Opinion
W.C. No. 4-631-793.
October 20, 2006.
ORDER OF REMAND
The respondents seek review of an order of Administrative Law Judge Cain (ALJ) dated April 6, 2006, that determined the respondents failed to overcome the Division-sponsored independent medical examination (DIME) physician's opinion that the claimant is not at MMI. We set the order aside and remand this matter for entry of a new order.
The pertinent facts appear to be essentially undisputed. The claimant sustained an admitted injury to her right knee when she fell down at work on January 3, 2004. An MRI revealed a torn medial meniscus and chondromalacia. Dr. Sanderford performed surgery on the claimant's right knee and the claimant did poorly following the surgery. Dr. Sanderford recommended the claimant consider Synvisc injections and Dr. Smith, a treating physician, opined a Synvisc injection would help. Dr. Smith referred the claimant to Dr. Anderson for a second opinion. Dr. Sanderford concurred in the recommendation for Synvisc injections. On February 11, 2005, Dr. Smith placed the claimant at maximum medical improvement (MMI).
The claimant requested a DIME and the DIME physician, Dr. Lindberg, stated it was reasonable to assume the claimant tore the meniscus in the admitted injury and that the surgery that was done secondary to her injury would hasten the deterioration of her knee joint. The DIME physician further opined that the claimant was not at MMI because removal of the meniscal cartilage was going to make her knee progressively deteriorate and require a trial of Synvisc injections. Following the DIME report the parties took the DIME physician's deposition and the physician was shown medical documentation indicating the claimant suffered a previous right knee injury or injuries in December 2003. The DIME physician testified he could not state to a reasonable degree of medical probability whether the injuries of December 2003 or the admitted injury caused the meniscal tear.
Dr. Arnold performed an independent medical examination for the respondents and testified he could not determine whether the claimant tore the meniscus in December 2003 or in the January 3, 2004 admitted industrial accident. Dr. Arnold stated that partial removal of the meniscus in the surgery would accelerate the preexisting arthritis of the knee. Dr. Arnold opined that the main reason for the degenerative arthritis in the claimant's knee was an injury that the claimant sustained in 2000, and that the surgery only contributed five to eight percent to the total degeneration.
The ALJ made the following findings regarding the opinions of the DIME physician. The DIME physician's opinion was that the cause of the torn meniscus cannot be determined as between the events in December 2003 and the admitted industrial injury of January 3, 2004. However, the DIME physician also expressed the opinion that the surgery performed to remove the meniscus aggravated the claimant's preexisting arthritis so as to cause the need for the Synvisc treatments. The DIME physician opined that the claimant was not at MMI because Synvisc treatment had a reasonable prospect of alleviating the claimant's ongoing pain and delaying the need for a knee replacement surgery.
The ALJ concluded that the DIME physician's factual determination that the surgery caused an aggravation of the preexisting arthritis compelled, as a matter of law, the conclusion that effects of the surgery were a compensable consequence of the admitted injury of January 3, 2004. The ALJ further determined that this was true regardless of the DIME physician's determination that the torn meniscus cannot be causally connected to the January 3, 2004 admitted injury.
The ALJ reasoned that under the "quasi-course of employment" doctrine the respondents admitted liability for the January 3, 2004, injury, and authorized the surgery as a form of medical treatment for the admitted injury. Consequently, the aggravation of the claimant's preexisting arthritis that developed as a result of the surgery occurred in the quasi-course of employment. The ALJ determined that it follows that because the need for Synvisc treatments is related to the claimant's arthritis the DIME physician's opinion supports a finding that the industrial injury has, albeit indirectly, caused a need for additional treatment, and that the respondents have not overcome the DIME physician's finding on the pertinent causation issue by clear and convincing evidence. The ALJ therefore found that the respondents had failed to overcome the DIME physician's opinion that the claimant was not at MMI.
The respondents contend that the DIME physician's inability to attribute the claimant's surgery and the resultant aggravation of her arthritic condition to her admitted injury is binding and thus it is established that the claimant's surgery was not part of her compensable injury. They therefore assert that the claimant is at MMI.
In our opinion, the DIME physician's factual determination that the surgery caused an aggravation of the preexisting arthritis does not compel the conclusion that the effects of the surgery are a compensable consequence of the admitted injury of January 3, 2004. Nor is that determination dispositive of whether the respondents overcame the DIME physician's determination concerning MMI. The ALJ found that the DIME physician determined that the surgery for the torn meniscus accelerated the claimant's preexisting arthritis. Findings of Fact, Conclusions of Law, and Order at 5. The ALJ determined that the potentially binding opinion of the DIME physician was the specific opinion that the authorized surgery aggravated the arthritis so as to cause the need for the Synvisc treatments. In our view it is the opinion of the DIME physician that the claimant was not at maximum medical improvement, from the results of the admitted injury, which the respondents are obligated to overcome. Section 8-40-210 (11.5), C.R.S. 2006.
As we read the ALJ's order, he concluded that because the surgery was "authorized", no further factual inquiry was warranted concerning the respondents' liability for its consequences. Hence, the ALJ reasoned that by "authorizing" the surgery the respondents were therefore liable for any treatment that followed, without regard to the respondents' right to later challenge relatedness. We do no believe this is a correct statement of the law.
Our courts have held that regardless of the filing of an admission for medical benefits or an order containing a general award of medical benefits, insurers retain the right to dispute whether the need for medical treatment was caused by the compensable injury. See Hanna v. Print Expediters, Inc., 77 P.3d 863 (Colo.App. 2003) (concerning Grover medical benefits; Snyder v. Industrial Claim Appeals Office, 942 P.2d 1337 (Colo.App. 1997) (concerning an admission for medical benefits); Williams v. Industrial Commission, 723 P.2d 749 (Colo.App. 1986). This principle recognizes that even though an admission is filed the claimant bears the burden of proof to establish the right to specific medical benefits, and the mere admission that an injury occurred and treatment is needed cannot be construed as a concession that all conditions and treatments which occur after the injury were caused by the injury. Cf. HLJ Management Group, Inc. v. Kim, 804 P.2d 250 (Colo.App. 1990) (filing of admission does not vitiate respondents right to litigate disputed issues on a prospective basis).
In Snyder v. Industrial Claim Appeals Office, supra, the court concluded that "in a dispute over medical benefits that arises after the filing of a general admission of liability, an employer can assert, based on subsequent medical reports, that the claimant did not establish the threshold requirement of a direct causal relationship between the on-the-job injury and the need for medical treatment." Snyder, 942 P.2d at 1339. Here, we understand the ALJ to have found that when the respondents admitted liability for the January 3, 2004, injury and provided the surgery as a form of medical treatment for the admitted injury, they became liable for the aggravation of the claimant's preexisting arthritis that subsequently developed, regardless of whether the need for the surgery can be causally connected to the admitted injury. We are not persuaded that the quasi-course of employment doctrine compels this conclusion.
While the surgery in the present case was authorized, in our opinion the respondents retain the right to dispute liability for specific medical treatment on grounds of whether there exists a direct causal relationship between the on-the-job injury and the need for the medical treatment See Snyder v. Industrial Claim Appeals Office, supra. Whether the respondent's sustained their burden of proof is a factual question for resolution by the ALJ. City of Durango v. Dunagan, 939 P.2d 496 (Colo.App. 1997). We do not believe that the quasi-course of employment doctrine compels the conclusion in this case that the effects of the surgery are a compensable consequence of the admitted injury of January 3, 2004, regardless of the whether the torn meniscus can be causally connected to the admitted injury.
As noted by the ALJ in his order the DIME physician's findings concerning the cause of the medical condition and the need for specific treatment of the condition are inherent elements of determining maximum medical improvement. We conclude that in order to determine whether the respondents carried their burden of overcoming the opinion of the DIME physician that the claimant was not at maximum medical improvement, a factual determination must be made as to whether the torn meniscus was causally connected to the admitted injury. The factual determination shall include a finding on whether based on subsequent medical reports the respondents overcame the DIME physician's opinion on relatedness by successfully severing the direct causal relationship between the on-the-job injury and the need for the Synvisc injections. We therefore set the order aside and remand the matter for additional findings.
IT IS THEREFORE ORDERED that the ALJ's order dated April 6, 2006, is set aside, and the matter is remanded for further proceedings and entry of a new order consistent with the views expressed herein.
INDUSTRIAL CLAIM APPEALS PANEL
___________________________________ John D. Baird
___________________________________ Thomas Schrant
Teri Sanchez, Evans, CO, Family Dollar Stores, Inc., c/o FDS OF Colorado, Evans, CO, St. Pauls Travelers, Troy Arrington, Dallas, TX, Thomas, Pollart, Miller Wetmore, LLC, Margaret Keck, Esq., Greenwood Village, CO, (For Respondents).
Regina M. Walsh Adams, Esq., Greeley, CO, (For Claimant).