor relating to Employee's symptoms associated with TOS. Dr. Estep stated: "I feel at this time that work is not the prevailing factor of her underlying difficulty. It was discussed with her previously and again today that thoracic outlet work (sic) is not a prevailing factor of her underlying disease process which is causing her the most problem." Dr. Woodward reported: "The patient has a prevailing work related diagnosis of extensor-tendonopathy in right>left forearm/wrist/hand regions. This diagnosis was the cause of the patient's initial work related right dorsal forearm pain and swelling. The patient continues to report intermittent bilateral dorsal forearm pain and symptoms now, I cannot identify any current objective physical abnormalities on exam today related to the UE extensor tendon diagnosis condition. The patient has numerous other bilateral UE symptoms and signs that do not have a prevailing work related causation. . . ." See the summary of the doctors' reports as set forth above.

In summary, this judge does not find that the work activity that Claimant performed at EGS was the prevailing factor in causing both the diagnosis of TOS and any resulting disability. This is because the undersigned judge does not find that Claimant's work at EGS was the primary factor, in relation to any other factor causing both the medical condition and the disability. Stated another way, it is this judge's determination that if Claimant has TOS then the primary factor in the development of that condition is due to activities that predate her employment at EGS. Employee's

diagnosed condition and disease of thoracic outlet syndrome (as diagnosed by the doctors) did not arise out of and in the course of her employment with Employer EGS.

(2) Whether the alleged incident of occupational disease (TOS) caused the injuries and disabilities for which benefits are now being claimed.

Missouri statute defines "occupational disease" as, "an identifiable disease arising with or without human fault out of and in the course of employment." Section 287.067.1 RSMo. Because this judge has determined that the condition of TOS did not arise out of and in the course of Employee's work at EGS Claimant has therefore not sustained an occupational disease of TOS. The answer to this question is in the negative.

(3) Whether the Employer and insurer are obligated to pay for certain past medical care and expenses in the amount of $\ 54,457.00.

Employee seeks a ruling from this judge awarding her the above sum of money for past medical expenses that are represented in Claimant's Exhibit 5. During cross-examination at trial Claimant testified that all of her medical expenses relating to TOS were paid by her private health insurance carrier, Blue Cross and Blue Shield. Claimant's testimony during direct examination by her attorney, Ms. Fisher, at first stated that all the medical expenses reflected within that exhibit related to the treatment of TOS. However, Claimant then also stated that one portion of the expenses within the exhibit related to a second surgery (reported by Dr. Thompson in his report letter, Exhibit 4) that related to a subclavian transplant. The undersigned judge has reviewed the Claimant's testimony on that point and it is simply unclear as to whether she is claiming to recover any portion of the expenses relating to that second surgery. Regardless, considering the answer to the first issue addressed and answered above, Claimant has failed in her burden to establish that she is entitled to any further past medical expenses to be paid beyond the amount of medical expenses that have already been stipulated to and paid by Employer, i.e., $\ 30,017.96. Employer is not obligated to pay for any further past medical expenses incurred by Employee.

(4) Whether the Employee has sustained injuries that will require additional or future medical care in order to cure and relieve the Employee of the effects of the injuries.

As stated above, the undersigned judge has found the opinions of Dr. Estep and Dr. Woodward most persuasive. Regarding this issue, Dr. Woodward stated: "Regarding the patient's work related bilateral UE tendonopathy condition, she has reached MMI at this time. No additional future work injury medical treatment is necessary." Exhibit A. Similarly, from his last visit with Employee Dr. Estep noted: "It was discussed with her previously and again today that thoracic outlet work (sic) is not a prevailing factor of her underlying disease process which is causing her

the most problem. I recommend that work comp no longer cover any aspect of this and that she should seek treatment on her own for thoracic outlet." Exhibit C. Based on these opinions and the analysis herein, Employer is not required to provide any future medical care or treatment.

(5) Whether the Employee is entitled to temporary disability benefits? (The employee seeks payment of $40,961.51, which represents 150.86 weeks of temporary total disability compensation payable at a rate of $271.52 for the period of December 3, 2016 to October 24, 2019.)

Claimant's position is that she voluntarily left her employment with EGS due to the effects of TOS. Her last day of employment with EGS was December 2, 2016. Based on the answer to issues #1 and #2 above, Claimant is not entitled to any temporary total disability compensation. Therefore, Employer is not obligated to provide temporary total disability compensation to Claimant as presented above in Issue #5.

(6) Whether the Employee sustained any permanent disability as a consequence of the alleged incident of occupational disease; and, if so, what is the nature and extent of disability.

The parties have stipulated that on or about June 23, 2016, Employee sustained an incident of occupational disease which arose out of and in the course of her employment, i.e., bilateral tendinitis. The above issue asks this judge to decide whether Claimant has sustained any permanent disability as a consequence of an alleged occupational disease culminating on or about June 23, 2016, and, if so, what is the nature and extent of such disability.

As determined above, within this Award, the undersigned has found most persuasive, the opinions of Doctors Estep and Woodward. Indeed, with respect to the issue of whether Claimant sustained any permanent disability as a consequence of an occupational disease culminating on June 23, 2016, Dr. Woodward's February 16, 2017, examination record provides the following:

"Regarding the patient's work related bilateral UE tendonopathy condition, she has reached MMI at this time. No additional or future work injury treatment is necessary. Work status: may perform full time regular duties with regard to prevailing work injury conditions. Final work injury disability rating: Upper extremities=right UE - 10% at the 200 week level for the work related condition; left UE - 5% at the 200 week level for the work related condition." See, Exhibit A. The undersigned judge finds this opinion by Dr. Woodward is most persuasive, constitutes substantial and competent evidence, and this ALJ agrees with this opinion in determining the nature and the extent of Claimant's permanent disability.

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Therefore, based on Dr. Woodward's assessment and opinions set forth above the undersigned judge determines that Claimant's permanent disability associated with her work at EGS is permanent and partial in nature. Furthermore, the extent of the permanent and partial disability is 5% at the 200 week level with respect to the left UE and 10% at the 200 week level with respect to the right UE.

(7) If the Court finds that the Claimant is permanently and totally disabled, is the Employer liable for such benefits or is the Employer only liable for permanent partial disability benefits as the Second Injury Fund would be liable for permanent total disability benefits had they been properly impleaded in the claim.

The Employer has asked this question to be answered. However, the Second Injury Fund is NOT a party to this workers' compensation claim and this judge sees no reason to engage in an analysis or discussion of any potential liability of the Second Injury Fund (SIF) had the SIF been named as a party. Instead, the parties asked this judge to address and answer a series of specific issues which this ALJ has accomplished. Again, this judge, as stated above, agrees with and accepts the diagnosis and opinions of Doctors Estep and Woodward that Claimant's work at EGS was not the prevailing factor in causing both the medical condition (TOS) and the alleged disability resulting from the medical condition of TOS.

CONCLUSION AND AWARD

The undersigned judge finds that Employee - Kimberly Zachary-Holland - failed to meet her burden to prove the compensability of the thoracic outlet syndrome (TOS). In summary, this judge does not find that the work activity that Claimant performed at EGS was the prevailing factor in causing both the diagnosis and condition of TOS and any resulting disability. This is because the undersigned judge does not find that Claimant's work at EGS was the primary factor, in relation to any other factor causing both the medical condition and the disability. Stated another way, it is this judge's determination that if Claimant has TOS then the primary factor in the development of that condition is due to activities that predate her employment at EGS. Employee's diagnosed medical condition and disease of thoracic outlet syndrome (as diagnosed by the doctors) did not arise out of and in the course of her employment with Employer EGS.

However, the record does show that Claimant has permanent partial disability. Indeed, Employer stipulated to the fact that on or about June 23, 2016, Claimant suffered an incident of occupational disease, i.e., bilateral tendinitis. Dr. Woodward opined that Claimant's permanent disability associated with her work at EGS is permanent and partial in nature. Furthermore, he assigned the extent of the permanent and partial disability as: 5% at the 200 week level with respect to the left UE and 10% at the 200 week level with respect to the right UE.

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Therefore, Employee's final award of compensation is calculated as follows:

Total compensation - permanent partial disability = $8,145.60

ATTORNEY'S FEE:

The Employee's attorney, Jan L. Fisher, is allowed a fee of 25% of all sums awarded herein for necessary legal services rendered to Employee. The amount of the fee shall constitute a lien on the compensation awarded herein. Interest, if any, on all sums awarded shall be paid as provided by law.

Made by:

I certify that on 4-14-21, I delivered a copy of the foregoing award to the parties to the case. A complete record of the method of delivery and date of service upon each party is retained with the executed award in the Division's case file.

By __________________________

Kevin R. Thomas

Administrative Law Judge

Division of Workers' Compensation

By __________________________