Toyota Motor Manufacturing Kentucky, Inc. v. Lawson, No. 2008-CA-002386-WC (Ky. App. 11/6/2009)
| Decision Date | 06 November 2009 |
| Docket Number | No. 2008-CA-002386-WC.,No. 2009-CA-000064-WC.,2008-CA-002386-WC.,2009-CA-000064-WC. |
| Parties | TOYOTA MOTOR MANUFACTURING, KENTUCKY, INC. Appellant/Cross-Appellee v. Stephanie LAWSON, Appellee/Cross-Appellant and Hon. John W. Thacker and Hon. Joe W. Justice, Administrative Law Judges, and Workers' Compensation Board, Appellees/Cross-Appellees |
| Court | Court of Appeals of Kentucky |
H. Douglas Jones, Kenneth J. Dietz, Florence, Kentucky, Brief for Appellant/Cross Appellee.
Charles W. Gorham Lexington, Kentucky Brief for Appellee/Cross Appellant
Before: LAMBERT, MOORE, and VANMETER, Judges.
Toyota Motor Manufacturing USA, Inc., appeals from an opinion and order of the Workers' Compensation Board, reversing an opinion and order of an Administrative Law Judge (ALJ) finding a knee surgery, proposed by Appellant Stephanie Lawson, to be non-compensable on the ground that it was not reasonable and necessary for the cure and relief of Lawson's work-related injury. The Board reversed the ALJ based solely upon its conclusion that Toyota had failed, as required, to reopen the underlying award and file a separate medical fee dispute within thirty days of its denial of Stephanie Lawson's proposed surgery through its utilization review procedure.
In addition to Toyota's petition, Lawson cross-petitions this Court, arguing the ALJ's finding that her proposed surgery was unreasonable and unnecessary was not supported by substantial evidence.
As to Toyota's appeal, finding the Board committed error, we reverse. Regarding Lawson's cross-appeal, we remand to the Board for further findings.
On November 13, 2001, while working for Toyota, Lawson sustained an injury to her right knee, due to deep squatting and long periods of sitting, stair climbing and getting in and out of cars. This matter was initially resolved via a settlement agreement approved on July 13, 2005.
On or about August 20, 2007, Mark G. Siegel, M.D., Lawson's treating orthopedic doctor, requested preauthorization from Toyota to perform a lateral retinacular reconstruction on Lawson's right knee. Toyota referred Dr. Siegel's request to GENEX Services, Inc. for utilization review (i.e., to review the requested health care services for medical necessity and appropriateness). In its report, dated August 27, 2007, GENEX recommended that Toyota approve Lawson's proposed surgery.
On September 12, 2007, Lawson moved to reopen her award for the purpose of seeking Temporary Total Disability (TTD) and Permanent Disability (PD) income benefits, based upon the worsening of her injury. In relevant part, the motion stated that:
2. After the workers' compensation settlement was approved, the Plaintiff continued treating with her treating orthopedic surgeon, Dr. Mark G. Siegel. Plaintiff's work-related injury has worsened to the extent that Dr. Siegel has now recommended additional surgical intervention. Once Plaintiff undergoes said surgical intervention, the Plaintiff anticipates that she will not be at maximum medical improvement and will be temporarily totally disabled. Furthermore, the Plaintiff anticipates that her condition has worsened to the extent that she is now entitled to additional permanent disability benefits. Subsequently [sic], Plaintiff moves to reopen her workers' compensation claim for a worsening of her work-related injury.
On September 13, 2007, Lawson served her motion upon Toyota and the Office of Workers' Claims. On that same date, Irene Slater at GENEX called Dr. Siegel and said the case had been extended pending an independent medical evaluation.
On September 20, 2007, Martin G. Schiller, M.D., evaluated Lawson for an independent medical examination on behalf of Toyota. His report recommended against further surgery on Lawson's knees. Subsequent to the independent medical examination, Lawson's proposed surgery was cancelled.
On October 8, 2007, Toyota filed a response denying the claims asserted in Lawson's motion to reopen her award.
On October 22, 2007, Lawson's motion to reopen her award was sustained to the extent the claim was reopened and assigned to an ALJ for further adjudication. At the March 12, 2008 benefit review conference, Lawson and Toyota identified as contested issues "the medical fee dispute/compensability of surgery" and "TTD."
On May 23, 2008, the ALJ dismissed Lawson's claims. Specifically, the ALJ held that
the [surgery] recommended by Dr. Siegel is not reasonable or necessary for the cure and/or relief of the claimant's work injury. Accordingly, the Administrative Law Judge finds in favor of the defendant/employer on the medical fee dispute. And, as the medical fee dispute is decided in favor of the defendant/employer, no income benefits for temporary total disability are payable.
On June 4, 2008, Lawson petitioned for reconsideration and argued that Toyota had waived its right to contest the compensability of her proposed surgery because it had failed to timely reopen her award for the purpose of filing a medical fee dispute. Her petition was denied on July 7, 2008.
Subsequently, Lawson appealed the ALJ's May 23, 2008 order denying compensability of her proposed surgery and TTD and the ALJ's July 7, 2008 order denying reconsideration to the Board.
On November 20, 2008, the Board reversed the ALJ's July 7, 2008 order with regard to the medical fee dispute, holding that, in order to contest Lawson's proposed surgical procedure, Toyota had a burden to timely file a motion to reopen Lawson's award within thirty days of August 27, 2008, which date was the conclusion of Toyota's utilization review process. Finding Toyota failed to do so, the Board held that Toyota obligated itself to pay for her proposed surgery regardless of any question of reasonableness or necessity. With regard to Lawson's claim for TTD, the Board remanded this issue to the ALJ for further findings.
Toyota now appeals, contending that: 1) it had no obligation to reopen Lawson's claim and file a medical fee dispute within thirty days of the utilization review; 2) if such obligation existed, Lawson waived it as an issue by not raising it prior to the hearing in the matter; and 3) Lawson's own filing to reopen her claim made said obligation moot. In addition, Lawson cross-appeals, contending that there was not sufficient evidence to support the ALJ's finding that her proposed surgery was unreasonable and unnecessary.
When we review a decision of the Worker's Compensation Board, we will only reverse the Board's decision where the Board has overlooked or misconstrued the controlling law or so flagrantly erred in evaluating the evidence that a gross injustice has occurred. Daniel v. Armco Steel Co., 913 S.W.2d 797, 798 (Ky. App. 1995). Ultimately, we must review the ALJ's decision to accomplish this.
Regarding the ALJ's decision, the Supreme Court of Kentucky has held that when the ALJ finds in favor of the party with the burden of proof, then the reviewing court will affirm the ALJ's decision if it is supported by substantial evidence. Special Fund v. Francis, 708 S.W.2d 641, 643 (Ky. 1986). However, if the ALJ finds against the party with the burden of proof, then the reviewing court may only reverse if the evidence compels a finding in the favor of the party with the burden of proof. Daniel, 913 S.W.2d at 800; see also Lee v. Int'l Harvester Co., 373 S.W.2d 418, 420-21 (Ky. 1963). In addition, as the finder of fact, the ALJ, not this Court and not the Board, has sole discretion to determine the quality, character and substance of the evidence. Whittaker v. Rowland, 998 S.W.2d 479, 481 (Ky. 1999) (quoting Paramount Foods, Inc. v. Burkhardt, 695 S.W.2d 418, 419 (Ky. 1985)). Not only does the ALJ weigh the evidence, but the ALJ may also choose to believe or disbelieve any part of the evidence regardless of its source. Whittaker, 998 S.W.2d at 481 (quoting Caudill v. Maloney's Discount Stores, 560 S.W.2d 15, 16 (Ky. 1977)).
We turn first to Toyota's contention that the Board erred in reversing the ALJ. Lawson contends, and the Board found, that the ALJ erred in making any determination on the subject of a medical fee dispute because Lawson reopened her award only on the ground that her condition had worsened. In order to bring the issue of a medical fee dispute before the ALJ, Lawson asserts that it was necessary for Toyota to have separately reopened her award for that purpose and that incorporating the issue into her reopening was improper. We disagree.
We begin by stating that Lawson's filing of a motion to reopen in order to allege a worsening of her condition did not, by itself, operate to place the issue of a medical fee dispute before the ALJ. In the recent case of Bartee v. Univ. Med. Ctr., 244 S.W.3d 91 (Ky. 2008), the Supreme Court of Kentucky held that an employer's motion to reopen a workers' compensation case to dispute certain medical expenses does not place the issue of TTD before the ALJ. In Bartee, the employee moved to reopen the case for a ruling on the question of entitlement to TTD. That motion was denied as having been filed outside the time limitations set forth in KRS 342.125(3) and (8). The benefit review conference memorandum listed the sole issue as "medical fee dispute/compensability of surgery." Thereafter, the claimant asserted in her brief not only that the surgery was compensable but also that she was entitled to TTD benefits from the date of the surgery until her return to work. The ALJ awarded TTD benefits because he believed it was a natural extension of the medical dispute. Alternatively, the ALJ concluded that the principles of waiver and estoppel precluded the employer from objecting to the TTD award. The Board affirmed the ALJ's award based upon different reasoning.
In reversing, the Supreme Court held that 1) the employee had not properly sought to invoke the...
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