Case Title: Forni v. Pathfinder Mines

Citation: 

Docket Number: 

State: wyoming

Court: Wyoming Supreme Court

Date: 1992-07-22T00:00:00Z

Document:
Forni v. Pathfinder Mines1992 WY 84834 P.2d 688Case Number: 91-206Decided: 07/22/1992Supreme Court of Wyoming
Frederick T. 
FORNI,

 Petitioner 
(Employee-Claimant),

v.

PATHFINDER MINES, 

Respondent 
(Employer-Respondent).

 

Rooney, J., Retired, filed a 
specially concurring opinion.

J. John Sampson, 
Sheridan, for petitioner.

Stephenson D. 
Emery, Williams, Porter, Day & Neville, P.C., Casper, for 
respondent.

Before MACY, C.J., THOMAS, 
URBIGKIT,* and GOLDEN, JJ., and ROONEY, J., Retired.

* Chief Justice at time of 
oral argument.

THOMAS, Justice.

[¶1]      The dispositive 
question presented by this case is whether evidence was presented to the hearing 
examiner sufficient to justify reopening the case of Frederick T. Forni (Forni) 
on the statutory ground of fraud. Beyond that threshold question, the case 
presents an issue with respect to whether a hearing examiner in a worker's 
compensation case can draw a conclusion on the issue of medical causation from 
circumstantial evidence that is contrary to the expert medical opinion, as well 
as the unrebutted testimony of the injured workman. A tertiary substantive issue 
relates to the justification for treatment of diabetes and depression as 
essential prerequisites to surgical procedures on Forni's back. The hearing 
examiner ruled that the evidence justified reopening of the case. He then 
decided that the treatment sought was for non-covered, preexistent injuries. 
With respect to the treatment for diabetes and depression, necessary predicates 
to the back surgery, he decided that the treatment was not covered.

[¶2]      We hold that the 
circumstances demonstrated in this record did not justify a reopening of the 
case on the statutory ground of fraud. We then rule that the hearing examiner 
must follow evidence, as distinguished from inferences that he might draw from 
circumstances, and the evidence in this case does not support his ruling with 
respect to the award for treatment of the back injury. We also make it clear 
that this is a situation in which the ancillary treatment for diabetes and 
depression, necessary as requisites to the ultimate back surgery, is 
compensable. The decision of the hearing examiner is reversed with instructions 
to enter an award in favor of Forni.

[¶3]      Forni, as 
appellant, states the issues of the case in this way:

I. The administrative law 
judge's actions, findings, conclusions and order in denying appellant's claim 
are arbitrary, capricious, and an abuse of discretion, were not supported by the 
evidence, and are contrary to the evidence.

II. The administrative 
law judge's finding that the diabetes treatment required as part of the surgery 
[was not compensable] was arbitrary, capricious, and an abuse of discretion, was 
unsupported by the evidence, and was contrary to the evidence.

Pathfinder Mines 
(Pathfinder), as appellee, rephrases those issues in this way:

I. Whether the 
Administrative Law Judge's finding that Employer carried its burden to reopen 
the award of benefits to Claimant pursuant to W.S. 27-14-605(a) is supported by 
substantial evidence.

II. Whether the 
Administrative Law Judge's finding that Claimant failed to carry his burden of 
proving a causal connection between the incident of June 29, 1989, and his back 
injury is supported by substantial evidence.

[¶4]      Forni suffered an 
injury to his back on June 29, 1989, while he was employed by Pathfinder at its 
Shirley Basin mine. That injury was not immediately reported, partly because 
Forni was able to continue working until July 10, 1989, when he no longer could 
tolerate the pain. The delay in reporting also was explained in part because 
Pathfinder had an incentive program that rewarded employee crews which were able 
to go six months without a lost-time accident. If such an accident occurred, the 
entire crew was denied the incentive, and Forni did not want to assume the 
responsibility of that incentive being lost by other members of the 
crew.

[¶5]      Ultimately, 
Forni's injury was diagnosed as "spinal stenosis L4-5 secondary to ruptured disc 
and hypertrophy of ligamentum flavum." Worker's compensation benefits were paid 
without objection from either the Worker's Compensation Division or Pathfinder 
until April 16, 1990. See Wyo. Stat. § 27-14-601(a) (1991). On April 16, 1990, 
Pathfinder notified the Worker's Compensation Division that, "[a]ll claims filed 
by Frederick T. Forni are denied by the employer on the basis that it is our 
belief that medical treatment unrelated to the injury may be occurring." The 
question arose because Forni was treated for depression and diabetes preparatory 
to a surgical procedure on his back necessitated by the injury.

[¶6]      In a letter dated 
April 26, 1990, the Worker's Compensation Division advised Forni of Pathfinder's 
objections, and he was told, "[t]he Division will try to informally resolve this 
matter with your employer and will notify you of the final determination." The 
informal resolution was not achieved and, pursuant to an order of June 1, 1990, 
the matter was set for hearing before an administrative hearing officer on 
August 8, 1990. Subsequently, it was reset for September 6, 1990. During all of 
this time, Forni was recuperating from the back surgery which had been performed 
on January 24, 1990.

[¶7]      Prior to the 
actual hearing, on August 15, 1990, Pathfinder presented its petition to reopen 
Forni's claim relying upon Wyo. Stat. § 27-14-605(a) (1991), which 
provides:

(a) If a determination is 
made in favor of or on behalf of an employee for any benefits under this act, an 
application may be made to the division by any party within four (4) years from 
the date of the last payment for additional medical and disability benefits or 
for a modification of the amount of benefits on the ground of increase or 
decrease of incapacity due solely to the injury, or upon grounds of mistake 
or fraud. (Emphasis added.)

Pathfinder's 
contention was that, "as a result of fraud, misrepresentation, or other 
misconduct," Forni received benefits for his June 29, 1989 injury. In accordance 
with the same allegations, Pathfinder also requested relief pursuant to 
Wyo.R.Civ.P. 60(b).

[¶8]      The fraud 
allegations arise out of a question on the first page of his employment 
application and Forni's answer to the question. These were:

List Any Illness or 
Injuries For Which You Have Consulted a Doctor Within Last 5 Years.

Answer: Carpal Tunnel 
Syndrome and swollen elbow.

In addition, 
Forni completed an "EMPLOYMENT APPLICANT'S PHYSICAL QUESTIONNAIRE," in which he 
was asked if he had knowledge of ever having any of the following, "[h]ead, 
spinal or back injury or ailment." Forni's answer was "No." However, in a 
section of the questionnaire immediately following, and on the same page, Forni 
responded that he had been under a doctor's care for a lost-time industrial 
accident on two occasions. The closing paragraph of the application, which 
Forni, executed stated:

I hereby certify that the 
answers to the foregoing are accurate and true to the best of my knowledge and 
belief. I further certify I understand that if I fraudulently represent my 
physical condition for the purpose of obtaining employment I may be subject to 
dismissal from my employment by the Company, and, further, that any claim for 
Workmen's Compensation arising out of misrepresentation may be 
denied.

[¶9]      The dispositive 
question in this case is whether the decision of the administrative hearing 
officer to reopen the claim because of fraud is supported by substantial 
evidence. The findings by the administrative hearing officer on this issue 
were:

     7. That the Claimant 
[Forni] was hired for employment in February of 1990 [1989 is the correct year], 
at which time he submitted an employment application which indicated he suffered 
from carpal tunnel syndrome and a swollen elbow; he specifically denied that he 
ever suffered from any kind of head, spinal, or back injury.

     8. That the Claimant 
suffered from and was treated for previous back injuries or problems in August 
of 1984 and May of 1988.

The hearing 
officer denied any relief under Wyo.R.Civ.P. 60(b) because the motion was not 
timely filed, but he did rule that reopening was appropriate under Wyo. Stat. § 
27-14-605(a), concluding:

The Employer has 
attempted to proceed under this provision and therefore has the burden to prove 
that there was mistake or fraud in the granting of any benefits to the Employee. 
In this regard, evidence was presented by the Employer which shows that at the 
time the Claimant applied for employment with the Employer he did not indicate 
to the Employer that he had had previous incidents and/or problems with his 
back. Testimony was presented by the Claimant's physicians showing that the 
Claimant had in fact been treated, previously in particular, for problems with 
his back. The Office notes that the extent of the Claimant's back problems was 
not fully diagnosed during these earlier treatments and the Claimant may not 
have been aware of any major or serious back problems. Nevertheless, the 
Employee was aware that he had been treated for and had some problems related to 
his back at the time he applied for employment with the Employer. The Claimant, 
therefore, failed to reveal this questionable, yet known condition to the 
Employer, and therefore, "inadvertently" misled the Employer. As a result, the 
basic issue of the nature of the Claimant's condition as it relates to his back 
is opened pursuant to 27-14-605 as of August 15, 1990.

[¶10]   The language of these findings and 
the conclusions is somewhat loose. Forni informed Pathfinder that he had been 
treated by a doctor "within the last 5 years" for carpal tunnel syndrome and 
swollen elbow. The 1984 treatment alluded to by the hearing examiner was almost 
four and one-half years old at the time of the application. Forni testified that 
his recollection was that the injury was over five years old at the time he 
filled out the application. The hearing officer conceded that Forni may not have 
perceived during treatment that it was for a "[h]ead, spinal or back injury or 
ailment," but apparently gave no credit to Forni's testimony. During the time 
that he was treated for the carpal tunnel syndrome, Forni also was treated for a 
minor injury suffered in an automobile accident that occurred when he was a 
passenger in a police van. Forni said he did not include that occurrence because 
it was a minor strain that he didn't think fit the category and because, when he 
was released to return to work after the carpal tunnel surgery, his back no 
longer bothered him. The hearing officer found that Forni had been treated for 
back injuries or "problems," but Forni was not asked to reveal back "problems." 
He was asked to disclose any back "injury or ailment." In the ordinary course of 
employment concerns, these are not monumental distinctions, but the statutory 
requirement here is fraud.

[¶11]   The term "injury" has a fairly 
broad meaning in terms of the worker's compensation statutes, and that 
definition has generated no small amount of legal controversy. Wyo. Stat. § 
27-14-102(a)(xi) (1991). If Forni's prior treatments were for "injuries" in the 
statutory sense, they necessarily would have had to have been injuries included 
within the worker's compensation program. A dictionary definition of "injure" is 
more limited, "2 a: to inflict bodily hurt on injured by a falling 
brick> b: to impair the soundness of ." WEBSTER'S THIRD NEW INTERNATIONAL 
DICTIONARY 1164 (1986). The dictionary continues with this 
statement:

[I]NJURY, HURT, 
DAMAGE, HARM and MISCHIEF mean in common the act or result of inflicting on a 
person or thing something that causes loss, pain, distress, or impairment. 
INJURY is the most comprehensive, applying to an act or result involving an 
impairment or destruction of right, health, freedom, soundness, or 
loss of something of value * * *.

WEBSTER'S 1164 
(emphasis added).

"Ailment" is 
defined as "1: a bodily sickness, disorder, or chronic disease." WEBSTER'S 45. 
Both of these terms connote something that is permanent or characterized by 
"chronic" manifestations, i.e., something that is marked by long duration or 
frequent recurrence over a long time. WEBSTER'S 402. We do not intend to 
attribute to Forni hypertechnicality in his responses, but to impress upon this 
area of the law that the choice of words can be very significant, especially 
when they are invoked to identify fraud or misrepresentation. It also is 
significant that Forni responded correctly to having been twice injured in 
industrial accidents, the thrust of that response having been ignored by 
Pathfinder and the hearing officer. Our conclusion is that Forni answered the 
rather imprecise questions encompassed by the questionnaire with a fair degree 
of accuracy. Moreover, witnesses for Pathfinder testified that they could not 
say that Forni would not have been hired had he "interpreted" the questions the 
way Pathfinder now says they were intended.

[¶12]   These circumstances do not 
constitute the basis for a finding of fraud. See generally Duffy v. Brown, 708 P.2d 433 (Wyo. 1985) (elements of fraud); Dale R. Agthe, Annotation, Right to 
Unemployment Compensation as Affected by Misrepresentation in Original 
Employment Application, 23 A.L.R. 4th 1272 § 4[a] (1983) (characterizations by 
an individual of state of health in the nature of error in judgment, not 
conscious wrongdoing); Anne M. Vann, Annotation, Insured's Statement, in 
Application for Life or Health Insurance or its Reinstatement, that he is in 
Good Health, as Absolute Representation of, or Mere Statement of his Good-faith 
Belief in, his Good Health, 26 A.L.R.3d 1061 § 6[b] (1969) (statement of health 
qualified by "to the best of my knowledge and belief" an expression of opinion 
not a warranty or false statement). The record does not support the conclusion 
of the hearing officer that the case should be reopened upon the ground of 
fraud. 

[¶13]   Furthermore, even if one were to 
concede for purposes of argument that the application for employment was in 
error in some material respect, the concern under the statute is the obtaining 
of worker's compensation benefits because of fraud. The statute, given a liberal 
interpretation, cannot be perceived as foreclosing worker's compensation 
benefits that were not fraudulently obtained simply because of inaccuracies 
uttered in obtaining the employment. As this court said in Woodman v. Grace 
Bomac Drilling, 736 P.2d 313 (Wyo. 1987), the fraud to which the statute alludes 
must occur in connection with the award for the injury. See 3 ARTHUR LARSON, LAW 
OF WORKMEN'S COMPENSATION, § 81.51(b) (1989). Although we conclude from our 
review of the evidence that there was no fraud even in connection with the 
original employment, we note that the waiver of worker's compensation benefits 
that Pathfinder attempted to enforce may, in the circumstances of this case, 
contravene the provisions of Article 10, Section 4 of the Wyoming Constitution. 
See Horvath v. Sheridan-Wyoming Coal Co., 58 Wyo. 211, 131 P.2d 315 
(1942).

[¶14]   Our conclusion that the fraud must 
occur in connection with the award makes it important to address the evidence in 
this case that demonstrates the causal connection between Forni's injury and the 
benefits. The hearing officer, among his findings and conclusions, 
stated:

     In considering the 
evidence that was presented it would appear that until the Employer further 
investigated this matter the Claimant's condition was a result of the injury of 
June 1989. However, in looking at the injury in light of the medical evidence 
presented in regard to the Claimant's previous back problems it appears that the 
Claimant's back "injury" of June 1989 cannot be related solely to the incidents 
which occurred on that date. In fact it appears by the very nature of the injury 
that the particular treatment was for the previous problems that had not 
responded to conservative treatment.

There is no 
medical evidence in this record to support this statement. The testimony is 
unmistakably to the contrary. Patrick McDonald, M.D., reported that Forni 
suffered from a ruptured disc that was a medical problem wholly consistent with 
the injurious event described to him by Forni. Dr. McDonald had treated Forni 
twice previously and had detected no such injury on those occasions. It is true 
that, in response to some rather speculative, and perhaps obtuse, 
cross-examination, Dr. McDonald did agree "it was possible"1 Forni could have experienced a 
ruptured disc in his 1988 automobile accident. However, because of the low-grade 
pain Forni described and his rather speedy recovery, tests (X-ray, CAT scan, 
MRI) that could have established, or refuted, that possibility were not 
indicated and were not performed, according to Dr. McDonald. In short, the 
treating physician's testimony was about as certain as such medical testimony 
can be.

[¶15]   We have held that medical testimony 
is not required if it is not essential to establish a causal connection between 
the accident and the injury. Hansen v. Mr. D's Food Center, 827 P.2d 371 (Wyo. 
1992). We also have held that the finder of fact is not necessarily bound by the 
medical evidence. McCarty v. Bear Creek Uranium Co., 694 P.2d 93 (Wyo. 1985). On 
the other hand, we have acknowledged that where a medical question is complex, 
and the fact finding must be done in a realm that appropriately relies upon 
technical medical knowledge and expertise, medical testimony should not be 
ignored. Ludlow v. Wortham Machinery Co., 71 Wyo. 331, 257 P.2d 358 (1953). Here 
the medical testimony was not open to conjecture, nor was Forni's report of the 
accident, and the resolution of causal connection must come from this evidence. 
There is no evidence that supports the conclusion of the hearing 
officer.

[¶16]   In addition, we feel compelled to 
address the payment of benefits for the treatment of depression and diabetes 
that was rendered immediately prior to, and in preparation for, Forni's 
anticipated back surgery. This is the conclusion of the hearing 
officer:

     As far as the benefits 
as they relate to the Claimant's treatment for diabetes and depression. The 
Claimant would have required and received treatment of diabetes and depression, 
regardless of the condition of his back. The Office understands that the back 
condition could not be dealt with until such time as the diabetes and depression 
had been brought under control and the Claimant's health was such that the back 
surgery could be performed safely without concern for complications arising out 
of the diabetes and depression. However, the treatment and handling of these 
pre-existing conditions, diabetes and depression, under the Wyoming Worker's 
Compensation Act would result in the contributors to the fund acting as "the 
guarantors of the overall and continuing health of all persons who are employed 
in the state and covered by the Act." It would indeed be a noble endeavor for 
the Act to provide this kind of service to the workers of Wyoming. However, the 
purpose of the Act is to provide treatment for injuries which are directly 
related to a person's employment and not a person's general physical condition. 
Therefore, benefits under the Act for treatment of diabetes and depression are 
hereby denied.

We have espoused 
a rule of reason for settling such a matter:

     We would discern that 
in the absence of specific statutory direction, a rule of reason can be applied 
permitting inclusion of incidental or ancillary treatment procedures appropriate 
or necessary for proper attention to the work related occurrence as required or 
suggested by the medical practitioner, but not to include a more severe 
condition which predates the injury.

State ex rel. 
Wyoming Workers' Compensation Division v. Girardot, 807 P.2d 926, 930 (Wyo. 
1991).

[¶17]   The Girardot rule should be applied 
here. The medical testimony explicitly supports Forni's view that the treatments 
afforded for his depression and diabetes were necessary, and ancillary, to his 
back surgery. They properly are to be paid as a part of the expenses of his back 
injury. Diabetes was a preexistent condition unrelated to the back injury, but 
Forni's insulin intake level had to be in a proper and delicate balance for a 
changed dietary regimen and activity level brought about by the surgery together 
with its associated hospital stay and recuperation period. Likewise, Forni's 
depression, while it was a preexistent condition, was reactivated by his injury 
and the accompanying problems of inability to work in constant pain. The 
treatments for diabetes and depression, necessary to perform the surgery and of 
a different type and different regimen than those required by Forni's normal 
life routine, are compensable as part of the expenses of his back 
injury.

[¶18]   We reverse and remand this case to 
the Office of Administrative Hearings for entry of an order awarding benefits 
that are consistent with this opinion. 

ROONEY, Justice (Retired), 
specially concurring.

[¶19]   I concur with the reasoning of the 
majority of the court on the issues here presented. I do not, however, abandon 
my position in State ex rel. Wyoming Workers' Compensation Division v. Halstead, 
795 P.2d 760 (Wyo. 1990), i.e., a hearing officer cannot constitutionally act in 
these matters. 

 

FOOTNOTES

1 In a similar sort of 
cross-examination context, a physician testified it was possible to suffer a 
herniated disc in a fall from a motorbike. He then continued, "I can go further 
than that. I think you can get it from brushing your teeth." Bocek v. City of 
Sheridan, 432 P.2d 893, 895 (Wyo. 1967).