                   IN THE COURT OF APPEALS OF IOWA

                                   No. 17-1525
                            Filed September 12, 2018


CHRISTINE KEERAN,
     Plaintiff-Appellant,

vs.

QUAKER OATS COMPANY, INDEMNITY INSURANCE COMPANY OF NORTH
AMERICA and SECOND INJURY FUND OF IOWA,
     Defendants-Appellees.
________________________________________________________________


      Appeal from the Iowa District Court for Polk County, Lawrence P. McClellan,

Judge.



      Claimant seeks appellate review of an order affirming final agency action.

AFFIRMED.



      Robert R. Rush and Christoph P. Rupprecht of Rush & Nicholson, PLC,

Cedar Rapids, for appellant.

      Kent M. Smith of Scheldrup Blades Schrock Smith, PC, West Des Moines,

for appellees Quaker Oats Company and Indemnity Insurance Company of North

America.

      Thomas J. Miller, Attorney General, and Amanda R. Rutherford, Assistant

Attorney General, for appellee Second Injury Fund of Iowa.



      Considered by Potterfield, P.J., and Bower and McDonald, JJ.
                                         2


MCDONALD, Judge.

      Christine Keeran challenges the workers’ compensation commissioner’s

denial of her claim for workers’ compensation benefits. The agency record shows

Keeran sought workers’ compensation benefits for cumulative injuries to her knees

allegedly sustained during the course of her employment with Quaker Oats. The

deputy commissioner found Keeran failed to prove her knee injuries arose out of

and in the course of her employment with Quaker Oats and denied her claim for

benefits. Because the deputy commissioner found Keeran failed to meet her

burden of proof on the issues of causation and compensability, the deputy

commissioner concluded the remaining issues presented were moot. Keeran

sought intra-agency review of the deputy’s decision. The commissioner affirmed

the deputy’s decision in its entirety and adopted as final the relevant portions of

the deputy’s decision. The district court affirmed the commissioner’s denial of

Keeran’s claim. Keeran timely filed this appeal.

                                         I.

      Our review is governed by the Iowa Administrative Procedure Act, Iowa

Code chapter 17A. See Lakeside Casino v. Blue, 743 N.W.2d 169, 172 (Iowa

2007). The standard of review differs depending on the error alleged.          See

Jacobson Transp. Co. v. Harris, 778 N.W.2d 192, 196 (Iowa 2010).            Factual

challenges are reviewed for substantial evidence. See id. “Evidence is substantial

if a reasonable mind would find it adequate to reach a conclusion.” Quaker Oats

Co. v. Ciha, 552 N.W.2d 143, 150 (Iowa 1996). “If the error is one of interpretation

of law, we will determine whether the commissioner’s interpretation is erroneous
                                         3

and substitute our judgment for that of the commissioner.” Jacobson Transp. Co.,

778 N.W.2d at 196.

                                         II.

       In her first claim of error, Keeran contends the agency applied the wrong

legal standard to determine whether Keeran’s injury and disability arose out of her

employment with Quaker Oats. “When the agency exercises its discretion based

on an erroneous interpretation of the law, we are not bound by those ‘legal

conclusions but may correct misapplications of the law.’” Meyer v. IBP, Inc., 710

N.W.2d 213, 219 (Iowa 2006) (quoting Stroup v. Reno, 530 N.W.2d 441, 443 (Iowa

1995)).

       “Our workers’ compensation statute provides coverage for ‘all personal

injuries sustained by an employee arising out of and in the course of the

employment.’” Id. at 220 (Iowa 2006) (quoting Iowa Code § 85.3(1) (2001)). “This

statutory coverage formula gives rise to four basic requirements: (1) the claimant

suffered a personal injury, (2) the claimant and the respondent had an employer-

employee relationship, (3) the injury arose out of the employment, and (4) the injury

arose in the course of the employment.” Id. “The failure of any one requirement

results in a denial of a claim for benefits.” Id. To prove an injury arose out of

employment, the claimant must establish a “causal connection exists between the

employment and the injury.” Id. at 222. In addition to showing a causal connection

between her employment and the injury, the claimant must prove her work-related

injury is the proximate cause of her disability. See Ayers v. D & N Fence Co., 731

N.W.2d 11, 17 (Iowa 2007). “In order for a cause to be proximate, it must be a

substantial factor.” Id. (citation omitted). If the alleged injury resulted from the
                                          4


worsening, aggravation, or acceleration of a preexisting condition or injury, a

claimant may recover so long as she can show a causal connection between the

working conditions and her injury. See Musselman v. Cent. Tel. Co., 154 N.W.2d

128, 132 (Iowa 1967). “In other words, the injury must not have coincidentally

occurred while at work, but must in some way be caused by or related to the

working environment or the conditions of [her] employment.” Miedema v. Dial

Corp., 551 N.W.2d 309, 311 (Iowa 1996).

       We conclude the agency applied the correct legal standard to the question

of causation. Here, the agency stated Keeran needed only to “show that those

natural degenerative processes were accelerated, speeded up or aggravated by

her work activities.” This is a correct statement of the law. See Musselman, 154

N.W.2d at 132.     In addition, the agency also stated Keeran was required to

establish any injury was a proximate cause of her resulting disability. See Ayers,

731 N.W.2d at 17. This too was a correct statement of the law. We find no error

in the agency’s statement of the relevant legal principles.

                                         III.

       In her second claim of error, Keeran contends the agency’s findings

regarding medical causation were not supported by substantial evidence.

       The record reflects the following. Keeran worked for Quaker Oats for thirty-

nine years. She held various hourly positions during her employment, including:

sweeper, packer, baghandler, machine tender, and package line operator. These

positions required manual labor and repeated physical activity, including crawling,

squatting, lifting and pulling heavy items, climbing ladders, kneeling, and standing.
                                          5


      Over the course of her employment, Keeran experienced pain in both of her

knees. Keeran first met with Dr. Hugh MacMenamin in 2004. At that time, she

indicated she had experienced knee pain for several years. Dr. MacMenamin

diagnosed Keeran with arthrosis—a degenerative joint condition—in both knees.

      She sought treatment again in 2009 when her primary-care physician

referred her to Dr. Fred Pilcher. Dr. Pilcher noted Keeran did not suffer from a

specific knee injury but recommended corrective surgery to treat her pain. Keeran

did not undergo corrective surgery at that time. Keeran returned to Dr. Pilcher in

mid-2010. Dr. Pilcher diagnosed Keeran with degenerative meniscus disease and

degenerative arthritis in her left knee and meniscus tears and loose body in her

right knee. In August of the same year, Dr. Pilcher removed Keeran from work

due to her advanced knee pain although he did not attribute her knee condition to

Keeran’s work conditions.      Later the same month, Dr. Pilcher performed

arthroscopic surgery on Keeran’s knees and removed a loose body from her right

knee. Keeran returned to work in November without any restrictions. However,

she continued to experience pain.

      Keeran visited another physician, Dr. David Tearse, in September 2011.

Dr. Tearse suspected Keeran’s symptoms would not improve with additional

surgery and recommended pool therapy instead.          Keeran again visited her

primary-care doctor in November and complained of her ongoing pain. The doctor

referred Keeran to University of Iowa Hospitals and Clinics, Department of

Orthopedics (UIHC) for another opinion.

      Keeran treated with Dr. John Callaghan at UIHC in April 2012.           Dr.

Callaghan noted Keeran reported knee pain for the past three years.           Dr.
                                         6


Callaghan recommended knee-replacement surgery.            In May, Keeran visited

rheumatologist, Dr. Michael Brooks, who recommended knee-replacement

surgery and noted:

       She would certainly improve in terms of knee symptoms were she to
       quit her present work and I would expect it if she gets [knee
       replacements] that they would last longer if she were not stressing
       them at her present type of work. I would encourage her to avoid
       overuse of the knees in terms of climbing, squatting, kneeling or even
       walking and standing more than she needs to for everyday function.

       In June 2012, Dr. Sandeep Munjal began treating Keeran’s knee pain, and

Keeran agreed to a left knee replacement.        Keeran’s last day of work was

September 25, 2012.         She underwent knee-replacement surgery without

complications in October.     However, she received limited improvement and

underwent two rounds of surgical manipulation of her left knee. Keeran’s range of

motion remained limited, and, in June 2013, Dr. Munjal recommended physical

therapy and advised against “ladders or lifting heavy weights.”

       In October 2013, Keeran underwent an independent medical exam (IME)

with Dr. Stanley Mathew. When presented with the question, “Has Christine

sustained a cumulative injury to her knees arising out of and in the course of her

physically demanding work at Quaker Oats over 39 years?”               Dr. Mathew

concluded, “I do believe Christine had sustained a cumulative injury to her knees

arising out of course of physically demanding work at Quaker Oats for over 30

years.” Keeran shared Dr. Mathew’s IME report, as well as job descriptions from

Quaker Oats, with Dr. Munjal. Dr. Munjal signed a letter confirming he considered

the physical demands of Keeran’s work to be a contributing factor to her knee

injuries.
                                           7


       In June of 2014, Keeran underwent a second IME, at Quaker Oats’ request,

with Dr. Thomas Gorsche. Dr. Gorsche concluded, “while it is possible that work

duties of going up and down ladders continuously could aggravate and contribute

to developing arthritis, I believe in this situation it would be a minor contribution at

best.” He went on to state:

       In my opinion, since there is no specific injury that brought on her
       symptoms that they are more than likely related to her systematic
       risk factors such as her age, gender, ethnicity, genetic factors, and
       possibly dietary factors. It is medically possible that physical activity
       at work could have played a role in this, but in my medical opinion,
       that is unlikely. If it did play a role, in my opinion, it would be very
       minor.

       Our resolution of Keeran’s claim is controlled by the standard of review.

“Medical causation ‘is essentially within the domain of expert testimony.’” Cedar

Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa 2011) (citation

omitted). “Medical causation presents a question of fact that is vested in the

discretion of the workers’ compensation commission.”               Id. at 844.     The

commissioner’s findings may only be disturbed if they are not supported by

substantial evidence. Id. at 845.

       Here, the agency credited Dr. Gorsche’s medical opinion over the other

medical opinions. The commissioner concluded Dr. Gorsche presented the most

thorough opinion accounting for all of the medical evidence presented. Although

this court does “not simply rubber stamp the agency finding of fact,” this court also

does not declare evidence insubstantial “because different conclusions may be

drawn from the evidence.” See id. We will not reverse an agency decision where

“the evidence supports a different finding than the finding made by the

commissioner, but . . . the evidence [also] ‘supports the findings actually made.’”
                                        8

Meyer, 710 N.W.2d at 218 (quoting St. Luke’s Hosp. v. Gray, 604 N.W.2d 646, 649

(Iowa 2000)). Here, the evidence supports the findings actually made. The agency

did not commit reversible error.

                                        IV.

      The agency applied the correct law, and its findings of fact are supported

by substantial evidence. We affirm the judgment of the district court.

      AFFIRMED.
