McAree v. Gerber Products Co.

• Decision Date: 29 July 1975
• Docket Number: No. 74-42-A,74-42-A
• Citation: 115 R.I. 243,342 A.2d 608
• Parties: John J. McAREE v. GERGER PRODUCTS COMPANY. ppeal.
• Court: Rhode Island Supreme Court

Page 608

342 A.2d 608

115 R.I. 243

John J. McAREE v. GERGER PRODUCTS COMPANY.

No. 74-42-Appeal.

Supreme Court of Rhode Island.

July 29, 1975.

[115 R.I. 259] Raul L. Lovett, Providence, for petitioner.

Harold E. Adams, Jr., Providence, for respondent.

OPINION

KELLEHER, Justice.

This is an employee's appeal from the denial by the Workmen's Compensation Commission of his petition to review a preliminary agreement. The petitioner sought an order which would compel his employer to pay for a specialized medical treatment program whose goal would be the elimination of what appears to be a work-related addiction to drugs.

The sole question is whether or not the employer and its insurance carrier have a duty to pay for certain medical and psychiatric treatment which the employee's treating physician has recommended.

On July 16, 1969, McAree worked as a salesman for Gerber. On that date while lifting a case of his employer's baby food in a supermarket, McAree injured his back. He and Gerber reached an agreement as to liability for the injury and, on August 9, 1969, they executed a preliminary agreement which described McAree's ailment as a 'low back strain.' Gerber agreed to pay McAree $45 a week while he was totally incapacitated as well as 'all reasonable bills for hospital and medical service and for necessary mudicines' that are provided for by the Workmen's Compensation Act.

In the intervening years, McAree has been treated by Dr. Julius Stoll, surgeon in chief of the Rhode Island Hospital's Department of Neurosurgery. This treatment has included two major operations. The first was disc surgery, and the second was an attempt to relieve McAree of constant pain which continued after the first operation. The operation was not successful, however, and McAree continued to experience severe pain due to nerve damage unalleviated by either surgical attempt. In an effort to pinpoint the specific nerve roots which were the primary cause of the pain, Dr. Stoll, in August 1972, performed several complex diagnostic tests including a myelogram and a nerve block. Although he discovered the cause of his patient's discomfort, Dr. Stoll decided against operating a third time because he found quite a bit of scarring in the area and this created a high surgical risk which he advised his patient against taking.

Before the trial commissioner, the doctor testified that, further surgical remedies being ill-advised, his only treatment alternative to control McAree's discomfort was to prescribe large quantities of prescription pain killers. This medication is potentially addicting, and Dr. Stoll testified that, in his judgment, the employee was 'probably addicted' to the medication by now.

He told the commissioner that he now considered the addiction a serious problem which was in need of treatment. He also felt that the patient was experiencing psychological problems because of the pain and the resultant addiction and that he was 'too young a man to throw out the window.' He therefore had recommended to McAree that he seek treatment at a Massachusetts facility known as the New England Rahabilitation Center which had a 'pain unit' headed by a physician who enjoyed the unique distinction of being board certified as a neurologist, a psychiatrist, and a neurosurgeon, and whose clinic would treat the 'whole person.' Gerber's insurance carrier refused to sanction such treatment, and said it would not psy for it. The rehabilitation center, on the other hand, was not willing to admit McAree unless and until it received prior authorization from the carrier and assurances that it would be paid for its services.

Unable to resolve the impasse caused by the intransigence of Gerber, its carrier, and the center, McAree requested a hearing before the Workmen's Compensation Commission to determine whether the cost of the treatment fell within his employer's obligation. At the hearing before the trial commissioner, Dr. Stoll testified as to the history of his patient's condition and his recommendation for further treatment. He also explained the services available at the Massachusetts clinic. The trial commissioner issued a decision in which he found that the employee was in need of further medical services in order to cure, rehabilitate, or relieve him from the effects of his injury, and that such care was available at the Massachusetts clinic. He ordered the employer to pay all reasonable costs of the treatment. From this ruling Gerber appealed to the full commission.

The full commission reversed the decision of the trial commissioner and found that the employee had not met his burden of proving either that he was in need of further treatment, or that the rehabilitation center could offer such care. Additionally, the commission held that there was no statutory authority for the payment of services to out-of-state medical facilities, and that it lacked jurisdiction to rule on the employee's request for a determination of prior authorization of treatment. Any one of these four findings is sufficient to defeat the employee's claim. Because of the view we take of the case, we must review all four. We shall first consider the jurisdictional question.

The commission characterized the petition as one seeking permission to obtain treatment in the future and noted that the only express statutory provision for the obtaining of prior commission approval is G.L.1956 (1968 Reenactment) § 28-33-5, which requires that the employee obtain permission prior to any major surgery to be entitled to have his employer pay for the surgery. It therefore declared itself without jurisdiction to hear the employee's case. ¹

We disagree. Section 28-33-5 is not framed in exclusionary terms so as to prohibit any other kind of prior approval, but merely mandates that, as to 'major surgery,' ² prior approval must be obtained if the surgeon expects to be paid by the employer or the insurance carrier. We have repeatedly said that the Workmen's Compensation Act is to be construed liberally to effectuate its obvious purpose. Matthews v. Falvey Linen Supply, Inc., 110 R.I. 558, 294 A.2d 398 (1972).

It is our belief that the prior approval or 'no pay' proviso for major surgery is not a limitation on the commission's jurisdiction to adjudicate McAree's eligibility for treatment. Rather, the proviso acts as a limitation on the employee's right to incur substantial medical expenses before the employer has had an opportunity to make an investigation as to the necessity for the surgery. McAree and Gerber have a valid agreement which provides that the employer will pay for all reasonable medical treatment which was necessary to cure, rehabilitate, or relieve the employee from the effects of his injury. A clear disagreement has arisen between them as to whether the proposed treatment falls within the scope of this agreement. The Legislature has provided that employers and employees need not go before the commission in order to provide for compensation for all injuries but may settle the problem by private agreement. ³ However, where, as here, a conflict arises as to the scope and effect of such agreement, the commission is clearly the proper forum for resolving the dispute. Section 28-35-11 gives it the general, broad jurisdiction to determine '(a)ll questions arising under (the act) if not settled by agreement of the parties interested therein * * * except as otherwise provided.' More specifically, the commission is charged with the enforcement of any agreement approved by it. Section 28-35-7. We therefore hold that a dispute such as the one which arose here is subject to the determination of the commission, and within its jurisdiction to adjudicate.

The decree of the full commission contains a finding '(t)hat the petitioner has failed to prove by a fair preponderance of the reasonable evidence that the New England Rehabilitation Center, Inc. has complied with the provisions of the workmen's compensation act entitling it to be paid for any services rendered under Sec. 28-3-8.' Although we cannot fault the accuracy of this statement, we find it of no relevance to McAree's petition. Section 28-33-8 requires that, in order to be entitled to payment for its services, a hospital or attending physician must, within 15 days, notify the employer of the commencement of treatment, and submit bimonthly progress reports to it thereafter. The petition to the commission, and the hearing on the petition both occurred before the treatment had been commenced. We take judicial notice of the fact that time operates on a continuum and that events which may happen in the future have not yet occurred in the present. However, we fail to see how this obvious fact affects the result in this case or why it entered into the commission's decision to deny McAree's petition. The petition alleged that the employer was refusing to 'provide or pay for necessary medical services.' The trial commissioner ordered the employer to pay 'all reasonable charges' of such services. There is, of course, no way to determine what the reasonable costs for the services will be until they are offered. Nothing in the decision issued by the trial commissioner assures the hospital of actual payment. It must still comply with § 28-33-8 in order to be entitled to payment and future disputes may still arise as to what are the reasonable costs for the care it will give McAree. The commission was not asked to approve payment in futuro. Here, as we view the matter, the issue is whether or not the proposed course or treatment is necessary to cure, rehabilitate, or relieve McAree from the effect of his work-related injury. This was the issue to be resolved initially by the trial commissioner and by the full commission on review.

Of more relevance to the deciding of McAree's petition is a statement contained in the full commission's decision in which it questioned its 'authority to order payment for treatment rendered by the...