Ellis v. Missouri State Treasurer

• Decision Date: 14 December 2009
• Docket Number: No. SD 29573.,SD 29573.
• Citation: 302 S.W.3d 217
• Parties: Patsy ELLIS, Claimant-Respondent, v. MISSOURI STATE TREASURER as Custodian of the Second Injury Fund, Appellant.
• Court: Missouri Court of Appeals

302 S.W.3d 217

Patsy ELLIS, Claimant-Respondent, v. MISSOURI STATE TREASURER as Custodian of the Second Injury Fund, Appellant.

No. SD 29573.

Missouri Court of Appeals, Southern District, Division One.

December 14, 2009.

Rehearing Denied January 4, 2010.

Application for Transfer Denied March 2, 2010.

Chris Koster, Attorney General, and Christina M. Hammers, Assistant Attorney General, Jefferson City, MO, for Appellant.

Thomas P. Carlton, Joplin, MO, for Respondent.

DON E. BURRELL, Judge.

The Missouri State Treasurer, as custodian of the Second Injury Fund ("the SIF"), appeals an award by the Labor and Industrial Relations Commission ("the Commission") that ordered it to pay $165,459.99 to Patsy Evonne Ellis ("Claimant"). The SIF claims the Commission erred by 1) ordering the SIF to pay Claimant for medical bills that were already paid by Claimant's personal insurance or written-off by her medical providers; and 2) if the SIF was liable for anything other than Claimant's out-of-pocket medical expenses, by ordering the SIF to pay Claimant the entire billed amount of those expenses ("the full cost") instead of the amount actually paid by her personal insurance and accepted by her medical providers. Although the SIF believes the resolution of this appeal will require us to determine whether the Commission misapplied the law when it ruled that section 287.270¹ prevents the SIF from reducing its liability based on payments or write-offs made by entities other than Claimant's employer or its insurer, we do not reach that issue and affirm the award of the Commission based on the SIF's failure to rebut Claimant's evidence that she remained liable for the full cost of her medical treatment.

Background

Claimant was seriously injured in an automobile accident on December 10, 2004. It is undisputed that Claimant's accident was work-related, that her employer was uninsured for workers' compensation purposes, and that her injuries were severe. Fortunately, Claimant had various personal insurance policies that provided coverage for a significant portion of the medical treatment she received as a result of the accident. Claimant paid all of the premiums for these insurance policies.

The full cost of Claimant's treatment was $165,459.99. Claimant's personal insurance carriers paid her medical providers a total of $77,328.98 toward those bills. Claimant's medical providers also made various downward "adjustments"² to their bills. After crediting Claimant with the $77,328.98 paid by her insurance and $60 she had previously paid, Claimant's medical providers showed her as owing a remaining balance of $581.40—the amount the SIF claims it should have been directed to pay. We will refer to the amounts paid by and still expected from Claimant plus the payments made by her personal insurance carriers as the "discount price" of her medical bills ($77,970.38).

At the hearing on her claim for compensation, Claimant presented Exhibit T, a compilation of all of her medical bills. Claimant also testified that it was her "understanding" that she was still liable for the payment of the total amount of those bills ($165,459.99) as of the date of hearing and that they were all related to the treatment of her work-related accident. Exhibit T was received into evidence. During its cross-examination of Claimant, the SIF offered into evidence Exhibit # 1, a summary page showing the amounts billed by Claimant's various medical providers and indicating those amounts that had been paid toward them by Claimant's personal insurers and amounts that had been adjusted downward. Exhibit # 1 was also received into evidence.

The Administrative Law Judge ("ALJ") awarded Claimant the full cost of her medical treatment ($165,459.99). After it was timely requested to review that award, the Commission affirmed it and adopted the ALJ's decision as its own. Additional facts relevant to the resolution of this appeal will be set forth below in the context of our analysis of the SIF's claims of error.

Standard of Review

Section 287.495 governs appeals from the Labor and Industrial Relations Commission.

The appellate court shall have jurisdiction to review all decisions of the commission pursuant to this chapter where the division has original jurisdiction over the case. [ ... ] in the absence of fraud, the findings of fact made by the commission within its powers shall be conclusive and binding. The court, on appeal, shall review only questions of law and may modify, reverse, remand for rehearing, or set aside the award upon any of the following grounds and no other:

(1) That the commission acted without or in excess of its powers;

(2) That the award was procured by fraud;

(3) That the facts found by the commission do not support the award;

(4) That there was not sufficient competent evidence in the record to warrant the making of the award.

We defer to the Commission on issues of fact and the credibility and weight to be given to conflicting evidence but review questions of law de novo. Allcorn v. Tap Enter's, Inc., 277 S.W.3d 823, 827 (Mo. App. S.D.2009). "If, as here, the award of the Commission attaches and incorporates an award and decision of the ALJ, we may consider the findings, but only so far as they are consistent with the decision of the Commission." Braswell v. Mo. State Highway Patrol, 249 S.W.3d 293, 297 (Mo. App. S.D.2008). We will not reverse the decision of an administrative agency that reaches the right result even if it gave a wrong or insufficient reason for its ruling. See Davis v. School of the Ozarks, Inc., 188 S.W.3d 94, 105 (Mo.App. S.D.2006); SkillPath Seminars v. Summers, 168 S.W.3d 465, 467 (Mo.App. W.D.2005); Lauderdale v. Division of Employment Sec., 605 S.W.2d 174, 178 (Mo.App. E.D.1980) (internal citations omitted).

The facts are not viewed in the light most favorable to the Commission's decision. Hampton v. Big Boy Steel Erection, 121 S.W.3d 220, 223 (Mo. banc 2003); Kent v. Goodyear Tire and Rubber Co., 147 S.W.3d 865, 867 (Mo.App. W.D.2004). Instead, "[a] court must examine the whole record to determine if it contains sufficient competent and substantial evidence to support the award, i.e., whether the award is contrary to the overwhelming weight of the evidence." Hampton, 121 S.W.3d at 222-23. "Whether the award is supported by competent and substantial evidence is judged by examining the evidence in the context of the whole record." Id. at 223.

Analysis

The SIF's first point alleges the Commission erred as a matter of law when it determined that section 287.270 applies to claims brought against the SIF under section 287.220.5.³ The SIF claims its position is supported by sound public policy⁴ and two cases decided, respectively, by the eastern and western districts of this court. See Mann v. Varney Constr., 23 S.W.3d 231 (Mo.App. E.D.2000); Phillips v. Par Elec. Contractors, 92 S.W.3d 278 (Mo.App. W.D.2002).

Claimant argues that Mann and Phillips both failed to address critical language contained in section 287.220.5 and incorrectly refused to follow this district's decision in Wilmeth v. TMI, Inc., 26 S.W.3d 476 (Mo.App. S.D.2000), which assumed that section 287.270 did apply to claims brought against the SIF under section 287.220.5.

Whether section 287.270 applies to claims brought against the SIF under section 287.220.5 presents a difficult question of statutory construction, but it need only be addressed once it has been demonstrated that the claimant is no longer liable to pay her medical bills because they have been paid by a third party that will not be seeking reimbursement for that payment. See Farmer-Cummings v. Pers. Pool of Platte County, 110 S.W.3d 818, 822 (Mo. banc 2003) (stating that to reduce an injured employee's award for expenses she may still be held liable for would "vitiate[ ] the policy behind workers' compensation— to place upon the shoulders of industry the burden of workplace injury."). See also Leach v. Bd. of Police Comm'rs of Kansas City, 118 S.W.3d 646, 655 (Mo.App. W.D. 2003) ("Punishing a claimant for an employer's failure to insure thwarts the General Assembly's purpose in establishing the Second Injury Fund, and it ignores the legislature's mandate to construe workers' compensation statutes liberally by resolving all doubts in favor of compensation.") (citing Section 287.800; Thomas v. Hollister, Inc., 17 S.W.3d 124, 126 (Mo.App. W.D.2000)).

The SIF's second point on appeal alleges the Commission erred as a matter of law in granting an award that exceeded the "amount [Claimant]'s health care providers accepted as reasonable payment from [Claimant]'s private insurance companies contrary to section 287.140.3."

Section 287.140.3 provides, in pertinent part, that:

A health care provider shall not charge a fee for treatment and care which is governed by the provisions of this chapter greater than the usual and customary fee the provider receives for the same treatment or service when the payor for such treatment or service is a private individual or a private health insurance carrier.[⁵]

Based on this section, Appellant argues that if it has liability for any amount in excess of Claimant's actual out-of-pocket expenses, it should not exceed the $77,328.98 "discount price" paid by Claimant's personal insurers because the remainder of the $165,459.99 was either adjusted or written-off by her medical providers.⁶ This argument shares a common assumption with point one that Claimant has no liability to pay any amounts above those paid by her insurance carriers. As a result, before analyzing the SIF's specific allegations of error, we will first address the more general threshold issue of what expenses the SIF is statutorily required to pay, then proceed to a discussion of who has the burden of proving what continuing liability Claimant has in regard to her work-related medical bills.

Claimant's claim against the SIF was brought pursuant to section 287.220.5 which reads as follows.

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