Aetna Cas. & Sur. Co. v. Davis
| Decision Date | 26 September 1984 |
| Docket Number | No. 40910,40910 |
| Citation | 253 Ga. 376,320 S.E.2d 368 |
| Parties | AETNA CASUALTY & SURETY COMPANY v. DAVIS. |
| Court | Georgia Supreme Court |
Andrew J. Hamilton, Gwendolyn R. Tyre, Neely & Player, Atlanta, Roger A. Cone, Gregory T. Presmanes, Cone, Shivers & Presmanes, Atlanta, for Aetna Cas. & Sur. Co.
C. Lawrence Jewett, Atlanta, for Robin Davis.
On August 1, 1979, while working at a Pic compensation benefits, and by May 14, 1983, she had been paid $7,663.60 in indemnity benefits and all her authorized medical expenses up to that date--$15,885.61. Because there was a dispute between the employee and the workers' compensation insurer as to the extent of permanent disability, they entered into a settlement agreement which was approved by the Board of Workers' Compensation on June 29, 1981. Pursuant to the agreement, Davis received a lump sum payment of $12,493.00 in full and final settlement of all claims with one exception, which follows:
In December, 1981, Davis, who was then in Anchorage, Alaska, had surgery on her right knee. She submitted the expenses to Aetna for payment under the agreement. Aetna filed a notice to controvert with the Board, contending that the expenses were not a result of the August 1, 1979, injury, and that the expenses were not reasonable, necessary or authorized under OCGA § 34-9-200 et seq. Davis responded by filing suit in Fulton Superior Court alleging, inter alia, breach of contract and tortious breach of contract. She also sought judicial enforcement of the settlement agreement pursuant to OCGA § 34-9-106. On Aetna's motion, the trial court dismissed the complaint for failure to state a claim upon which relief could be granted and failure to exhaust administrative remedies. Davis appealed, and the Court of Appeals reversed. 169 Ga.App. 825, 314 S.E.2d 913.
The Court of Appeals first held that seeking judicial enforcement of the settlement agreement was premature because the compensability of the expenses submitted under the agreement presents a factual question which must be resolved by the Board. 1 The Court of Appeals went on, however, to hold that insofar as the complaint sought damages for breach of contract and tortious breach of contract, it was improperly dismissed. We granted Aetna's application for certiorari to consider this latter holding. Because the two holdings of the Court of Appeals are interrelated, we consider both of them.
1. We agree with the Court of Appeals that the issue of whether this claim is compensable should be submitted to the Board. The settlement agreement was approved by the Board and thus it represents an award of the Board. OCGA § 34-9-15; National Union Inc. Co. v. Mills, 99 Ga.App. 697, 109 S.E.2d 830 (1959). The duty of approving items of medical expense is placed squarely on the Board. Blair v. United States Fidelity & Guaranty Co., 140 Ga.App. 880(2), 232 S.E.2d 156 (1977); see also OCGA § 34-9-16. "If there must be further expense incurred after the award is made, bills for these expenses should be submitted to the board for making similar determination, approval and award." Turner v. Baggett Transportation Co., 128 Ga.App. 801, 806, 198 S.E.2d 412 (1973). The fact that this award arose from a settlement agreement approved by the Board does not change the applicability of these rules. Thus we conclude that Aetna was authorized by the Workers' Compensation Act to controvert and decline to pay the claim until such time as the...
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