Title: State ex rel. Sears Roebuck & Co. v. Indus. Comm'n

State: ohio

Issuer: Ohio Supreme Court

Document:

[Until this opinion appears in the Ohio Official Reports advance sheets, it may be cited as 
State ex rel. Sears Roebuck & Co. v. Indus. Comm., Slip Opinion No. 2011-Ohio-6525.] 
 
 
NOTICE 
This slip opinion is subject to formal revision before it is published in 
an advance sheet of the Ohio Official Reports.  Readers are requested 
to promptly notify the Reporter of Decisions, Supreme Court of Ohio, 
65 South Front Street, Columbus, Ohio 43215, of any typographical or 
other formal errors in the opinion, in order that corrections may be 
made before the opinion is published. 
 
SLIP OPINION NO. 2011-OHIO-6525 
THE STATE EX REL. SEARS ROEBUCK AND COMPANY, APPELLEE, v. INDUSTRIAL 
COMMISSION OF OHIO ET AL., APPELLANTS. 
[Until this opinion appears in the Ohio Official Reports advance sheets, it 
may be cited as State ex rel. Sears Roebuck & Co. v. Indus. Comm.,  
Slip Opinion No. 2011-Ohio-6525.] 
Workers’ compensation—Industrial Commission abused its discretion by 
ordering employer to pay a medical bill submitted by a claimant when the 
claimant did not substantiate that the purpose of the office visit was 
related to his injury—Court of appeals judgment affirmed. 
(No. 2010-0955—Submitted September 6, 2011—Decided December 20, 2011.) 
APPEAL from the Court of Appeals for Franklin County,  
No. 09AP-180, 2010-Ohio-1818. 
__________________ 
Per Curiam. 
{¶ 1} We are asked to determine whether appellant Industrial 
Commission of Ohio abused its discretion by ordering self-insured appellee, Sears 
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Roebuck and Company, to pay a medical bill submitted by appellant Timothy 
Mathews for a 1998 doctor’s visit.  Upon review, we find that it did. 
{¶ 2} Mathews was injured in an industrial accident on October 13, 
1987, and a workers’ compensation claim was allowed by Sears for torn muscles 
in the left leg, tears of the buttocks and bladder, and internal injuries.  For the next 
five years, Mathews had extensive medical treatment.  By 1993, however, 
treatment had diminished considerably, with approximately 10 visits total over the 
next four years.  The last injury-related bill submitted to either Sears or its third-
party administrator was paid on March 26, 1997. 
{¶ 3} In March 1999, Sears’s third-party administrator, Frank Gates 
Service Company, received a letter from Mathews’s attorney: 
{¶ 4} “I am enclosing a copy of a billing Timothy A. Mathews received 
from Dr. Urbanosky of Greater Ohio Orthopedic Surgeons, Inc. relative to an 
examination of September 22, 1998.  This was billed to your office for payment 
and was rejected on the basis that the claim had been inactive.  As your files 
should reflect, Mr. Mathews has been under the care of one or more physicians at 
Greater Ohio Orthopedic Surgeons, Inc.  His previous physician recently died and 
Dr. Urbanosky has taken over Mr. Mathews’ care. 
{¶ 5} “Is it really necessary to go further with regard to this billing to the 
extent that the claim needs to be activated and perhaps the hearing held?  I trust 
that your good judgment will see that this bill is promptly paid and that Mr. 
Mathews be advised accordingly. 
{¶ 6} “If your client is unwilling to pay this bill, please advise me 
immediately in order that we may take the appropriate action relative to this 
matter.” (Emphasis added.)  
{¶ 7} The invoice that accompanied the letter listed an amount due of 
$50 for an unspecified office exam and did not indicate what medical conditions 
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or complaints prompted the visit.  These omissions generated a follow-up letter 
from Frank Gates: 
{¶ 8} “We are in receipt of your letter dated March 12, 1999 requesting 
the employer reconsider their position on the payment of the outstanding bill from 
Greater Ohio Orthopedic Surgeons for service date September 22, 1998. 
{¶ 9} “We understand your concern regarding this one payment; 
however, Mr. Mathews has not received any medical treatment from this provider 
since February 6, 1996.  The employer agrees to consider accepting payment for 
this date of service, but we request you provide us with the office notes to prove 
the relationship and diagnosis to his October 13, 1987 claim.” 
{¶ 10} All agree that Mathews’s counsel never responded to this letter.  
Counsel never forwarded the requested information or requested a commission 
hearing. 
{¶ 11} In early 2008, Mathews asked Sears to authorize further treatment.  
Sears’s new third-party administrator, Helmsman Management Services, Inc., 
denied the request, relying on former R.C. 4123.52. Am.Sub.H.B. No. 238, 141 
Ohio Laws, Part II, 2761, 2837.  Under that statute, claim inactivity in excess of 
10 years permanently closed a workers’ compensation claim.  Because the last 
payment of expenses or compensation in Mathews’s claim was in 1997, 
Helmsman informed Mathews that his workers’ compensation claim was no 
longer open. 
{¶ 12} In an effort to toll the statute, Mathews’s new counsel revived the 
issue of the September 1998 doctor’s visit and requested a commission hearing on 
the payment of that bill.  Accompanying the motion were the doctor’s notes from 
that appointment:  
{¶ 13} “CURRENT CONDITION:  Timothy * * * was involved in a 
severe crush-type injury to his pelvis and thighs back in October of 1987.  * * * 
He did not require any pelvis or back surgery at the time and overall seems to 
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have recovered well.  * * * He states over the last two days or so his left leg has 
been feeling ‘heavy’ with associated tingling into the dorsum of his left foot.  He 
states it feels as if his leg falls asleep.  However, the tingling seems to be constant.  
He has minimal associated back pain or other radicular-type pains at this time. 
{¶ 14} “* * * 
{¶ 15} “IMPRESSION:  Mild L5 radiculopathy on the left. 
{¶ 16} “PLAN:  He has been encouraged to take his Motrin on a regular 
basis  * * *.  In addition, he has been encouraged to maintain his regular activities 
within the limits of any pain which presently is minimal.  I have encouraged 
aerobic-type activities, as well as abdominal exercises and gradual back muscle 
strengthening-type exercises.  I have encouraged him to minimize weight lifting-
type activities which he wishes to begin at least until this numbness is resolved.  
He has been warned that being in his 30’s he is, even without his prior injuries, at 
risk of having a disk herniation.  Should this manifest itself with more pain or 
frank numbness or limping/weakness, I have encouraged him to return for further 
evaluation.” 
{¶ 17} A commission staff hearing officer ordered Sears to pay the 
outstanding bill:   
{¶ 18} “By 04/21/1999 letter from the employer’s third part[y] 
administrator[, it] acknowledge[d] receipt of the [March 12, 1999] letter [from 
claimant’s counsel,] and [the third-party administrator] stated that the payment 
would be considered upon submission of office notes.  This letter does not 
constitute the denial of payment. 
{¶ 19} “The Staff Hearing Officer has considered [the] employer’s four 
defenses to the payment of this bill, and finds none of them [to be] well taken. 
{¶ 20} “First, the medical service is reasonably related to the allowed 
industrial injury.  Claimant suffered severe internal injuries in the vicinity of the 
lower back.  A referral to determine if a lower back injury was a part of those 
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severe injuries was reasonable and indicated.  Although no lower back injury is 
allowed in the claim, in the context of the location and severity of the claimant’s 
other injuries, and his complaints at the time, this referral is a reasonable expense 
of the allowed industrial injury.  This is demonstrated by the office notes of the 
medical service, notwithstanding the conclusion that the claimant did not have a 
medical condition which is a part of the allowed conditions in the claim.” 
{¶ 21} Sears filed a complaint in mandamus in the Court of Appeals for 
Franklin County, alleging that the commission had abused its discretion in 
ordering the bill to be paid because the visit related to a low-back condition that 
was not allowed in Mathews’s claim.  The court agreed and issued a writ of 
mandamus that vacated the decision and directed the commission to issue a new 
order denying payment of the bill. 
{¶ 22} This cause is now before this court on appeals as of right by 
Mathews and the commission. 
{¶ 23} Mathews seeks payment for the 1998 office visit generated by a 
low-back condition that has not been allowed in his claim.  Typically, payment is 
properly denied when a condition has not been allowed.  Appellants, however, 
insist that two cases in which treatment was authorized for a condition that had 
not been formally allowed in the claim support their position.  Upon review, we 
find that those cases are distinguishable from the one at bar. 
{¶ 24} In State ex rel. Miller v. Indus. Comm. (1994), 71 Ohio St.3d 229, 
643 N.E.2d 113, we approved a weight-loss program in a claim that had not been 
formally allowed for obesity.  There, the claimant’s physician sought 
authorization for a weight-loss program, based on his belief that claimant’s 
obesity was compromising her recovery from her allowed back condition.  The 
commission did not dispute the doctor’s opinion but felt that because obesity was 
not an allowed condition in the claim, treatment could not be authorized. 
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{¶ 25} We disagreed.  We stressed, among other things, that obesity was 
unique from an allowance standpoint because it was a generalized condition that 
could not be restricted to a specific body part. Id. at 233.  This, in turn, made it 
less amenable to the formal allowance mechanics of R.C. 4123.84, a characteristic 
that Mathews’s lumbar radiculopathy does not share. 
{¶ 26} Appellants also cite State ex rel. Jackson Tube Servs., Inc. v. Indus. 
Comm., 99 Ohio St.3d 1, 2003-Ohio-2259, 788 N.E.2d 625.  In Jackson Tube, the 
claimant’s workers’ compensation claim had been allowed for a torn rotator cuff.  
Continuing shoulder problems, however, as well as a failure to have a shoulder 
arthroscopy performed, prompted his doctor to express concern that “substantial 
pathology [wa]s still being missed,” most likely a secondary tear. Id. at ¶ 14.  For 
these reasons, he sought permission to both perform exploratory surgery to 
determine the cause of claimant’s persistent symptoms and to fix the problem he 
found. 
{¶ 27} The employer objected to the procedure, arguing that the shoulder 
conditions identified by the doctor as the potential source of claimant’s continuing 
problems had not been allowed in the claim.  The commission allowed the surgery 
nonetheless, and we upheld that decision.  We acknowledged that the issue was a 
difficult one, with compelling arguments being made by both sides: 
{¶ 28} “On one hand, claimant could not move for additional allowance 
beforehand, since without the surgery, the problematic conditions could not be 
identified.  On the other hand, self-insured JTS questions its recourse when 
ordered to pay for surgery that ultimately reveals any conditions to be 
nonindustrial.  It also fears that payment could be interpreted as an implicit 
allowance of all the conditions in the postoperative diagnosis.” Id. at ¶ 22. 
{¶ 29} Addressing the latter concern first, we stressed that an employee 
could not “circumvent additional allowance by simply asserting a relationship to 
the original injury.  The problem in this case, however, is that because any 
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conditions are internal, claimant could not know what conditions to seek 
additional allowance for without first getting the diagnosis that only surgery could 
provide.”  Id. at ¶ 25. 
{¶ 30} We were additionally persuaded by the physician’s consistent 
assertion that whatever condition was the source of the claimant’s shoulder 
complaints, that condition was related to the industrial injury.  We also noted that 
claimant’s doctor had indicated that irrespective of any other conditions that may 
be contributing to claimant’s problems, the allowed condition of torn rotator cuff 
had to be surgically repaired.  To deny the surgery simply because more 
conditions could be found would conflict with our earlier decision in State ex rel. 
Griffith v. Indus. Comm. (1999), 87 Ohio St.3d 154, 718 N.E.2d 423.  We closed, 
however, by clarifying that if other shoulder conditions were indeed found, 
further treatment or compensation could not be authorized unless the conditions 
were then additionally allowed in the claim. 
{¶ 31} Unlike Mathews, the claimant in Jackson Tube was not being 
treated for a condition arising in a part of the body that was not previously alleged 
to have been injured.  Not only had the latter claimant consistently alleged a 
shoulder condition, his workers’ compensation claim included one.  This,  
coupled with medical evidence discussing the probability of other related but 
undiagnosed shoulder conditions and a history of unresolved shoulder complaints 
since the date of injury, greatly enhanced the likelihood that any newly discovered 
shoulder conditions were connected to the industrial injury.  Under those 
circumstances, surgical authorization was reasonable—despite the lack of formal 
allowance beforehand—in order to diagnose with specificity what those other 
related conditions were. 
{¶ 32} In contrast, Mathews’s 1998 office visit was related to a part of the 
body that he never before alleged was injured.  Unlike in Jackson Tube, there is 
no evidence properly before us that establishes a history of low-back symptoms.  
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According to Dr. Urbanosky, Mathews’s back symptoms began just two days 
before his office visit.  We find it significant that in the 11 years between his 
industrial injury and the disputed office visit, there is no record of any low-back 
complaints. 
{¶ 33} More importantly, there is no evidence establishing, or even 
suggesting, a potential connection between his 1987 injury and his 1998 back 
symptoms.  To the contrary, Dr. Urbanosky indicated that Mathews had 
“recovered well” from his industrial injury.  She also stated that irrespective of 
any other factor, Mathews’s age alone put him at risk for the type of disc 
problems that could cause radiculopathy. 
{¶ 34} Appellants assert that a judgment in Sears’s favor rewards it for 
abusing its responsibilities as a self-insured employer.  They accuse Sears of 
failing to affirmatively act on the disputed bill when it was first presented for 
payment in 1999. This argument, however, lacks merit.  Sears’s third-party 
administrator asked Mathews’s former counsel to provide information to 
substantiate the purpose of the office visit, but counsel never responded.  Counsel 
also never requested a commission hearing, which could have conclusively 
resolved the matter.  Accordingly, we find no merit to appellants’s claim that 
Sears acted inappropriately. 
{¶ 35} The judgment of the court of appeals is affirmed. 
Judgment affirmed. 
O’CONNOR, C.J., and PFEIFER, LUNDBERG STRATTON, O’DONNELL, 
LANZINGER, CUPP, and MCGEE BROWN, JJ., concur. 
__________________ 
Reminger Co., L.P.A., and Kevin R. Sanislo, for appellee. 
Butler, Cincione & DiCuccio and Matthew P. Cincione, for appellant 
Timothy Mathews. 
January Term, 2011 
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Michael DeWine, Attorney General, and Colleen C. Erdman, Assistant 
Attorney General, for appellant Industrial Commission. 
______________________