FILED

June 21,2018

TN COURT OF
WORKERS’ COMPENSATION
CLAIMS

Time: 1:19 A.M. EASTERN

 

TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS

AT KNOXVILLE
DARLENE FREDIA EAVES, ) Docket No. 2016-03-1427
Employee, )
V. )
AMETEK, INC., ) State File No. 2405-2016
Employer, )
And )
TRUMBELL INSURANCE ) Judge Pamela B. Johnson
COMPANY, )
Carrier. )

 

EXPEDITED HEARING ORDER
(Decision on the Record)

 

This matter came before the Court on Darlene Fredia Eaves’ Motion for
Contempt, Fee Petition, and Petition for Payment of Medical Expenses Incurred to Date,
seeking a decision on the record. Ametek, Inc. did not request an evidentiary hearing.
The Court issued a Docketing Notice listing the documents to be considered. Upon
review, the Court holds it needs no additional information to determine whether Ms.
Eaves is likely to prevail at a hearing on the merits of the claim and decides the issues on
the written materials.

The central legal issues' are whether Ms. Eaves presented sufficient evidence to
prove that: (1) Ametek is in contempt of the Court’s Expedited Hearing Order entered
December 29, 2017, for its failure to authorize treatment ordered by Dr. Harold Cates, the
authorized treating physician; and (2) she is entitled to reimbursement of her medical
expenses incurred relative to the work-related injury, which was the subject of the
Expedited Hearing Order.

 

' Ms. Eaves filed a Fee Petition seeking attorney fees under Tennessee Code Annotated section 50-6-
226(d)(1) (2017) but later withdrew it.
For the reasons below, the Court holds Ms. Eaves failed to come forward with
sufficient evidence demonstrating she is likely to prevail at a hearing on the merits in
proving Ametek’s contempt, but she did provide sufficient evidence demonstrating she is
likely to prevail at a hearing on the merits on entitlement to past medical expenses.
Accordingly, the Court denies Ms. Eaves’ Motion for Contempt but grants her Petition
for Payment of Medical Expenses.

History of Claim
Prior Expedited Hearing

The relevant facts were more fully discussed in the December 29, 2017 Expedited
Hearing Order and are incorporated as if set forth below. For context, Ms. Eaves fell on
January 6, 2016, while using the crosswalk to Ametek’s parking lot after work. She
landed on her left side, injuring her left knee. She made a claim for workers’
compensation benefits, which Ametek denied.

The parties disputed whether a defect existed in the parking lot to cause the fall.
Ms. Eaves asserted she fell because her right heel caught in a crack in the pavement. She
also indicated it was dark outside with poor lighting. Ametek denied the existence of
cracks or other defects in the crosswalk and argued the lighting was sufficient. The Court
found Ms. Eaves fell after her heel caught in a crack and held it caused her fall.

Ametek then argued Ms. Eaves’ injuries were not caused by the fall but by work
she performed renovating rental property. Ms. Eaves’ primary care physician, Dr.
Johnathan Hutchings, indicated she had no prior problems with her knee before the fall,
and Dr. Cates stated the fall caused her symptoms and need for surgery. The Court
concluded Ms. Eaves came forward with sufficient evidence demonstrating she was
likely to prevail at a hearing on the merits that her injuries arose primarily out of and in
the course and scope of her employment.

As to medical benefits, the Court found Ms. Eaves was reasonable in seeking
medical treatment on her own once Ametek denied her claim. The Court ordered Ametek
to provide reasonable and necessary medical treatment related to the injury and named
Dr. Cates as the authorized treating physician. Because Ms. Eaves did not introduce
evidence as to past medical expenses, the Court denied her request for reimbursement.
The Court indicated Ms. Eaves could pursue her claim for past medical expenses and
temporary disability benefits at a later date. Ametek did not appeal the Expedited
Hearing Order.

Post-Expedited Hearing Medical Treatment

Following the hearing, Ms. Eaves continued treatment with Dr. Cates, who
ordered a CT scan on April 6, 2018, and knee replacement surgery on April 16. Ametek

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submitted Dr. Cates’ orders for utilization review (UR) on April 11 for the CT scan and
on April 17 for the surgery. The UR agent determined that the procedures were not
medically necessary. Ms. Eaves appealed the UR denial to the Bureau’s Medical
Director, who on May | overturned the denials. On May 8, Ametek’s carrier notified Dr.
Cates’ office of the decision, authorized the treatment, and instructed to proceed with
scheduling the procedures. Dr. Cates’ office scheduled the CT scan for June | and the
surgery for June 11.

Motion for Contempt

Ms. Eaves argued Ametek’s submission of the recommended procedures to UR
violated the Expedited Hearing Order, which required Ametek to provide reasonably and
necessary treatment related to the injury. Ms. Eaves further argued the referral to UR
violated the Bureau’s regulations. Specifically, she argued Ametek failed to initiate UR
within three business days after Dr. Cates’ recommendations. She further argued the UR
agent failed to: obtain a complete copy of Dr. Cates’ records, relied on a limited review
of one office note, and failed to effectively communicate with Dr. Cates before
determining the procedures were unnecessary.

In response, Ametek argued it complied with the Order and provided treatment
under Tennessee Code Annotated section 50-6-204, which requires the medical treatment
to be reasonable, medically necessary, and related to the work injury. It asserted it
authorized medical appointments and paid medical bills. It further argued that Tennessee
Compilation Rules and Regulations, Chapter 0800-02-06, Rules of Utilization Review,
allowed utilization review of the recommended procedures.

Ametek further asserted that it timely and properly submitted the requested
treatment to UR. Eric Gentry, the adjuster, stated he received Dr. Cates’ order for the CT
scan on April 11 and submitted a request for UR to determine the medical necessity on
April 12. Mr. Gentry received the request for surgery authorization on April 16, and he
contacted Dr. Cates’ office on the same day to request that the office forward all
supporting documents to UR. On April 17, Dr. Cates’ office sent records to UR, and Mr.
Gentry sent another request that UR determine the medical necessity of Dr. Cates’ orders.
The UR agent notified Mr. Gentry, Ms. Eaves’ counsel, and Ametek’s counsel on April
20 that the CT scan was not medically necessary. Following Ms. Eaves’ appeal to the
Medical Director and the overturn of the UR denial, Ametek contacted Dr. Cates’ office
to authorize the recommended treatment and to instruct his office to proceed with
scheduling. It asserted it cooperated with the scheduling of all medical appointments,
paid all submitted medical bills, and authorized all recommended treatment once UR
determined the treatment was medically necessary.
Petition for Payment of Medical Expenses

Ms. Eaves asked the Court to order Ametek to reimburse her and her health
insurance carriers for all medical expenses incurred relative to her work-related injury,
which was the subject of the prior Expedited Hearing. She received a lien from her
health insurance provider, listing billed charges of $26,847.69 and paid amounts of
$6,919.92. Ms. Eaves submitted itemized medical expenses and bills totaling
$27,785.80, including out-of-pocket expenses.

Ametek countered that these expenses were incurred before the Expedited
Hearing, and this Court has not made a final decision on compensability or its liability for
these expenses. It argued that unless this judgment is made or settlement occurs, the
expenses remain disputed. It also contended the medical bills are hearsay and lack
probative value to show whether the expenses are reasonable, necessary and/or related to
the work injury.

Ms. Eaves noted Ametek did not specifically object to any of the submitted
expenses. However, she alternatively requested an order directing Ametek to repay all
reasonable and necessary medical expenses incurred from the date of injury to the present
and directing counsel to confer to determine the appropriate amount.

Findings of Fact and Conclusions of Law

Ms. Eaves need not prove every element of her claim by a preponderance of the
evidence in order to obtain relief. McCord v. Advantage Human Resourcing, 2015 TN
Wrk. Comp. App. Bd. LEXIS 6, at *7-8, 9 (Mar. 27, 2015). Instead, she must come
forward with sufficient evidence from which this Court might determine she is likely to
prevail at a hearing on the merits. /d.; Tenn. Code Ann. § 50-6-239(d)(1).

Motion for Contempt

The Workers’ Compensation Law provides that the employer shall furnish, free of
charge to the employee, medical treatment made reasonably necessary by the work
injury. See Tenn. Code Ann. § 50-6-204 (a)(1)(A). To be entitled to treatment, the
employee must show, to a reasonable degree of medical certainty, that the employment
contributed more than fifty percent in causing the need for treatment, considering all
causes. See Tenn. Code Ann. § 50-6-102(14)(C). Shown to a reasonable degree of
medical certainty means that, in the opinion of the treating physician, it is more likely
than not considering all causes. Tenn. Code Ann. § 50-6-102(14)(D). Further, treatment
recommended by the authorized treating physician is presumed medically necessary. See
Tenn. Code Ann. § 50-6-204(a)(3)(H); see also Morgan v. Macy’s, 2016 TN Wrk. Comp.
App. Bd. LEXIS 39, at *17 (Aug. 31, 2016).
Here, Dr. Cates is the authorized treating physician under the Expedited Hearing
Order. Therefore, his recommended treatment is presumed medically necessary.
However, Ametek is entitled to seek utilization review. See generally Tenn. Comp. R. &
Regs. 0800-02-06.

Regulation 0800-02-06-.06(1) states an employer must submit a case for
utilization review within three business days of notification of the recommended
treatment. Mr. Gentry stated he submitted Dr. Cates’ orders for the CT scan and knee
replacement surgery within one day of receipt of the Order. Mr. Gentry further stated he
requested Dr. Cates’ office submit all supporting documents directly to the UR agent,
which it did.

The Court finds that it ordered Ametek to provide Ms. Eaves with medical
treatment under Tennessee Code Annotated section 50-6-204, which permits Ametek to
seek utilization review of recommended treatment. The Court further finds Ametek did
so within three days of notice of the recommendations. Following completion of UR and
Ms. Eaves’ appeal to the Medical Director, Ametek authorized Dr. Cates’ office to
schedule the recommended procedures within the timeframe under the Bureau’s
regulations. For these reasons, the Court holds Ms. Eaves failed to come forward with
sufficient evidence demonstrating that Ametek is in contempt of the Expedited Hearing
Order.

Petition for Payment of Medical Expenses

As noted above, an employer is legally obligated to provide an injured employee
with reasonable and necessary medical treatment that is causally-related to the work
accident. In circumstances where an employer refuses to provide medical treatment
and/or denies the claim, the employer bears the risk of being held responsible for medical
expenses if the claim is deemed compensable. See McCord, 2015 TN Wrk. Comp. App.
Bd. LEXIS 6, at *13, (“[A]n employer who elects to deny a claim runs the risk that it will
be held responsible for medical benefits obtained from a medical provider of the
employee's choice[.]|”).

In this case, the Court previously held in the Expedited Hearing Order that Ms.
Eaves demonstrated she is likely to prevail at a hearing on the merits that her injuries
arose primarily out of and in the course and scope of her employment with Ametek. The
Court also found that she was reasonable in seeking medical treatment on her own once
Ametek denied her claim. In the pending petition, Ms. Eaves introduced itemized
medical bills paid by her private health insurance and receipts documenting her out-of-
pocket expenses. Ametek objected on grounds of hearsay and argued the medical bills
lack probative value to show whether the expenses are reasonable, necessary and/or
related to the work injury. The Court overrules Ametek’s objections, grants her petition,
and concludes Ms. Eaves came forward with sufficient evidence demonstrating that she is

5
entitled to reimbursement of her medical expenses incurred relative to the work-related

injury.

IT IS, THEREFORE, ORDERED as follows:

1.

Ds,

Ms. Eaves’ Motion for Contempt is denied at this time.

Ms. Eaves’ Petition for Payment of Past Medical Benefits is granted. Ametek
shall repay all reasonable and necessary medical expenses that Ms. Eaves’ private
health insurer paid and shall reimburse Ms. Eaves for her out-of-pocket expenses
required for treatment of the work injury.

This matter is set for a Status Conference on August 27, 2018, at 2:00 p.m.
Eastern Time. The parties must call (865) 594-0091 or (toll-free) (855) 543-5041
to participate in the Scheduling Hearing. Failure to appear by telephone may
result in a determination of the issues without your further participation.

Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance
with this Order must occur no later than seven business days from the date of entry
of this Order as required by Tennessee Code Annotated section 50-6-239(d)(3)
(2017). The Insurer or Self-Insured Employer must submit confirmation of
compliance with this Order to the Bureau by email to
WCCompliance.Program@tn.gov no later than the seventh business day after
entry of this Order. Failure to submit the necessary confirmation within the period
of compliance may result in a penalty assessment for non-compliance.

For questions regarding compliance, please contact the Workers’ Compensation
Compliance Unit by email at WCCompliance.Program@tn.gov.

GON eS D ASLe Sh)

ENTERED June 21, 2017.

 

 

PAMELA B. JOHNSON, JUDGE
Court of Workers’ Compensation Claims
APPENDIX

The Court reviewed the entire case file in reaching its decision. Specifically, the
Court reviewed the following documents, marked as exhibits for ease of reference:

Exhibits:
1. Petition for Benefit Determination
Dispute Certification Notice
Expedited Hearing Order Granting Benefits
Motion for Contempt
Fee Petition
Petition for Payment of Medical Expenses Incurred to Date
Response in Opposition to Motion for Contempt
Motion for Second Opinion or Independent Medical Evaluation (IME)
9. Response to Motion for Second Opinion or IME
10. Order Denying Motion for Second Opinion or IME
11. Docketing Notice for On-The-Record Determination
12. Motion for Additional Time
13. Agreed Order Granting Additional Time
14. Employer’s Position Statement and Objections
15.Employee’s Reply to Employer’s Position Statement and Objections.

Sea 2

CERTIFICATE OF SERVICE

 

I hereby certify that a true and correct copy of the Expedited Hearing Order was
sent to the following recipients by the following methods of service on June 21, 2017.

 

 

 

 

 

 

 

 

Name Certified | Fax | Email | Service sent to:
oe Mail
Joshua J. Bond, X | jbond@hdclaw.com
Employee’s Attorney
Lynn C. Peterson, x lpeterson@lewisthomason.com
Employer’s Attorney

 

 

 

PENNY SHRUM, Court Clerk OS
WC.CourtClerk@tn.gov
