Case Title: In re Armstrong

Citation: 

Docket Number: 

State: wyoming

Court: Wyoming Supreme Court

Date: 1999-11-30T00:00:00Z

Document:
In re Armstrong1999 WY 155991 P.2d 140Case Number: 99-100Decided: 11/30/1999Supreme Court of Wyoming
 
IN 
THE MATTER OF THE WORKER'S COMPENSATION CLAIM OF BRIAN J. ARMSTRONG, AN EMPLOYEE 
OF UNITED BLOOD SERVICES:

BRIAN J. ARMSTRONG, 
Appellant (Petitioner/Claimant),

v.

STATE OF WYOMING, ex 
rel., WYOMING WORKERS' SAFETY AND COMPENSATION DIVISION, Appellee 
(Respondent).

 

W.R.A.P. 12.09(b) 
Certification from the District Court of Laramie County, The Honorable Edward L. 
Grant, Judge.

Bill G. Hibbler, 
Cheyenne, WY, representing appellant.

Gay Woodhouse, 
Attorney General; John W. Renneisen, Deputy Attorney General; Gerald W. Laska, 
Senior Assistant Attorney General; and Bernard P. Haggerty, Senior Assistant 
Attorney General, representing appellee.

Before 
LEHMAN, C.J., and THOMAS, MACY, GOLDEN, and HILL, JJ.

HILL, 
Justice.

[¶1]      A contested case 
hearing was held to review the Wyoming Workers' Safety and Compensation 
Division's denial of Appellant Brian Armstrong's request for payment of certain 
medical benefits. The hearing examiner determined that Appellant failed to 
establish a causative connection between his claims and a work injury and, 
rather, that his medical treatment was due to a pre-existing condition. We 
affirm.

ISSUES

[¶2]      Appellant 
presents the following issues for review:

 

I. Whether the 
actions and final determinations of Appellee, Workers' Compensation Division, 
denying medical benefits to Appellant, Brian J. Armstrong, are arbitrary, 
capricious or an abuse of discretion[.] 

II. Whether the 
actions and final determinations of Appellee, Workers' Compensation Division, 
denying medical benefits to Appellant, Brian J. Armstrong, are contrary to 
law[.]

III. Should the 
Division be estopped from denying payment of Mr. Armstrong's medical bills 
incurred after his compensable injury?

Appellee (the 
Division) provides a single issue:

A. Was the 
Hearing Examiner's decision within her discretion and in accordance with 
law?

FACTS

[¶3]      On December 27, 
1997, Appellant saw Dr. Giltner at Health Reach for an existing problem with 
back pain. As a result of that visit, Appellant received a prescription for 
Percocet to relieve the pain. Several days later, on December 31, 1997, 
Appellant fell, injuring his ankle and back, when leaving a restaurant during 
his lunch hour while employed at United Blood Services. He then timely filed a 
report of the injury with the Division. On January 8, 1998, the Division issued 
an Initial Review: Notice of Lack of Information, which Appellant claims he 
never received. However, Appellant did receive the Division's Final 
Determination letter dated February 3, 1998, which stated, "[b]ased on the 
Division's investigation, the injury is covered by the Wyoming Workers' 
Compensation Act and claims for medical or disability benefits will be reviewed 
and paid if compensable." Neither Appellant nor his employer filed an appeal in 
response to the final determination.

[¶4]      Fourteen days 
later, on February 17, 1998, the Division issued another Initial Review: Notice 
of Lack of Information seeking information regarding the possibility of a 
pre-existing condition. On February 18, 1998, before receiving the latest notice 
from the Division, Appellant was admitted to Poudre Valley Hospital and 
underwent emergency back surgery the next day. Just prior to surgery, Appellant 
informed his surgeon, Dr. Turner, that payment for the surgery would be made by 
the Division. Dr. Turner had his nurse telephone the Division to verify this 
statement. She was told that Appellant had an open and active case for lumbar 
injury.

[¶5]      On May 5, 1998, 
the Division requested its physician, Dr. Kline, to review the medical 
information which had been submitted. Dr. Kline recommended "[o]n back: pay for 
the initial examination [plus] 10 days for re-exam etc. No more." As Appellant 
sent his claims to the Division, his claim analyst, Beverly Johnson, determined 
whether to pay or deny individual charges. The denial of payment was based upon 
the Division's belief that Appellant was presenting bills for the treatment of a 
pre-existing condition. By June 16, 1998, Appellant had incurred approximately 
$19,000.00 in medical bills for which the Division denied 
payment.

[¶6]      At Appellant's 
request, a contested case hearing was held on October 26, 1998, and the hearing 
examiner issued an Order Denying Benefits on November 5, 1998. An appeal was 
timely filed in the district court, where the matter was certified to this Court 
pursuant to W.R.A.P. 12.09.

STANDARD OF 
REVIEW

[¶7]      When an 
administrative decision is certified to this Court pursuant to W.R.A.P. 12.09, 
we review the decision under the standards applicable to a reviewing court of 
first instance. Sheridan rRace Car Association v. Rice Ranch, 864 P.2d 30, 32 
(Wyo. 1993). W.R.A.P. 12.09 requires review of an agency action in accordance 
with Wyo. Stat. Ann. § 16-3-114(c) (LEXIS 1999), which provides in relevant 
part:

(c) . . . The 
reviewing court shall:

(ii) Hold 
unlawful and set aside agency action, findings and conclusions found to 
be:

(A) Arbitrary, 
capricious, an abuse of discretion or otherwise not in accordance with 
law[.]

Agency action is 
arbitrary and capricious if it is "willful and unreasonable, without 
consideration and in disregard of the facts and circumstances." Corman v. State, 
ex rel. Wyoming Workers' Compensation Division, 909 P.2d 966, 971 (Wyo. 1996). 
In evaluating whether an agency acted arbitrarily or capriciously, we examine 
the record to determine the agency's consideration of relevant factors and 
whether the decision is rational. Id. An agency's conclusions of law will be 
affirmed only if they are in accordance with law. Mitchell v. State, ex rel. 
Wyoming Workers' Compensation Division, 968 P.2d 37, 40 (Wyo. 1998). When the 
determination to be reviewed presents a mixed question of fact and law, such as 
when a conclusion is reached through the application of legal precepts to the 
factual events of a particular case, the reviewing court will defer to the 
findings of fact, but will correct misapplications of the law to those facts. 
Aanenson v. State, ex rel. Wyoming Workers' Compensation Division, 842 P.2d 1077, 1079-80 (Wyo. 1992).

DISCUSSION

[¶8]      Contrary to the 
order in which it is presented, Appellant's argument necessarily begins with his 
second and third issues: whether the Division should be estopped from denying 
payment of Appellant's medical bills incurred after December 31, 1997, the date 
of his fall. Appellant insists that because the Division issued a final decision 
stating that his injury was compensable, the Division could not challenge 
payment for individual medical claims. Appellant fails to recognize the 
distinction between a determination that a claimed injury is compensable and the 
Division's authority to analyze each charge submitted by the claimant to 
determine whether that charge is causally related to the workplace injury. This 
distinction is expressly stated in the Division's final determination issued to 
Appellant: "claims for medical or disability benefits will be reviewed and paid 
if compensable." Appellant was plainly given notice that his medical bills would 
be paid only if they related to treatment for his compensable 
injury.

[¶9]      Wyo. Stat. Ann. § 
27-14-601(b) (LEXIS 1999) states that, "[f]ollowing review of each bill and 
claim for medical and hospital care pursuant to W.S. 27-14-401(b), the division 
may approve or deny payment of all or portions of the entire amount claimed." In 
turn, Wyo. Stat. Ann. § 27-14-401(b) (LEXIS 1999) provides, "[n]o fee for 
medical or hospital care under this section shall be allowed by the division 
without first reviewing the fee for appropriateness and reasonableness in 
accordance with its adopted fee schedules." This is precisely what the Division 
did in this case.

[¶10]   In addition, the statement to Dr. 
Turner's nurse that Appellant had an open file for a lumbar injury is not 
equivalent to a guarantee of payment. Such pre-approval is beyond the authority 
held by the Division. Daiss v. Division of Workers' Safety and Compensation, 965 P.2d 692, 695 (Wyo. 1998). Consequently, the hearing examiner did not err in her 
determination that the Division is not estopped from denying benefits based upon 
its actions in this case, and that the denial of payment is not contrary to 
law.

[¶11]   Finally, Appellant asserts that the 
hearing examiner erred in holding that the payment of some claims, and the 
denial or others, was not arbitrary or capricious. As one example, he points to 
the Division's payment for a prescription on February 20, 1998, and its refusal 
to pay for the same medication four days later. The record, however, presents an 
adequate explanation for the Division's actions. The hearing examiner found 
credibility in the claims analyst's testimony that some bills were paid in error 
because they were never submitted to her. Her case plan, after discovering 
Appellant's lengthy pre-existing lumbar problems, included paying all medical 
bills incurred within ten days of the December 31, 1997, accident. This decision 
was based upon a consultation with the Division's medical review staff. We find 
no abuse of discretion in the hearing examiner's determination that the medical 
bills were not paid in an arbitrary or capricious manner.

CONCLUSION

[¶12]   The recognition that an injury is 
compensable is not a guarantee that every medical bill submitted for treatment 
after the injury will be considered as work-related and promptly paid. There is 
a substantial amount of evidence recounting Appellant's long history of back 
ailments. At the same time, no evidence was presented which established that 
Appellant's medical bills were related to treatment for the injury he sustained 
on December 31, 1997. The Order Denying Benefits is affirmed.