Dealer's Lot, Inc. v. Jenkins
| Decision Date | 20 November 2012 |
| Docket Number | Record No. 2441-11-3 |
| Court | Virginia Court of Appeals |
| Parties | THE DEALER'S LOT, INC. AND ERIE INSURANCE EXCHANGE v. LYDIA CAROL JENKINS |
UNPUBLISHED
Present: Judges Elder, Beales and Senior Judge Willis
Argued at Salem, Virginia
MEMORANDUM OPINION* BY
The Dealer's Lot, Inc. and its workers' compensation insurance carrier, Erie Insurance Exchange (collectively, employer),1 appeal the commission's decision ordering it to pay for the cost of a surgery that Lydia Jenkins (claimant) underwent on March 25, 2010 at the University of Virginia Medical Center. On appeal, employer argues that the commission erroneously held it responsible for this surgery under the doctrine of imposition. For the following reasons, we affirm the commission's decision in this case.
Claimant suffered a workplace injury to her right wrist on February 24, 2003. Employer did not dispute the compensability of this injury, and the commission entered an award for medical benefits entitling claimant to "payment of all reasonable and necessary medical treatment causally related to the Feb. 24, 2003 accident for as long as necessary."
The record on appeal also establishes that claimant was treated for the unrelated condition of rheumatoid arthritis in her right hand and fingers. This treatment dates back at least to May 2007, according to the record.3
On January 6, 2010, Dr. A. Bobby Chhabra of the University of Virginia Health System examined claimant. Dr. Chhabra's notes from that examination indicate that claimant's "rheumatoid nodules are really bothering her in her small and ring fingers and then the triggering of her index as well as the numerous nodules and tenosynovitis of her thumb." Dr. Chhabra noted that he and claimant "discussed treatment options" and agreed that it would be best if claimant underwent surgery to "remove her rheumatoid nodules from her ring, small finger, and thumb as well as do a tenosynovectomy of her index and thumb flexor tendons as these are painful."
It is undisputed that claimant discussed her upcoming surgery with Nasha Monroe, a workers' compensation specialist for employer's insurance carrier, during a February 16, 2010 telephone conversation. Monroe's claims management note from February 16, 2010, which is part of the commission record, states: The claims management note also indicates that Monroe said she would follow up with claimant "post surgery, but not before June."
The record is also undisputed that Monroe communicated with Dr. Chhabra's office about the doctor's treatment of the claimant. The commission record contains a document from Dr. Chhabra's billing office stating that claimant's treatment was covered under "INS PLAN CODE: W00 WORKERS COMP VA," while listing Monroe as the insurance plan contact. This document also contains the following notation: "030510 APPROVED PER NASHA MONROE." (Emphasis added).
On March 25, 2010, Dr. Chhabra performed the surgery that is the subject of this appeal. According to Dr. Chhabra's notes, "rheumatoid nodules and masses" were removed from claimant's right small finger, ring finger, middle finger, index finger, and thumb during this procedure.
After Dr. Chhabra performed the March 25, 2010 surgery on claimant, employer's insurance carrier inquired in an April 29, 2010 letter to Dr. Chhabra whether the March 25, 2010 surgery had been causally related to claimant's compensable fractured wrist from February 2003. Dr. Chhabra's undated handwritten response states, "No. Related to diagnosis of Rheumatoid Arthritis."
On May 24, 2010, claimant received an invoice from the University of Virginia Medical Center indicating that she owed $16,384 for the March 25, 2010 surgery. The invoice stated the total cost of the surgery, $17,932, had been billed to employer's insurance carrier, which waslisted as claimant's primary insurance (with no secondary insurance listed). According to the invoice, employer's insurance carrier had paid $1,548 of this total, leaving claimant responsible for the remainder of the total cost.
Claimant filed an application for a hearing in the commission on June 7, 2010, seeking payment from employer for the outstanding cost of the March 25, 2010 surgery. Claimant then amended her application less than two months later, when she received an additional invoice from the University of Virginia Health Services Foundation stating that she also owed $1,080 for the anesthesia from the March 25, 2010 surgery.4
The parties stipulated before the deputy commissioner that the reason for claimant's March 25, 2010 surgery was not causally related to claimant's compensable injury that occurred in February 2003. Due to this stipulation, claimant has conceded that employer would not ordinarily be required to cover the cost of the surgery under the provisions of Code § 65.2-6035 or under the commission's medical benefits award to the claimant arising from the February 24, 2003 compensable injury. However, claimant argued in the commission that employer should still be responsible for the cost of the March 25, 2010 surgery under the equitable doctrine of imposition, which empowers the commission in appropriate cases to "'do full and complete justice' where the actions of an employer constitute an imposition on an employee." Cheski v. Arlington County Pub. Sch., 16 Va. App. 936, 940, 434 S.E.2d 353, 356 (1993) (quoting John Driggs Co. v. Somers, 228 Va. 729, 734, 324 S.E.2d 694, 697 (1985)). According to claimant,employer's pre-operative approval of this surgery, followed by employer's post-operative refusal to cover the cost of the surgery, created a substantial imposition on claimant - leaving her with a very large medical bill of over $16,000.6
Consequently, much of the evidence before the deputy commissioner related to the nature of Monroe's pre-approval of the March 25, 2010 surgery. Claimant presented a June 16, 2010 letter from Dr. Chhabra to claimant's counsel, in which the doctor stated:
In response to your letter regarding Ms. Jenkins' surgical intervention on March 25, 2010, attached to your letter is pre-authorization approval from Nasha Monroe from Erie Insurance. The procedure was performed after pre-authorization was obtained from this insurance company. If this was an error, please take this up with the insurance company but we would expect payment from the surgery provided as we had pre-authorization.
(Emphasis added). Dr. Chhabra also indicated in a sworn affidavit that he performed the March 25, 2010 surgery pursuant to "authorization obtained from Nasha Monroe on 3/5/10." In addition, as noted supra, the commission record contains a document from Dr. Chhabra's billing office indicating that the doctor's treatment of claimant had been "APPROVED PER NASHA MONROE" on March 5, 2010.
Furthermore, claimant's testimony at the evidentiary hearing before the deputy commissioner largely concerned her recollection of the February 16, 2010 telephone conversation with Monroe. Claimant testified that Monroe indicated during this conversationthat the upcoming surgery with Dr. Chhabra was approved. When asked by her counsel whether Monroe said that this approval was "conditional" or "contingent on anything," claimant replied, "No, sir." Claimant testified that she would not have undergone the March 25, 2010 surgery without Monroe's prior approval, adding that she "couldn't have afforded it."7
At her deposition, Monroe testified that she only "conditionally approved surgery for treatment that was causally related to [claimant's] original injury" and she denied providing unconditional approval for the surgery during the February 16, 2010 telephone conversation with claimant or in any communications with Dr. Chhabra's billing office.
Concerning the February 16, 2010 telephone conversation with claimant, Monroe testified that she knew that claimant was contemplating surgery with Dr. Chhabra at the time of this conversation. Monroe testified that the purpose of the conversation was not to provide the insurance carrier's approval for any surgery - and instead explained that the conversation reflected the normal procedure of maintaining communication with a claimant who has an open medical benefits award. Monroe stated that she did not know that the surgery related to claimant's rheumatoid arthritis (rather than claimant's compensable wrist injury) until after the surgery occurred. Furthermore, Monroe denied knowing that claimant suffered from rheumatoid arthritis at the time of the February 16, 2010 telephone conversation with claimant. However, Monroe acknowledged that she had access to a file with claimant's medical records and could not recall "actually reviewing [claimant's] medical records" until after the surgery occurred.
Monroe also testified that it is the "normal practice" to give conditional approval when a claimant's medical provider requests approval for upcoming medical treatment. Monroe testified that she gave conditional approval for claimant's surgery to an individual named Karen Painter,whom Monroe's claims management note for March 4, 2010 identifies as the medical provider contact for Dr. Chhabra's office. However, Painter's own recollection of the nature of Monroe's approval of the surgery was never made a part of the commission record. The parties agreed that it was unnecessary to depose Painter, and employer never proffered what it expected her testimony would have been.
Reversing the ruling of the deputy commissioner, the full commission unanimously found that it was appropriate to hold employer responsible for the cost of the March 25, 2010 surgery under the specific facts of this case. The commission noted that an employer...
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