Opinion
W.C. No. 4-631-793.
July 17, 2007.
FINAL ORDER
The claimant seeks review of an order of Administrative Law Judge Cain (ALJ) dated March 22, 2007, that determined the claimant was at maximum medical improvement (MMI) and denied the claimant's request that the respondents be ordered to provide Synvisc treatments to assist her in attaining MMI. We affirm.
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. The claimant requested a Division-sponsored independent medical examination (DIME) and 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. However, the DIME physician was later shown medical records relating to an early right knee injury the claimant suffered on December 16, 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.
We previously remanded this matter in our order of October 20, 2006 for a factual determination to be made as to whether the torn meniscus was causally connected to the admitted injury. This involved the issue of 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.
On remand, the ALJ made the following findings. The DIME physician expressed conflicting opinions, as reflected in his written report and his deposition testimony, concerning whether or not the torn meniscus was caused by the January 3, 2004 industrial injury. The ALJ found that the DIME physician's opinion was that the torn meniscus could not be causally linked to the January 3, 2004, industrial injury with greater than 50 percent probability. The ALJ found that it is the DIME physician's opinion that it is as likely as not that the torn meniscus was caused by the December 16, 2003, injury as by the injury of January 3, 2004. The DIME physician testified that the claimant needs the Snyvisc injections to treat the effects of the surgery for the torn meniscus, but he also determined that the cause of the torn meniscus could not be causally linked to the industrial injury of January 3, 2004, with greater than 50 percent probability. It was the DIME physician's opinion that the claimant was at MMI for all conditions that were causally related to the industrial injury of January 3, 2004. The ALJ concluded that the claimant failed to prove it is highly probable and free from serious doubt that the DIME physician erred in finding that the torn meniscus was not causally related to the industrial injury because it is just as likely that the torn meniscus was caused by an injury other than the one that occurred on January 3, 2004. Therefore, the ALJ found the claimant was at MMI for the industrial injury of January 2, 2004 and denied the claimant's request that the respondents be ordered to provide Snyvisc treatments to assist her in attaining MMI.
On review it does not appear that the claimant challenges the factual conclusion that the torn meniscus was not shown to be causally related to the industrial injury. In any event there is ample evidence supporting this factual conclusion including the opinion of the Dime physician and the opinion of Dr. Arnold. Instead the claimant contends that the claim was admitted and the surgery paid for by the respondents and, further, that the need for the Synvisc injections was a result of the surgery. Thus, the claimant asserts that the respondents should be precluded from denying responsibility to the claimant because the DIME physician can no longer state the injury caused the need for the surgery. We disagree.
The claimant admits that the surgeon did nothing wrong, but nevertheless, the surgery itself set up the need for further treatment. The respondents did not expose the claimant to malpractice nor does the claimant contend that the she was not in need of the surgery. There is no reason to believe that the surgery would not have been undertaken but for the compensable injury. Here, the respondents paid for recommended surgery that was later discovered not to be related to the industrial accident, but rather, related to a prior injury. The ALJ found that the causal connection between the injury and the surgery had been broken. In the present case neither the industrial accident nor the payment of medical bills by the insurer created the need for the surgery and the subsequent need for the Snyvisc treatments.
While the claimant appears to be still in need of treatment following the surgery, as we noted in our previous order on this claim, 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). 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. 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).
Here, the claimant argues 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. The ALJ with record support has found that the torn meniscus cannot be linked to the industrial injury with greater than 50 percent probability and therefore the proposed Synvisc treatment cannot be causally connected to the industrial injury.
IT IS THEREFORE ORDERED that the ALJ's order dated March 22, 2007, is affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
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John D. Baird
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Thomas Schrant
Terri Sanchez, 1601 San Juan Circle, Evans, CO, Regina M. Walsh Adams, Esq., Greeley, CO, (For Claimant).
Family Dollar Stores, FDS of Colorado, Evans, CO, Margaret Keck, Esq., Greenwood Village, CO, (For Respondents).
St. Paul Travelers, Troy Arrington, Dallas, TX.