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Stretzinger v. Claims Management, Inc.

Court of Appeals of Louisiana, Fifth Circuit

December 11, 2019

RALPH STRETZINGER
v.
CLAIMS MANAGEMENT, INC. AND WAL-MART

          ON APPEAL FROM THE OFFICE OF WORKERS' COMPENSATION, DISTRICT 7 STATE OF LOUISIANA NO. 18-1388 HONORABLE SHANNON BRUNO BISHOP, JUDGE PRESIDING

          COUNSEL FOR PLAINTIFF/APPELLEE, RALPH STRETZINGER Suzette Tagesen Murphy.

          COUNSEL FOR DEFENDANT/APPELLANT, WAL-MART ASSOCIATES, INC. AND/OR WAL-MART STORES, INC. D/B/A WAL-MART STORES AND/OR ALL ITS SUBSIDIARIES AND AFFILIATES Patrick F. Robinson.

          Panel composed of Judges Jude G. Gravois, Robert A. Chaisson, and Hans J. Liljeberg.

          ROBERT A. CHAISSON, JUDGE.

         In this workers' compensation case concerning the denial of requested medical treatment, Wal-Mart appeals a judgment from the Office of Workers' Compensation which declared that Ralph Stretzinger was entitled to receive the requested medical treatment, a L4-5-S1 lumbar interbody fusion, and awarded him penalties and attorney's fees. For the following reasons, we affirm the judgment in part and reverse the judgment in part.

         FACTS AND PROCEDURAL HISTORY

         It is undisputed that on March 9, 2014, Mr. Stretzinger slipped and fell on a wet floor while working at Wal-Mart and sustained multiple serious injuries to his neck, back and lower extremities. In the months and years following the accident, Mr. Stretzinger received medical treatment for pain and other symptoms for his lower back from multiple medical providers. In 2016, following a course of conservative treatment which failed to prevent deteriorating symptoms, Mr. Stretzinger's orthopedist, Dr. K. Samer Shamieh, recommended a L4-5-S1 lumbar interbody fusion. The claims adjuster initially denied this request for treatment as not medically necessary and appropriate according to the Louisiana Workers' Compensation Treatment Guidelines. In accordance with the procedures set forth in these guidelines, Mr. Stretzinger sought review of this denial with the Medical Director of the Office of Workers' Compensation ("OWC"). In a January 19, 2017 letter, the medical director, following a review of the documentation, supported the denial of the requested surgery, but noted, "[t]he patient has criteria except for a psychosocial evaluation as required per the guidelines." Mr. Stretzinger submitted to the psychological examination in February, 2017, and was found to be a good candidate for surgery.

         On November 8, 2017, Dr. Shamieh again requested authorization for the spinal fusion surgery. On December 22, 2017, Wal-Mart, through its adjustor, denied the requested medical treatment as "not related to the on the job injury" and "not in accordance with the Medical Treatment Schedule or R.S. 23:1203.1(D)."

         Mr. Stretzinger again sought review of this denial with the OWC Medical Director, who, in January, 2018, rejected Mr. Stretzinger's application on the basis that disputes relating to compensability and/or causation (such as whether the requested medical treatment is "not related to the on the job injury") are not addressed by the medical director. The medical director made no findings as to whether the requested spinal surgery fell within the medical treatment guidelines.

         On March 6, 2018, Mr. Stretzinger filed a disputed claim for compensation with the OWC. In its answer, Wal-Mart denied that Mr. Stretzinger is entitled to the proposed lumbar fusion surgery because the treatment is contrary to La. R.S. 23:1203.1 and unrelated to Mr. Stretzinger's work accident.

         A hearing on the claim was held on October 22, 2018. At the start of the hearing, Wal-Mart abandoned its argument that the proposed surgery was unrelated to Mr. Stretzinger's work accident and stipulated that there was no dispute in terms of compensability. At the hearing, the parties contested whether the surgery was medically necessary. After taking the issue under advisement, the OWC judge, on January 28, 2019, issued a judgment with written reasons in favor of Mr. Stretzinger and against Wal-Mart. Specifically, the judge decreed Mr. Stretzinger entitled to the lumbar fusion recommended by Dr. Shamieh and ordered Wal-Mart to pay $4, 000 in penalties as well as attorney's fees and costs pursuant to La. R.S. 23:1201(I) and La. R.S. 23:1201(F).

         On appeal, Wal-Mart raises the following assignments of error:

1) Whether the judge legally or manifestly erred in finding the lumbar fusion surgery proposed by Dr. Shamieh as necessary under La. R.S. 23:1203, La. R.S. 23:1203.1, and the Louisiana Workers' Compensation medical treatment guidelines.
2) Whether the judge legally or manifestly erred in assessing penalties and attorney's fees based on the denial of treatment purportedly disallowed under the medical treatment guidelines.
3) Whether the judge legally or manifestly erred in awarding two separate penalties based on a single denial of treatment.

         Additionally, Mr. Stretzinger has filed an answer to Wal-Mart's appeal seeking an award of costs, including attorney's fees, incurred in opposing this appeal. We address these assignments of error in turn in our discussion below.

         DISCUSSION

         Entitlement to Surgery

         In its first assignment of error, Wal-Mart argues that the trial court legally erred in determining Mr. Stretzinger had met his evidentiary burden of proving entitlement to lumbar fusion surgery, because, according to Wal-Mart, Mr. Stretzinger had a heightened burden. Accordingly, our ...


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