SUSAN GARNO V. SOLECTRON USA; ET AL.
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RENDERED : DECEMBER 16, 2010
TO BE PUBLISHED
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APPELLANT
SUSAN GARNO
ON APPEAL FROM COURT OF APPEALS
CASE NO . 2009-CA-001425-WC
WORKERS' COMPENSATION BOARD NO. 02-66400
SOLECTRON USA;
HONORABLE GRANT S. ROARK,
ADMINISTRATIVE LAW JUDGE; AND
WORKERS' COMPENSATION BOARD
APPELLEES
OPINION OF THE COURT
AFFIRMING
An Administrative Law Judge (ALJ) found that the claimant's Form 114
requests for reimbursement of medical expenses were non-compensable with
respect to expenses incurred more than 60 days before being submitted and
that no reasonable grounds excused the delay.' The Workers' Compensation
Board and the Court of Appeals affirmed . Appealing, the claimant asserts that
her reimbursement requests were timely and that her attempts to request
reimbursement were reasonable under the circumstances .
1 803 KAR 25:096, § 11(2) and (3).
We affirm because the record does not reveal an error in applying the law
or an abuse of the ALJ's discretion . Contrary to the claimant's assertion, the
March 2006 order finding her injuries to be work-related and directing
insurance carriers to pay interlocutory temporary total disability (TTD) and
medical benefits equally was enforceable . The record did not compel a finding
that she submitted a reimbursement request before entry of the interlocutory
order or show a reasonable cause for her failure to do so until January 2007.
The claimant worked for Solectron-USA from February 2002 until
sometime in February 2004 . She filed an application for benefits in January
2005 in which she alleged that she sustained work-related low back injuries on
October 14, 2002 and January 15-16, 2004 . She listed Royal 8v Sun Alliance
(now Arrowpoint Capital Corporation) as the employer's workers' compensation
insurance carrier. Although Royal insured Solectron's liability in 2002, St.
Paul Travelers insured its liability in 2004 . ALJ Cowden joined Travelers as a
party on May 9, 2005, the date of the first scheduled Benefit Review Conference
(BRC), and counsel representing Solectron as insured by Travelers entered an
appearance shortly thereafter .
ALJ Cowden bifurcated the claim in December 2005 because the
claimant had not reached maximum medical improvement (MMI) from an L3-45 fusion performed in June 2005. The issues submitted for a decision at that
time included work-relatedness/causation; the apportionment of liability
between the carriers; whether an injury occurred as defined by the Workers'
Compensation Act; and the claimant's entitlement to temporary total disability
(TTD) benefits and medical expenses .
In an order and award entered on March 24, 2006, ALJ Cowden found
the alleged injuries to be work-related and ordered Royal to pay all TTD and
medical benefits due from October 14, 2002 through January 16, 2004 .
Convinced that the injuries contributed equally to the need for the L3-4-5
fusion, ALJ Cowden apportioned equal liability to the insurance carriers for
TTD and medical benefits after January 17, 2004, which included the surgery.
Questions concerning the extent and duration of disability, application of
benefit modifiers, and entitlement to vocational rehabilitation were held in
abeyance until such time as the claimant reached maximum medical
improvement (MMI) . An amended order entered on May 4, 2006 specified the
periods of TTD resulting from the 2002 injury for which Royal bore sole liability
and specified January 14, 2004 as being the final date from which Royal bore
sole liability for the claimant's medical expenses.
Evidence produced subsequently indicated that the claimant moved to
Florida in November 2005 and began treatment with Dr. Billys, who
recommended a discogram and possible fusion at L5-S1 . Dr. Gleis evaluated
the claimant for Solectron and reported in September 2006 that she had
reached MMI from the surgery performed in 2005 . He stated that he did not
think the additional surgery proposed by Dr. Billys would improve her low back
condition . The claim was then reassigned to ALJ Roark, who ordered TTD to
be terminated and removed the claim from abeyance .
On January 29, 2007 the claimant's attorney submitted to the carriers
multiple Form 114 reimbursement requests with attached invoices and receipts
that claimed over $20,000.00 in out-of-pocket medical expenses, some of which
dated to 2002 and 2003. The forms were signed by the claimant and dated
"May 9, 2005." The submission also contained
a document indicating that Dr.
Billys was scheduled to perform the L5-S 1 fusion on January 31, 2007 .
The carriers filed medical disputes to contest the requests, asserting on
their Form 112 filings that the requests were untimely under 803 KAR 25:096,
§ 11 and were not supported by the documentation necessary to determine if
the expenses were compensable. They contested liability for the L5-S 1 fusion
and treatment provided by Dr. Billys and moved to have him joined as a party,
complaining that the claimant failed to request pre-authorization, which
prevented the employer from conducting utilization review, and also
complaining that she failed to complete the form she was given in September
2006 to designate Dr. Billys as her treating physician .
The claimant filed with the Office of Workers' Claims on May 9, 2008 and
submitted to the carriers a document styled "COMPLIANCE WITH
ADMINISTRATIVE LAW JUDGE'S ORDER" as well as various attachments. The
submission did not include a Form 114 reimbursement request or certify that
the expenses were incurred for the cure or relief of the claimant's injuries. The
attachments included receipts for some prescriptions the claimant received
from 2006 through 2008, which listed the copays ; a printout that listed some
of the same as well as other prescriptions and included handwritten copays;
and a list of other expenses and mileage. A separate printout from the Florida
Orthopedic Institute listed various charges for the period from May 2006
through November 2007 but failed to explain their necessity. The carriers filed
supplemental medical disputes to contest payment, asserting that the claimant
failed to follow the proper procedure to request reimbursement and that the
request was untimely.
The claimant acknowledged at the hearing that she failed to direct
medical bills incurred after March 2006 to be submitted directly to the carriers.
She also acknowledged that she knew they were equally liable but used her
health insurance coverage instead. She stated that she knew Dr. Billys failed
to seek approval for surgery but blamed the failure on one of his employees.
ALJ Roark agreed with ALJ Cowden's previous findings that the claimant
sustained compensable injuries in 2002 and 2004 and that the injuries
contributed equally to any work-related medical expenses she incurred on and
after January 15, 2004 . Finding the opinions of Drs . Gleis and Schiller to be
more reliable than those of Dr. Billys, ALJ Roark determined that the L5-S 1
fusion was non-compensable because it was neither reasonable nor necessary
treatment for the injuries . Noting that the March 2006 order found expenses
for treating the work-related injuries to be compensable, the ALJ determined
that the claimant offered no reasonable excuse for her failure to submit
reimbursement requests until January 11, 2007. The ALJ concluded as a
consequence that expenses incurred more than 60 days before January 11,
2007 and subsequent expenses incurred more than 60 days before submission
were not compensable under KAR 25 :096, § 11 .
The claimant asserts that ALJ Roark erred by finding her reimbursement
requests to be untimely. She argues that she made reasonable attempts to
seek reimbursement; pointing to her hearing testimony that she first submitted
reimbursement requests to the attorney who represented Solectron at the May
9, 2005 BRC and to the fact that the requests submitted in January 2007 were
dated May 9, 2005.2 She also argues that her obligation to submit
reimbursement requests did not begin with the interlocutory order of March
24, 2006 because the order would not have been enforceable . She maintains
that her requests were timely, reasoning that she was entitled to submit them
within a reasonable period after ALJ Roark entered the final award but did so
before he entered the award. We disagree. The record reveals no error in
applying the law or abuse of discretion by ALJ Roark.
KRS 342 .020 entitles an injured worker to reasonable and necessary
medical treatment for the effects of a work-related injury.3 It also seeks to
ensure that medical services are provided efficiently and economically by
requiring injured workers to designate a single treating physician or physicians'
2 Nothing in the record supports the claimant's testimony that she submitted the
3
reimbursement requests at the BRC. Solectron denied receiving them. Moreover,
Travelers was not joined as a party until the date of the BRC and did not enter an
appearance until sometime thereafter . Both carriers attached Form 114
reimbursement requests dated May 9, 2005 to the medical disputes that they filed
after receiving the claimant's January 29, 2007 submission . The claimant filed
requests dated May 9, 2005 into the record on June 11, 2008.
KRS 342 .020( 1) .
group to supervise medical serviceS;4 by permitting employers to provide
medical services through a managed health care system;5 and prohibiting fees
that exceed medical fee schedules.6 KRS 342.020 and the accompanying
regulations also seek to ensure the prompt billing and payment of compensable
medical expenses by imposing certain duties on providers, employers, and
injured workers .
KRS 342 .020(1) requires a provider to submit
a statement for services
within 45 days of the date that treatment of a work-related injury is initiated
and every 45 days thereafter . It then requires the employer to pay the provider
within 30 days of receiving the statement unless the period is tolled by
regulation, such as during utilization review . At issue presently is 803 KAR
25 :096, § 11, which permits a worker to be reimbursed for reasonable expenses
incurred in accessing compensable medical treatment. The regulation requires
a reimbursement request to be made on a Form 114 and submitted to the
employer within 60 days of incurring the expense but permits reasonable
grounds to excuse a failure to submit a timely Form 114.
We find no merit in the claimant's argument that her obligation to
present reimbursement requests did not arise until a final award was entered
because the interlocutory order would not have been enforceable. KRS
342 .275(2) authorizes an ALJ to "grant or deny any benefits afforded under this
KRS 342.020(5) .
s KRS 342.020(3) and (4) .
6 KRS 342.020(1) . See also KRS 342.035 .
7 803 KAR 25:190, § 5(4) .
4
chapter, including interlocutory relief. . . ." Moreover, KRS 342 .305 permits a
party to obtain a circuit court judgment in accordance with "an order or
decision of the administrative law judge or board, or an award of the
administrative law judge unappealed from. . . ." These provisions clearly
permit the terms of an ALJ's interlocutory order and award to be enforced until
superseded by a subsequent order or award.
The interlocutory order and award entered in March 2006 found the
claimant's injuries to be work-related and directed the insurance carriers to
pay TTD and medical benefits equally. The order on reconsideration entered in
May 2006 found Royal solely liable for compensable medical expenses incurred
through January 14, 2004. Nothing in the record compelled a finding that the
claimant submitted a reimbursement request before January 2007 or
demonstrated a reasonable cause for her failure to do so until then.
The decision of the Court of Appeals
All sitting. All concur.
is affirmed.
COUNSEL FOR APPELLANT,
SUSAN GARNO:
Wayne C. Daub
600 West Main Street
Suite 300
Louisville, KY 40202
COUNSEL FOR APPELLEE,
SOLECTRON USA:
Kimberly K. Van Der Heiden
Allen, Kopet 8s Associates, PLLC
P.O . Box 34048
Lexington, KY 40588
and
Lyn Douglas Powers
Fulton & Devlin
.
2000 Warrington Way
Suite 165
Louisville, KY 40222
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