carl-a-nelson-company-and-zurich-north-america-ins-co ( 2015 )

IN THE COURT OF APPEALS OF IOWA
No. 15-0323
Filed November 25, 2015
CARL A. NELSON & COMPANY and
ZURICH NORTH AMERICA INS. CO.,
Petitioners-Appellants/Cross-Appellees,
vs.
BYRAN SLOAN,
Defendant-Appellee/Cross-Appellants.
________________________________________________________________
Appeal from the Iowa District Court for Polk County, Douglas F. Staskal,
Judge.
An employer appeals, and a worker cross-appeals, the district court’s
judicial review decision, which affirmed in part and reversed in part the workers’
compensation commissioner’s award of benefits. DISTRICT COURT DECISION
AFFIRMED ON APPEAL; DISTRICT COURT DECISION REVERSED IN PART
AND AGENCY DECISION AFFIRMED IN PART AND REVERSED IN PART ON
CROSS-APPEAL.
Sasha L. Monthei of Scheldrup Blades, Cedar Rapids, for
appellants/Cross-appellees.
Toby J. Gordon of Swanson, Gordon, Benne, Clark & Kozlowski, L.L.L.P.,
Burlington, for appellee/Cross-Appellant.
Heard by Vogel, P.J., and Vaitheswaran and Bower, JJ.
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VOGEL, Presiding Judge.
Carl A. Nelson & Company and Zurich North American Insurance Co. (the
Employer) appeal, and Byran Sloan cross-appeals, the district court’s judicial
review decision, which affirmed in part and reversed in part the workers’
compensation commissioner’s award of benefits to Sloan. The Employer claims
the district court erred in affirming the agency’s causation finding and erred in
affirming the agency’s misinterpretation and misapplication of the law of
intervening causes. In the cross-appeal, Sloan claims the district court erred in
modifying the provision of the agency’s decision that ordered medical “bills” that
had been paid by Sloan’s private health insurer be paid directly to Sloan.
We agree with the district court that substantial evidence supports the
agency’s causation finding, and we likewise find no error in the agency’s
interpretation or application of the law of intervening causes. With respect to the
cross-appeal, we conclude the district court erred in its interpretation of the
controlling case law. Therefore, we affirm in part and reverse in part the district
court’s judicial review decision.
I. Background Facts and Proceedings.
At the agency level, the parties stipulated Sloan sustained an injury to his
back in the course and scope of his employment on August 15, 2011, while lifting
concrete forms out of a trench. Sloan was treated for what was described as a
back strain, and he was returned to full-duty work with no restrictions on August
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24, 2011. The dispute in this case centers on what effect an incident that
occurred on October 30, 2011,1 had on that stipulated work injury.
On October 30, 2011, Sloan was assisting a friend move some go-kart
frames into a trailer. When Sloan tried to slide a frame that had been placed on
the trailer by a bobcat, he felt a sudden onset of pain and numbness in his back
and legs. Sloan described the pain as being similar to what he experienced
when the initial injury occurred. When conservative treatment for this injury
failed, Sloan underwent back surgery and was subsequently released at
maximum medical improvement on January 14, 2013.
The workers’ compensation case was tried before a deputy commissioner
on April 9, 2013. The deputy heard the testimony of Sloan and his wife, and
received the parties’ exhibits and briefs. The deputy denied Sloan’s claim after
determining the go-kart incident was an intervening and superseding cause of
Sloan’s injury. It was the deputy’s opinion that “[t]he greater weight of the
evidence supports a finding that [Sloan] sustained an injury, returned to baseline
and then suffered a new injury assisting a friend.” The deputy further concluded,
“There were no competent medical opinions tying [Sloan’s] original work injury to
his ongoing back problems.”
Sloan appealed to the commissioner, who reversed the deputy’s
conclusion, finding “the greater weight of evidence supports the finding that
claimant’s work injury was a proximate and natural cause of the disability he
suffered from at the time of the arbitration hearing.” The commissioner stated the
1
The record is unclear whether the incident happened on October 29, 2011, or October
30, 2011. For our purposes we will use the date of October 30.
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“chain of causation can only be broken when the claimant’s conduct amounts to
an intentional violation of an express or implied prohibition and it medically
supersedes the claimant’s original condition.” While the commissioner noted the
evidence was “quite compelling” that the go-kart incident substantially worsened
or aggravated Sloan’s condition, it did not amount to an intervening or
superseding cause because Sloan “was simply engaged in an ordinary activity of
daily living, namely helping a friend transport items on a trailer he owned” and not
engaged in conduct that was “contrary to any express or implied duty owed to his
employer following his work injury.”
The commissioner also held the Employer is responsible for the medical
treatment Sloan received following the go-kart incident. The commissioner noted
“the vast majority of the medical bills were unpaid as of the date of the hearing.”
The Employer was to pay those bills directly to the medical provider. However,
those bills that were paid by Sloan’s private health insurance “shall be
reimbursed directly to [Sloan] as the Iowa Supreme Court has mandated in
Ruud.” See Midwest Ambulance Serv. v. Ruud, 754 N.W.2d 860, 867–68 (Iowa
2008).
The Employer filed for judicial review with the district court, who affirmed
the agency’s causation opinion, finding, “the commissioner’s determination is
clearly supported by substantial evidence in the record.” While the district court
noted that the evidence in this case could support the contrary conclusion, as the
deputy commissioner found, the court acknowledged its duty was to review the
evidence to support the decision made by the agency, not the decision that the
agency could have made. The court likewise affirmed the agency’s analysis of
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the intervening and superseding cause, concluding “there is really no point in the
court reiterating that discussion when the court has no disagreement either with
the commissioner’s judgment regarding the law or his application of the law to
the facts.” The court agreed substantial evidence supported the agency’s
conclusion that “Sloan’s helping a friend loading and moving go-karts . . . was no
more strenuous than his normal work activities.”
However, the court modified the agency’s decision with respect to the
payment of medical bills that had been covered by Sloan’s private health insurer.
The court determined the agency misinterpreted the supreme court’s holding in
Ruud as mandating direct reimbursement to Sloan. Instead, the district court
held the Employer is to
either (1) directly reimburse Sloan for the expenses approved by
the commissioner as part of Sloan’s claim that were paid by the
health insurer; or (2) reimburse the insurer for such amounts and
pay any remaining amounts of any such expenses not paid by the
health insurer directly to the provider.
From this ruling the Employer appeals the causation ruling, and Sloan
cross-appeals the ruling on the reimbursement of medical expenses paid by his
private health insurer.
II. Scope and Standard of Review.
As our supreme court stated in Cedar Rapids Community School District
v. Pease, 807 N.W.2d 839, 844–45 (Iowa 2011):
Our decision is controlled in large part by the deference we afford
to decisions of administrative agencies. Medical causation
presents a question of fact that is vested in the discretion of the
workers’ compensation commission. We will therefore only disturb
the commissioner’s finding of medical causation if it is not
supported by substantial evidence.
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The Employer also objects to the agency’s interpretation of the law and
application of the law to the facts with respect to its discussion of intervening and
superseding causes. We give no deference to the agency’s interpretation of law
where, as here, the agency has not been clearly vested by the legislature with
the authority to interpret that law. Iowa Code § 17A.19(10)(c), (l) (2013); Burton
v. Hilltop Care Ctr., 813 N.W.2d 250, 256–57 (Iowa 2012); Renda v. Iowa Civil
Rights Comm’n, 784 N.W.2d 8, 14 (Iowa 2010) (“When a term has an
independent legal definition that is not uniquely within the subject matter
expertise of the agency, we generally conclude the agency has not been vested
with interpretative authority.”). We will only disturb the agency’s application of
law to the fact if that application is “irrational, illogical, or wholly unjustifiable.”
Burton, 813 N.W.2d at 256.
With respect to the claim regarding the reimbursement of medical benefits
paid by a private health insurer, Sloan articulates the varying standards of review
that are applicable in judicial review proceedings, but he fails to articulate
precisely which standard is applicable to the claim he makes on appeal.
“Because of the widely varying standards of review, it is ‘essential for counsel to
search for and pinpoint the precise claim of error on appeal.’” Jacobson Transp.
Co. v. Harris, 778 N.W.2d 192, 196 (Iowa 2010) (citation omitted). We interpret
the claim to be one that implicates the agency’s interpretation of law, both
statutory law and the supreme court’s ruling in Ruud. Thus, we give no
deference to the agency’s interpretation as we conclude the agency has not been
clearly vested by the legislature with the authority to interpret that law. See
Renda, 784 N.W.2d at 14.
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III. Causation.
The question of medical causation is “essentially within the domain of
expert testimony.” Pease, 807 N.W.2d at 845. It is the commissioner, as the
trier of fact, who must “weigh the evidence and measure the credibility of
witnesses.” Id. “The determination of whether to accept or reject an expert
opinion is within the ‘peculiar province’ of the commissioner.” Id. We will disturb
the agency’s decision on medical causation only if it is not supported by
substantial evidence. Id.
In this case, the commissioner reviewed the medical opinions on the issue
of causation and determined, of the three experts who offered opinions on
causation, the opinion of Kenneth Bussey, M.D., was most persuasive. The
commissioner concluded the other two causation opinions were based “almost
entirely, upon the stated proposition that [Sloan] was not suffering from radicular
symptoms between August 15, 2011 and October 30, 2011.” Based on his
review of the medical records, the commissioner determined that this proposition
was not supported by the evidence. The commissioner credited Sloan’s
testimony that he requested a full-duty release to work on August 24, 2011, not
because he was healed but because he could not financially afford to be on light-
duty with shorten work hours any longer. The commissioner concluded there
was “simply no reasonable basis to disbelieve claimant’s uncontroverted, sworn
testimony that he was still suffering from back and leg pain (radiculopathy) when
he was released” back to work. The commissioner concluded:
Therefore, the work-related injury either caused the
herniated disc or it weakened claimant’s discs in his spine so that
the second injury caused the final or worsened herniation. In either
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event, claimant has met his burden of proof to demonstrate that the
disability was a natural consequence of the work injury. The
subsequent non-work injury merely completed or furthered the
injury which began at work.
It is therefore concluded that for all of these reasons the
greater weight of evidence supports the finding that claimant’s work
injury was a proximate and natural cause of the disability he
suffered from at the time of the arbitration hearing.
Giving deference as we must, we, like the district court, conclude substantial
evidence supports the commissioner’s causation determination. While a different
conclusion could be reached based on the evidence presented, that is not the
standard of review we must apply in judicial review proceedings. Burton, 813
N.W.2d at 256 (“This review is limited to the findings that were actually made by
the agency and not other findings that the agency could have made.”).
The Employer also challenges the agency’s interpretation and application
of the law with respect to the question of intervening and superseding causation.
The agency cited with approval Larson’s treatise on Workers’ Compensation
Law, which holds, “The basic rule is that a subsequent injury, whether an
aggravation of the original injury or a new and distinct injury, is compensable if it
is the direct and natural result of a compensable primary injury.” 1 Arthur Larson
& Lex K. Larson, Larson’s Workers’ Compensation Law ch. 10, § 10.01, at 10-2
to 10-3 (rev. ed. 2015); see also Oldham v. Scofield & Welch, 266 N.W. 480, 482
(Iowa 1936) (“In other words, where an accident occurs to an employee in the
usual course of his employment, the employer is liable for all consequences that
naturally and proximately flow from the accident.”).
The commissioner held the go-kart incident was a direct and natural result
of the August 15, 2011 work injury based on the opinion of Dr. Bussey. The
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commissioner then concluded this connection was not severed by Sloan’s activity
in attempting to slide the go-kart frame on the trailer because the back was
rendered “more vulnerable” by the work injury. See id. § 10.06[2], at 10-15. The
action of Sloan was not considered “negligent” so as to break the chain of
causation because Sloan’s actions were not rashly undertaken with knowledge of
the risk created by the weakened member. See id. § 10.06[3], at 10-17. The
commissioner also noted the action taken by Sloan was not “an intentional
violation of an express or implied prohibition” by Sloan’s treating physician. See
id. § 10.09[4], at 10-27. Sloan had been released by the Employer’s doctor to full
duty with no restrictions as of August 24, 2011, and the action Sloan took was
not any more physically demanding than the work he had performed for the
Employer during the interim two months between his return to work and his
subsequent reinjury.
Based on our review of the record and the applicable law, we agree with
the district court that the agency did not misinterpret the law with respect to
intervening and superseding cause. See Iowa Code § 17A.19(10)(c). In
addition, we do not find the agency’s application of the facts to that law, to be
“illogical, irrational or wholly unjustifiable.” See id. § 17A.19(10)(m).
We therefore affirm the district court’s judicial review decision with respect
to the Employer’s appeal.
IV. Payment of Medical Expenses.
Sloan cross-appeals the district court’s judicial review decision. He claims
the court erred when it modified the agency’s decision by holding that the
Employer can either pay the medical expenses that had been paid by Sloan’s
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private health insurance to him directly or to his health insurance company.
Sloan maintains the supreme court’s ruling in Ruud mandates the payments
must be made to him, not his private health insurance company.
In Ruud, the employee sustained an injury and was unable to return to
work. 754 N.W.2d at 863. She continued on her employer’s group health
insurance after she left employment though COBRA and personally paid the
required premiums in full. Id. The employer was ultimately found responsible for
the injury, and the supreme court determined the employer was not entitled to a
credit under Iowa code section 85.38(2)2 for the medical benefits covered by the
group health insurer because the employer did not pay any portion of the
premium during the time the employee was covered under COBRA. Id. at 867
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Iowa Code § 85.38(2) provides:
a. In the event the employee with a disability shall receive any
benefits, including medical, surgical, or hospital benefits, under any group
plan covering nonoccupational disabilities contributed to wholly or partially
by the employer, which benefits should not have been paid or payable if
any rights of recovery existed under this chapter, chapter 85A, or chapter
85B, then the amounts so paid to the employee from the group plan shall
be credited to or against any compensation payments, including medical,
surgical, or hospital, made or to be made under this chapter, chapter 85A,
or chapter 85B. The amounts so credited shall be deducted from the
payments made under these chapters. Any nonoccupational plan shall
be reimbursed in the amount deducted. This section shall not apply to
payments made under any group plan which would have been payable
even though there was an injury under this chapter or an occupational
disease under chapter 85A or an occupational hearing loss under chapter
85B. Any employer receiving such credit shall keep the employee safe
and harmless from any and all claims or liabilities that may be made
against them by reason of having received the payments only to the
extent of the credit.
b. If an employer denies liability under this chapter, chapter 85A, or
chapter 85B, for payment for any medical services received or weekly
compensation requested by an employee, and the employee is a
beneficiary under either an individual or group plan for nonoccupational
illness, injury, or disability, the nonoccupational plan shall not deny
payment for the medical services received or for benefits under the plan
on the basis that the employer’s liability under this chapter, chapter 85A,
or chapter 85B is unresolved.
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(“We therefore hold that under Iowa Code section 85.38(2), the employer must
contribute in whole or in part to a group insurance plan for the benefit of the
claimant in order to be entitled to the statutory credit. Because Midwest and
Combined have not proven that they contributed to Ruud’s COBRA payments,
they cannot prevail on their claim under section 85.38(2).”). The supreme court
then went on to address the commissioner’s ruling that the employer was to pay
Ruud directly for the medical expenses paid by the health insurer on Ruud’s
behalf. Id. at 867–68. The supreme court noted the commissioner had
concluded,
that amounts paid by private insurance are attributable to the
plaintiff as if she made those payments herself. The commissioner
reasoned that other health insurance plans may have subrogation
rights against an insured who receives benefits under workers’
compensation. In order to avoid a situation where a health
insurance company sought reimbursement from the claimant for
expenses that the employer has not paid, the commissioner held
that the employer must pay to the claimant an amount equal to the
medical benefits that were covered by the insurer.
Id. at 868. The supreme court then concluded, “the commissioner has adopted
the most sensible approach to this unusual issue.” Id.[A]n employee who pays group health insurance premiums has, in
effect, paid for medical expenses covered by the group plan. We
therefore hold that the commissioner did not err in ordering direct
payment to the claimant for past medical expenses paid through
insurance coverage obtained by the claimant independent of any
employer contribution.
Id. (emphasis added).
We find the supreme court’s ruling definitive with regard to whom an
employer should pay medical expenses that have previously been paid by health
insurance coverage to which the employer did not contribute. We disagree with
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the district court’s assessment that the holding in Ruud does not apply in this
case. We do not find the supreme court’s ruling in Ruud distinguishable, as the
district court did, because Sloan did not personally pay for the premiums or
provide proof his wife paid the premiums—the health insurance at issue in this
case was provided through his wife’s employer. The dispositive issue in Ruud
was that the injured worker’s employer did not contribute to the plan but the
employee secured coverage independent of any employer contribution. Id. The
same holds true here.
We also disagree with the district court that there could be other ways for
these medical expenses to be paid. The supreme court determined “the most
sensible approach” was for the employer to pay the injured worker directly, who
would then be responsible to the health insurer for any subrogation claim. Id.We find the Ruud decision controlling, and reverse the district court’s ruling to the
contrary.
However, we do reverse the agency’s decision with respect to the
terminology used. While the commissioner stated it was adhering to the Ruud
decision, it used the terminology “bills which have been paid” rather than the
terminology used in Ruud, “past medical expenses paid.” We therefore reverse
the commissioner only to the extent of bringing the language into compliance
with the holding in Ruud. The Employer is responsible to make direct payment to
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Sloan for “past medical expenses paid through insurance coverage.” See id.(emphasis added). The agency’s decision is affirmed in all other respects.
DISTRICT COURT DECISION AFFIRMED ON APPEAL; DISTRICT
COURT DECISION REVERSED IN PART AND AGENCY DECISION
AFFIRMED IN PART AND REVERSED IN PART ON CROSS-APPEAL.