IN THE COURT OF APPEALS OF IOWA

No. 14-1070

Filed April 8, 2015

UNITED HEARTLAND, INC. and

CAMANCHE COMMUNITY SCHOOL DISTRICT,

Respondents-Appellants,

vs.

KATHALEEN BROWN,

Petitioner-Appellee.

________________________________________________________________

Appeal from the Iowa District Court for Polk County, Dennis J. Stovall, 

Judge. 

An employer school district appeals a judicial review order affirming an 

award of benefits by the workers’ compensation commissioner to a claimant 

teacher based on her respiratory injury arising from exposure to dust or mold in 

her classroom. AFFIRMED.

Thomas D. Wolle of Simmons, Perrine, Moyer, Bergman, P.L.C., Cedar 

Rapids, for appellants.

Paul J. McAndrew Jr. of Paul McAndrew Law Firm, P.L.L.C., Coralville, for 

appellee.

Considered by Danilson, C.J., and Doyle and Tabor, JJ.
2

TABOR, J.

A school district challenges its obligation to pay workers’ compensation 

benefits to a former elementary school teacher who claims she developed 

respiratory difficulties from exposure to mold or dust in her classroom. The 

commissioner found Kathaleen Brown proved she “sustained a pulmonary 

function injury arising out of and in the course of her employment” with the 

Camanche Community School District. The school district contends that decision

was not supported by substantial evidence and represents an “irrational, illogical, 

or wholly unjustifiable” application of law to fact. Viewing the record as a whole 

and affording proper deference to the agency’s findings, we affirm the award of 

benefits.

I. Background Facts and Proceedings

Brown taught fourth graders at the Camanche elementary school from 

1998 through 2010. The fourth grade classrooms were located in the original 

section of the school built in 1961.1 

From 1998 through 2000, Brown taught in Room 114, a windowless room 

with little ventilation. In the fall of 2000, Brown developed severe bronchitis and 

also received treatment for multiple asthma attacks. During 2000, Brown missed 

thirteen days of school due to lung ailments. Citing her health problems, she 

complained to the administration about the uncleanliness of the school and 

asked to be assigned to a different classroom. In 2001, Brown started teaching 

 

1 The principal testified that section of the elementary school has a flat roof and drop 

metal pan ceiling tiles that become rusty and stained when water leaks into the building.
3

in Room 110 and stayed in that location until her employment ended nine years 

later. 

Brown’s testimony before the agency showed the coinciding of her lung 

problems and the presence of contaminants in her classroom. Brown testified to 

seeing “stained ceiling tiles where there was definitely water intrusion and rusting 

in holes through those metal pan ceilings.” She believed the “buildup of dirt and 

grunge was an ongoing problem” at the school from 2000 forward. She recalled 

the heat registers in the classrooms were “filthy.” Brown also recalled having 

problems with bronchial infections and sinus infections during the school years 

starting in 2000, and then her health would bounce back over the summers when 

she was away from the school building. Between March 2003 and May 2010, 

Brown saw her family physician more than two dozen times for respiratory 

problems, and the visits were almost exclusively during the school year. In 

October 2007 she was hospitalized for six days with pneumonia. Brown testified: 

“I didn’t realize there was any correlation with a breathing problem until I was 

actually diagnosed in 2010 with occupational environmental lung disease.”

After her hospitalization in 2007, Brown brought a humidifier into her 

classroom to help with her chronic cough. When refiling it with water, she 

noticed mold on the filter.2 Brown sent a sample of the filter to a California 

laboratory for testing; lab technicians confirmed the presence of mold. The 

school removed the humidifier from her classroom, informing her she could not 

have the appliance there because it was not provided by the district. 

 

2 According to Brown, an identical humidifier unit in her home showed no mold 

accumulation during the same time frame. 
4

The school also followed up with an environmental inspection in the spring 

of 2008. It was the first of four separate indoor air quality investigations between 

2008 and 2011.3 The 2008 study revealed ventilators in Brown’s classroom were 

“covered by a layer of particulate material.” Carpet dust samples showed fungal 

growth. The study recommended the school district use higher quality air filters, 

check and change the filters more frequently, and vacuum the floors daily and 

clean the carpets annually. An industrial hygienist suggested the school develop 

a “remedial cleaning strategy.” 

In May 2008, Brown consulted with Dr. Humphrey Wong of Pulmonary 

Associates in Davenport. He determined she had asthma based on a positive 

methacholine challenge test.4 From an overall review of her records, Dr. Wong 

opined that Brown “had a significant amount of exacerbations and instability of 

symptoms which seemed to be clustered around the school year despite 

maximal medical therapy.” Dr. Wong referred Brown for allergy testing. She 

tested negative for five common molds. Dr. Vijay Sabins explained the negative 

 

3 A subsequent inspection in September 2010 found mold growth on surface samples in 

Brown’s classrooms, but overall the findings indicated a low risk to human health. The 

report recommended cleaning various parts of the ventilator units in those classrooms. 

On April 25, 2011, the school district retained Dr. Harry Elston to conduct another air 

quality test. Dr. Elston noted it appeared as though the building had been “recently and 

thoroughly cleaned before the surveillance.” He nevertheless observed “multiple 

instances of historical and current water intrusion throughout the building.” An air 

sample from Room 114, where Brown had taught, tested positive for aspergillus, a 

fungus strongly associated with respiratory illness and which was not identified in an 

outdoor air sample. Brown retained industrial hygienist Daniel Brust to perform yet 

another test on April 29, 2011. Brust detected elevated levels of carbon dioxide, 

indicating a lack of fresh air circulating in the classrooms. He also noted stained ceiling 

tiles indicating water intrusion episodes from a leaky roof. 

4 Another expert in the case, Dr. Laurence Fuortes, explained the methacholine 

challenge test measures an individual’s degree of airway sensitivity to inhalant exposure 

at various doses.
5

results did not rule out environmental molds as the cause of Brown’s reactive 

airway reactions. In addition, the testing showed Brown was sensitive to the 

inhalant aspergillus. 

Also in 2008, Brown surveyed her colleagues at the elementary school 

because she believed others were experiencing breathing problems like hers. 

Brown provided the results to the school district.

Brown’s last day at work was May 26, 2010. Ten days earlier, she had a 

reactive airway breathing attack at school and sought help from the school nurse, 

who saw Brown using her emergency inhaler and suggested Brown ask her 

physician about using an oxygen tank while she was at school. Brown’s 

pulmonologist, Dr. Wong, placed her on a maintenance dose of steroids to help 

her get through the school year. But on May 25, Brown fell ill at school and the 

following day had a more severe incident in the school building, requiring her to 

go home early. She did not return for the final days of the term.5 

On June 2, 2010, Brown sought an opinion from Dr. Charles Bruyntjens, a 

pulmonary specialist. He diagnosed Brown with occupational environmental lung 

disease, hyper-reactive airways, and shortness of breath. He found the school 

environment either started her condition or aggravated a preexisting condition. In 

the fall of 2010, Brown received treatment from Huxley Family Physicians, 

specifically Dr. Allison Testroet and Physician’s Assisstant Hollie Wicker. They 

believed “her recurrent sinus and bronchial infections were related to her hyperreactive airways caused by exposure while working at the Camanche school.”

 

5 After Brown exhausted her sick leave, the school board voted on May 11, 2011 to 

terminate her employment effective at the end of the academic year.
6

Brown filed a claim for workers’ compensation benefits on October 28, 

2010. Brown, who was then fifty-seven years old, alleged she was exposed to 

contaminants in her workplace affecting her lungs, bronchial passages, and 

whole body. She alleged her injury date as June 2, 2010. The school district 

and its insurer United Heartland (collectively the school district) filed an answer 

denying her allegations. 

In April 2011, while her workers’ compensation claim was pending, Brown 

saw Dr. Jason Wittmer, a pulmonologist practicing in Des Moines.6 After 

examining Brown, Dr. Wittmer found no abnormal lung function and no airway 

obstruction. He opined that her symptoms of difficulty breathing were “discordant 

with the available objective measures.”

A few months later, Brown’s attorney arranged for an independent medical 

examination with Dr. Joel Kline at the University of Iowa Hospitals Pulmonary 

Clinic in August 2011. After clinical testing, Dr. Kline reached an opinion that 

Brown suffered from asthma, which had been substantially aggravated by 

exposures she received while at the school. He believed the aggravation of her 

respiratory condition was more likely than not related to “water damage” in the 

workplace.

In September 2011, the school district’s attorney sought an opinion from 

Dr. Laurence Fuortes of the University of Iowa College of Public Health 

concerning the environmental conditions of the elementary school and Brown’s 

 

6 When Brown moved from Camanche to Huxley later in 2010, it was inconvenient to 

continue treatment with Dr. Bruyntjens, who practices in Davenport, and she decided to 

locate a pulmonologist in central Iowa. The deputy mistakenly stated in the arbitration 

ruling that Dr. Wittmer was retained by the school district to provide an IME.
7

physical symptoms. After reviewing the indoor air quality reports, Dr. Fuortes 

opined “the elementary school was not grossly contaminated” at least “in the post 

remediation period.” But he also acknowledged the ventilation systems showed 

evidence of contamination, including mold. Dr. Fuortes also commented on 

Brown’s diagnosis, saying if she had problematic asthma, it was not obvious at 

the present time.

A deputy workers’ compensation commissioner heard the matter on 

January 19, 2012, and issued an arbitration decision on April 10, 2012. The 

deputy decided Brown met her burden of proving an injury arising out of her 

employment. The school district appealed and Deputy Commissioner Larry 

Walshire, acting by designation of the commissioner, affirmed the arbitration 

decision on May 9, 2013. 

The school district sought judicial review. The district court affirmed the 

agency’s decision that Brown suffered a compensable injury arising out of her 

employment with the school district. The school district challenges the judicial 

review ruling on appeal.

II. Scope and Standards of Review

Courts review agency action under Iowa Code chapter 17A—the Iowa 

Administrative Procedures Act. Quaker Oats Co. v. Ciha, 552 N.W.2d 143, 149 

(Iowa 1996). Appellate courts and district courts both review for the correction of 

legal error. Id. at 149–50. If we reach the same conclusion as the district court 

we affirm, if not we reverse. Grundmeyer v. Weyerhaeuser Co., 649 N.W.2d 

744, 748 (Iowa 2002). 
8

Under section 17A.19(10), we may “reverse, modify, or grant other 

appropriate relief” if we decide the commissioner’s award of benefits “is not 

supported by substantial evidence” or is “[b]ased upon an irrational, illogical, or 

wholly unjustifiable application of law to fact that has clearly been vested by a 

provision of law in the discretion of the agency.” See Iowa Code § 17A.19(10)(f), 

(m) (2011).

The legislature defined “substantial evidence” as “the quantity and quality 

of evidence that would be deemed sufficient by a . . . reasonable person, to 

establish the fact at issue.” Id. § 17A.19(10)(f)(1). Evidence is not insubstantial 

just because another factfinder may have drawn a different conclusion. Cedar 

Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa 2011). The only 

question on appeal is whether the conclusion reached by the agency is 

supported by sufficient evidence. Id. We view the evidence through the lens of 

the record as a whole. Iowa Code § 17A.19(10)(f)(3). 

Our review is fact-intensive and thorough; we do not simply “rubber 

stamp” the agency’s decision. Pease, 807 N.W.2d at 845. But at the same time, 

we read the agency’s findings broadly and liberally with an eye to upholding 

rather than defeating its decision because the purpose of the law is to benefit 

workers. See IBP, Inc. v. Al-Gharib, 604 N.W.2d 621, 632 (Iowa 2000). 

III. Injury “arising out of” employment

The Iowa workers’ compensation provisions cover “all personal injuries 

sustained by an employee arising out of and in the course of the employment.” 

Iowa Code § 85.3(1); Meyer v. IBP, Inc., 710 N.W.2d 213, 220 (Iowa 2006). Our 
9

courts have teased that statutory language into four elements that must be 

proven to recover from the employer: “(1) the claimant suffered a ‘personal 

injury,’ (2) the claimant and the respondent had an employer-employee 

relationship, (3) the injury arose out of the employment, and (4) the injury arose 

in the course of the employment.” Meyer, 710 N.W.2d at 220. 

In this case, the school district challenges Brown’s proof of the first and 

third elements—claiming she did not establish she suffered an injury7and, even

if she did have an injury, she did not prove her condition “arises out of” her 

employment at the Camanche elementary school. We will address both claims in 

turn.

A. Proof of Injury

The school district contends substantial evidence does not support the 

acting commissioner’s conclusion that Brown suffered from “a pulmonary function 

injury” related to her work. The district highlights the opinions of Dr. Wittmer and 

Dr. Fuortes. Dr. Wittmer did not believe Brown had asthma and found no 

evidence of airflow obstruction or “other pulmonary functional abnormality.” 

Likewise, Dr. Fuortes found Brown did not show a “chronic impairment of the 

respiratory system.” The school district then dismisses the “contrary opinions of 

Drs. Bruyntjens and Kline.” The district contends the agency found Dr. 

Bruyntjens “was simply not credible” and asserts Dr. Kline’s opinion was based 

on erroneous information supplied by Brown. 

 

7 The school district asserted the deputy failed to analyze Brown’s case under Iowa 

Code chapter 85A rather than under chapter 85. But the district notes it is not appealing 

the agency’s finding that Brown’s claim is properly analyzed as an injury rather than an 

occupational disease.
10

We are not persuaded by the school district’s substantial evidence 

argument for two reasons. First, we cannot totally disregard the opinion of Dr. 

Bruyntjens. In asking us to do so, the district overstates the agency’s credibility

finding. It is true the acting commissioner’s characterized Dr. Bruyntjens’s 

testimony as “confusing and not helpful” and stated that he appeared to 

“contradict himself on more than one occasion.” But the agency did not find his 

views to be entirely unreliable or unbelievable. An agency may accept or reject 

an expert opinion in whole or in part. Sherman v. Pella Corp., 576 N.W.2d 312, 

321 (Iowa 1998). The record included evidence that Dr. Bruyntjens was a welltrained pulmonologist who diagnosed Brown as having an occupational 

environmental lung disease, including hyper-reactive airways and shortness of 

breath. He based his diagnosis on Brown’s medical history as documented by 

Dr. Wong, as well as Brown’s outward symptoms. Like the district court, we 

conclude the opinion of Dr. Bruyntjens contributes to the substantial evidence 

supporting the agency’s finding of injury.

Second, we do not perceive Dr. Kline’s opinion as being tainted by the 

subjective information he received from Brown. Dr. Kline reviewed Brown’s 

medical records, including earlier pulmonary function tests, before examining her. 

He found a positive methacholine challenge test to support his diagnosis of 

asthma. He also reviewed several air quality reports, which discussed examples 

of water damage to the school he reasonably considered in reaching his opinion 

that the school environment caused or exacerbated her condition. 
11

The agency was entitled to rely on Dr. Kline’s assessment of Brown’s lung 

injury and its nexus to the school environment, as well as accepting at least 

some of the opinions from Dr. Bruyntjens. We are not allowed to reweigh the 

evidence considered by the acting commissioner. See Westling v. Hormel Foods 

Corp., 810 N.W.2d 247, 254 (Iowa 2012). Accordingly, we find substantial 

evidence to back the agency’s conclusion that Brown suffered a pulmonary 

function injury.

B. Causal connection to employment 

Having determined Brown suffered an injury at the time of the employment 

relationship, we turn to the third requirement—whether the injury “arose out of”

her work for the school district. See Meyer, 710 N.W.2d at 222. An injury “arises 

out of” the employment if a causal connection exists between the employment 

and the injury. Id. In the context of workers’ compensation law, this causation 

element means the injury must be a “natural incident” of the work or, in other 

words, “a rational consequence of the hazard connected with the employment.” 

Id. (explaining concept of proximate or legal cause from tort law is misplaced in 

deciding “work-connectedness” for compensation law). 

The school district argues Brown cannot show her injury was caused by 

harmful conditions in the elementary building. The district contends “at least 

some dust, some moisture, and some mold” is incidental to “every workplace, 

everywhere.” The district argues, without citation to any authority, that because 

there was no evidence the dust, mold, and moisture in the elementary school 
12

was greater than anywhere else, Brown’s injury cannot be said to have arisen out 

of her employment.8 

In response, Brown emphasizes that “employers take employees as they 

find them at the time of employment,” citing Bearce v. FMC Corp., 465 N.W.2d 

531, 536 (Iowa 1991). The district court seized on that argument, stating: “the 

fact that air quality tests found conditions at the school that would not be 

hazardous for most humans is irrelevant.” The court believed the air quality tests 

provided “numerous examples of conditions, elements or substances in the 

school that may afflict a susceptible individual.” In the court’s estimation: “There 

is ample evidence in the record to support a finding that [Brown’s] pulmonary 

problems were caused by a condition, element, or substance in the workplace.” 

We agree with the district court. The agency record contains expert 

evidence establishing a causal connection between her injury and conditions in 

the elementary school. On the question of conditions or working environment, 

the record is replete with proof that water had infiltrated the roof and ceiling tiles 

in the fifty-year-old wing of the school building that housed the fourth grade 

classrooms where Brown taught. A history of water intrusion was documented 

by Dr. Elston, the industrial hygienist retained by the school district in 2011. That 

water damage, in the opinion of Dr. Kline, more likely than not was the culprit 

behind Brown’s lung injury. As Dr. Bruyntjens asserted: “where there is water

 

8

Iowa courts have abandoned any requirement that the employer subject the employee 

to a risk or hazard greater than that faced by the general public. Lakeside Casino v. 

Blue, 743 N.W.2d 169, 174–75 (Iowa 2007) (employing actual-risk rule rather than 

increased-risk rule). 
13

there is mold.” Brown herself documented mold on the filter of her humidifier. In 

addition, indoor air testing pointed to heavy dust accumulation and elevated 

levels of carbon dioxide from low ventilation in the building. Even Dr. Fuortes 

acknowledged Brown complained of respiratory symptoms consistent with a 

poorly maintained ventilation system.

The expert testimony establishing causation is corroborated by Brown’s 

evidence from lay persons who experienced sinus and respiratory problems 

when they were in the elementary building during the school year, which 

dissipated when they were away from the building.9 For instance, fellow teacher 

Lisa Clarke recalled suffering sinus headaches, drainage, and sore throats while 

teaching in a classroom that harbored a “musty, moldy type of smell.” Another 

teacher, Susan Reckman, testified she incurred regular sinus infections during 

her years of teaching in the elementary school that went away when she was 

gone from the building; she also recalled water-stained ceiling tiles and other 

“wet places” around the school. Lori Lyons, a mother of two students, testified 

they were repeatedly diagnosed with respiratory infections and asthma while 

attending Camanche elementary from 2002 through 2009, but have had far less 

health problems since leaving the school.

In summary, the agency’s findings of fact were supported by substantial 

evidence and its application of law to the facts was not irrational, illogical or 

 

9 We acknowledge the agency found the probative value of the depositions and 

testimony from the lay witnesses to be “quite low.” But the agency decided the 

nonprofessional evidence could be used to bolster the expert testimony.
14

wholly unjustifiable. See Iowa Code § 17A.19(10); Lakeside Casino, 743 N.W.2d 

at 173.

AFFIRMED.