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Gotreaux v. Liberty Mutual Insurance Co.

Court of Appeals of Louisiana, Third Circuit

December 18, 2019

CHRISTINE GOTREAUX
v.
LIBERTY MUTUAL INSURANCE COMPANY, ET AL.

          APPEAL FROM THE OFFICE OF WORKERS' COMPENSATION - DISTRICT 04 PARISH OF LAFAYETTE, NO. 18-08509 ANTHONY PALERMO, WORKERS' COMPENSATION JUDGE.

          Mark L. Riley The Glenn Armentor Law Corporation COUNSEL FOR: Plaintiff/Appellant - Christine Gotreaux.

          Corey M. Meaux Allen & Gooch, A Law Corporation COUNSEL FOR: Defendants/Appellees - Liberty Mutual Insurance Company and Quick Turn Merchandising.

          Court composed of Ulysses Gene Thibodeaux, Chief Judge, Phyllis M. Keaty, and Candyce G. Perret, Judges.

          ULYSSES GENE THIBODEAUX CHIEF JUDGE.

         Plaintiff, Christine Gotreaux, filed an appeal to the Office of Workers' Compensation (OWC) Medical Director after her employer, Quick Turn Merchandising, and its insurer, Liberty Mutual Insurance Company (collectively Defendants), denied her orthopedic surgeon's request for approval for a thoracic spinal fusion. The Medical Director denied the appeal, finding no segmental instability or other criteria to warrant its approval of Plaintiff's request. Plaintiff then appealed the Medical Director's decision to the OWC. Finding Plaintiff had failed to prove, by clear and convincing evidence, that the Medical Director's decision was not in accordance with the Workers' Compensation Act (WCA), the Workers' Compensation Judge (WCJ) rendered judgment in favor of Defendants, dismissing the matter with prejudice.

         Although our review of the record reveals no manifest error in the WCJ's review of the Medical Director's finding as to segmental instability, we nevertheless reverse its dismissal of Plaintiff's claim as we find the WCJ legally erred in too narrowly interpreting the lumbar fusion guidelines he relied upon in refusing to overturn the Medical Director's decision that Plaintiff was not entitled to a variance under the WCA. Accordingly, we affirm the judgment on the issue of segmental instability, reverse the judgment as to dismissal, and remand this matter to the WCJ for further proceedings consistent with this opinion.

         I.

         ISSUE

         We shall decide whether the WCJ erred misinterpreting the application of the Medical Treatment Schedules and thereby denying the claim.

         II.

         FACTS AND PROCEDURAL HISTORY

         This workers' compensation claim arises out of an accident that occurred on April 9, 2011, when Plaintiff was employed by Quick Turn Merchandising to provide services at a Lowe's store in Lafayette, Louisiana. While moving a rack of plants, Plaintiff felt her back crack. Although Defendants initially denied the claim, the matter was litigated and ultimately resolved by a consent judgment which stated that Plaintiff was injured in the course and scope of her employment, compensation was due at the rate of $262.50 per week, and medical treatment was to be provided pursuant to the OWC medical treatment guidelines.

         Over the last eight years, Plaintiff has seen numerous physicians and has had multiple surgeries, including both lumbar and cervical spinal fusions. There have also been several additional disputes about payments and medical treatment since the original consent judgment.

         The current dispute and appeal arise from a Form 1010 request made by Dr. Mark McDonnell, Plaintiff's orthopedic surgeon, for authorization or approval for a thoracic spinal fusion that was not preauthorized by the medical treatment guidelines. Defendants denied the request for a lack of segmental instability. A Form 1009 appeal to the Medical Director was denied for lack of instability or other fusion criteria. Plaintiff then filed a Form 1008 to appeal the Medical Director's decision.

         A hearing was held for the parties to present arguments and evidence regarding the merits of Plaintiff's appeal, during which Plaintiff introduced several exhibits: (1) Dr. McDonnell's medical records; (2) the Form 1010; (3) the Form 1009; (4) the Medical Director's decision; (5) excerpts from the medical treatment guidelines on lumbar spine, La. Admin. Code tit. 40, Pt. I, § 2023(G)(4)(d); (6) New York State medical guidelines for mid and lower back injuries; (7) ...


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