Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Daniels v. State

Court of Appeals of Louisiana, Second Circuit

July 17, 2019

ROBERT DANIELS Plaintiff-Appellee
v.
THE STATE OF LOUISIANA, THROUGH THE DEPARTMENT OF TRANSPORTATION AND DEVELOPMENT Defendant-Appellant

          Appealed from the Office of Workers' Compensation, District 1-E Parish of Franklin, Louisiana Trial Court No. 1201716 Brenza Irving Jones Workers' Compensation Judge

          STATE OF LOUISIANA DOTD EDDIE DAVID GILMER Assistant Attorney General Counsel for Appellant

          LAW OFFICES OF STREET & STREET By: Curtis Daniel Street Counsel for Appellee

          Before MOORE, STONE, and McCALLUM, JJ.

          STONE, J.

         In this workers' compensation case, the appellant, the State of Louisiana, through the Department of Transportation ("DOTD"), denied the appellee, Robert Daniels', request for an inpatient surgical procedure. Subsequently, the Office of Workers' Compensation Administration, through its Medical Director ("OWC"), also denied that request. The workers' compensation judge ("WCJ") reversed the decision of the OWC and ordered DOTD to provide and pay for the inpatient surgical procedure.

         On appeal, in light of the Louisiana Supreme Court holding in Church Mut. Ins. Co. v. Dardar, 2013-2351 (La. 5/7/14), 145 So.3d 271, this Court reversed the decision of the WCJ and remanded this matter for the parties to present evidence to the WCJ to show by clear and convincing evidence whether the medical director's conclusion was appropriate pursuant to La. R.S. 23:1203. See Daniels v. State, Dep't of Transp. & Dev., 48, 578 (La.App. 2 Cir. 6/25/14), 144 So.3d 1123.

         Thereafter, the WCJ found in favor of Daniels and awarded costs of the requested surgical procedure, penalties, attorney fees, and payment for medical expenses associated with non-emergency care. For the following reasons, we affirm the judgment of the WCJ.

         FACTUAL BACKGROUND AND PROCEDURAL HISTORY

         The following facts are taken from this Court's prior 2014 opinion:

On October 28, 2010, Daniels suffered a work-related accident while employed by DOTD when he fell off a backhoe injuring the right side of his body, in particular his right shoulder. Payment of workers' compensation benefits associated with Daniels' work-related accident was initiated without dispute. An orthopedic physician, Dr. Douglas Brown, performed surgery on Daniels' right shoulder on June 13, 2011. The DOTD covered all of these medical expenses.
Thereafter, Daniels began complaining of lower back pain. After reviewing diagnostic tests, Dr. Brown recommended that Daniels undergo inpatient surgery-L4-5, L5-S1 anterior lumbar interbody fusion with LDR PEEK cages, bone marrow stem cells, morselized allograft, and SEP monitoring. The DOTD sought a second medical opinion from Dr. Powell Auer, who recommended that Daniels undergo more testing. After receiving a provocative lumbar discography report from Dr. John Ledbetter, Dr. Brown again recommended surgery. F.A. Richard & Associates, Inc. ("FARA"), as the insurance representative for Daniels' employer, denied Dr. Brown's request, finding that the recommended surgery did not meet the criteria established for intensity of services pursuant to the Louisiana Workers' Compensation Treatment Guidelines.
A disputed claim for medical treatment was filed with the Office of Workers' Compensation Administration ("OWC") Medical Director on behalf of Daniels. The medical director denied the appeal on March 6, 2012, concluding that the evidence did not support approval of the requested services per the Louisiana Medical Treatment Guidelines ("MTG"). As a result, Daniels filed Form 1008 (disputed claim for compensation), initiating the present claim.
On February 21, 2013, this matter was heard by the WCJ, who found that Daniels was entitled to the recommended surgery, and further, that the MTG did not apply since they went into effect after Daniels' accident.

         DOTD filed an appeal of that judgment on March 18, 2013. This Court reversed the judgment in favor of Daniels and remanded the matter to the OWC to allow the parties to present evidence to the WCJ to show by clear and convincing evidence, whether the medical director's conclusion was appropriate. This case was heard by the WCJ again on October 19, 2017. Following the presentation of Daniels' case-in-chief, DOTD moved for involuntary dismissal. After oral arguments regarding the motion for dismissal, both Daniels and DOTD were instructed to provide briefs to the court on the issue of whether or not the plaintiff had shown by clear and convincing evidence that the decision of the OWC Medical Director to deny the surgical treatment requested was a misapplication of the MTG.

         On January 18, 2018, the WCJ rendered a decision denying DOTD's motion to dismiss, and trial resumed on March 19, 2018. Before trial proceedings began, both parties entered into a settlement for the indemnity portion of Daniels' workers' compensation claim. The settlement agreement reserved Daniels' right to proceed with the current litigation and agreed to allow the medical portion of the claim to continue. At the conclusion of trial, the WCJ found in favor of Daniels, ordered DOTD to provide and pay for the requested surgical procedure, and awarded $611 in medical expenses associated with non-emergency care. Daniels' demands for penalties and attorney fees were denied and dismissed with prejudice.

         On April 10, 2018, Daniels filed a motion for new trial for re-argument, alleging that the judgment signed by the WCJ was incorrect because it did not reflect the decisions of the court or Daniels' demands as addressed in the WCJ's reasons for judgment. On May 4, 2018, Daniels also filed a motion to enforce settlement agreement, alleging that DOTD had failed and refused to pay the proceeds of the settlement agreement for the indemnity claim. Daniels' motion for new trial was heard before the WCJ on May 14, 2018. After the hearing, the court granted Daniels' motion for new trial and set a hearing for oral arguments to be heard on August 13, 2018.

         On June 11, 2018, Daniels' motion to enforce settlement agreement was heard by the WCJ. After the hearing, the WCJ's oral reasons for judgment were announced in open court. A judgment ordering DOTD to pay $14, 400[1] in penalties for the settlement and $1, 500 in attorney fees was signed and rendered on June 18, 2019. DOTD filed a motion for new trial on June 29, 2018, requesting that the June 18, 2018, judgment be withdrawn, and that the issues of the enforceability of the settlement, and penalties and attorney awards be reconsidered by the court.

         During the hearing on August 13, 2018, the WCJ announced her reasons for judgment in open court, and ordered that the judgment signed on June 28, 2018, be revoked and rescinded; ordered DOTD to provide and pay for the surgery recommended by Dr. Brown; awarded $611 in expenses related to non-emergency care; and, denied Daniels' request for the payment of penalties and attorney fees. That same day, the WCJ also heard DOTD's motion for new trial. After the hearing, the WCJ denied that motion. DOTD filed the instant appeal.

         DISCUSSION

         Claim for Lumbar Interbody Fusion Surgery

         The first issue presented in this case is whether the WCJ erred in granting Daniels' requested claim for surgery. In its first and second assignment of error, DOTD questions both the WCJ's decision and the reasons in support of the decision to grant Daniels' claim and order DOTD to pay for the requested surgery.

         Under La. R.S. 23:1203.1(I), the claimant's initial burden on appeal before the medical director remains one of proof by a preponderance of the evidence. Church Mut. Ins. Co. v. Dardar, 145 So.3d 271, supra; Gilliam v. Brooks Heating & Air Conditioning, 49, 161 (La.App. 2 Cir. 7/16/14), 146 So.3d 734. However, a claimant seeking judicial review of a decision made by the medical director must prove the necessity of the sought-after medical treatment by clear and convincing evidence. Gilliam, supra; Friedman v. Ecolab, Inc., 50, 358 (La.App. 2 Cir. 2/3/16), 187 So.3d 491.

         The clear and convincing standard in a workers' compensation case is an intermediate standard falling somewhere between the ordinary preponderance of the evidence civil standard and the beyond a reasonable doubt criminal standard. Hatcherson v. Diebold, Inc., 00-3263 (La. 5/15/01), 784 So.2d 1284; Young v. Physicians & Surgeons Hosp., 39, 348 (La.App. 2 Cir. 3/2/05), 895 So.2d 723. To prove a matter by clear and convincing evidence means to demonstrate that the existence of the disputed fact is highly probable or much more probable than its nonexistence. Young, supra; Hollingsworth v. Steven Garr Logging, 47, 884 (La.App. 2 Cir. 2/27/13), 110 So.3d 1219.

         Whether the claimant has carried his burden of proof and whether testimony is credible are questions of fact to be determined by the WCJ. See Buxton v. Iowa Police Dep't, 2009-0520 (La. 10/20/09), 23 So.3d 275; City of Shreveport v. Casciola, 43, 132 (La.App. 2 Cir. 3/26/08), 980 So.2d 203. Factual findings in workers' compensation cases are subject to the manifest error or clearly wrong standard of appellate review. Buxton, supra; Casciola, supra.

         In this case, DOTD asserts that the WCJ largely based its decision to grant Daniels' claim on its own incorrect conclusion relating to utilization of inessential discretionary indicators. Specifically, DOTD takes issue with the the WCJ's conclusion that the OWC Medical Director's decision denying the surgical procedure recommended was based on discretionary indicators not required for a spinal fusion. To that end, DOTD argues that Daniels failed to meet his burden and show by clear and convincing evidence that the decision of the medical director to deny the surgical treatment recommended by his treating physician Dr. Brown was a misapplication of the MTG.

         We disagree. Following the trial on the merits, the WCJ, in her oral reasons for judgment, stated:

A review of the medical evidence and the MTG revealed the medical director denied the requested surgery based upon discretionary indications for a spinal fusion. The requirements for the spinal fusion were clearly met. Medical records revealed all pain generators were adequately defined and treated. Physical medicine and manual therapy interventions are noted. The MRI and discography clearly showed disc pathology on the two levels at issue.
In regard to the last indicator, jurisprudence has held the psychosocial evaluation is unnecessary unless the treating physician feels it needs to be done. A psychosocial evaluation is required only when the surgeon has concerns about the relationship between symptoms and findings or when the surgeon is aware of indications of psychosocial consultations or risk factors.
According to Louisiana Revised Statute 23:1203.1(K), after the issuance of the decision by the medical director, any party who disagrees with the decision may then appeal by filing a disputed claim for compensation, which is LWC Form 1008. The decision may be overturned when it is shown by clear and convincing evidence that a decision of the medical ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.