TENNESSEE BUREAU OF WORKERS' COMPENSATION 

COURT OF WORKERS' COMPENSATION CLAIMS 

AT MURFREESBORO 

Kaled Girgis, ) Docket No.: 2015-05-0303 

Employee, ) 

v. ) 

LaCosta, Inc., ) State File No.: 59197-2015 

) 

Employer, ) 

And ) 

Accident Fund, ) Judge Thomas Wyatt 

Insurance Carrier. ) 

COMPENSATION HEARING ORDER FOR TEMPORARY DISABILITY, 

PERMANENT DISABILITY AND MEDICAL BENEFITS-DECISION ON THE 

RECORD 

This matter came before the undersigned Workers' Compensation Judge on 

October 30, 20 17, for a Compensation Hearing. The parties stipulated the 

compensability of the claim, including stipulation of La Costa, Inc.'s liability for charges 

that Kaled Girgis incurred personally for treatment of his back injury. The sole issue for 

the Court's determination is whether LaCosta must pay Mr. Girgis directly for his past, 

unpaid, medical charges. For the reasons set forth below, the Court holds that the 

providers who treated Mr. Girgis' back injury must submit their charges to LaCosta or its 

carrier for payment under the workers' compensation fee schedule. 

History of the Claim 

Mr. Girgis injured his back at Bridgestone's Murfreesboro tire plant. He worked 

there under a contract by which LaCosta provided cleaning services. 

LaCosta initially denied that Mr. Girgis' injury arose primarily out of and in the 

course and scope of employment, thus necessitating that Mr. Girgis seek treatment on his 

own. Mr. Girgis came under the care of orthopedist Dr. Sanat Dixit, who surgically 

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repaired discs at the L4-5 and L5-S 1 spinal levels. Mr. Girgis received bills totaling 

more than $90,000 for unauthorized treatment of his then-denied, but now-compensable, 

back injury. 

Mr. Girgis filed a Petition for Benefit Determination to challenge LaCosta's denial 

of his claim. After extensive participation in litigation, LaCosta accepted the 

compensability of Mr. Girgis' claim. The parties now stipulate that LaCosta shall pay 

Mr. Girgis $16,348.80 in temporary disability benefits, $12,656.80 in permanent partial 

disability benefits, and mileage reimbursement for 815 miles at the statutory rate. The 

parties also agreed that Dr. Dixit will provide ongoing reasonable and necessary medical 

treatment ofMr. Girgis' compensable injury. 

LaCosta also agreed to pay for treatment that Mr. Girgis received during the 

period of denial. However, Mr. Girgis insists that LaCosta pay the full, billed, charges 

directly to him so he can pay the treating providers himself. LaCosta asserts that the 

treating providers must submit their charges for payment under the workers' 

compensation fee schedule. The parties, thus, submitted the payment issue to the Court 

for determination on the record without an evidentiary hearing. Upon review, the Court 

determined that the record contains sufficient evidence to allow the Court to decide the 

payment issue on the record. 1 

Findings of Fact and Conclusions of Law 

In deciding the disputed issue, the Court seeks guidance, as it must, from the 

statutes and bureau regulations that govern the payment of medical bills in workers' 

compensation claims. Tennessee Code Annotated section 50-6-204(a)(l)(A) (2016) 

requires the employer to "furnish, free of charge to the employee, such medical and 

surgical treatment, medicine, medical and surgical supplies . . . made reasonably 

necessary by [a work-related] accident[.]" The law, however, does not require that the 

employer pay the treating provider's full, billed, charges for compensable medical 

services and supplies. Section 50-6-204(a)(3)(A)(iii) limits the employer's liability for 

compensable treatment to "the maximum allowable fees that are established in the 

applicable medical fee schedule adopted pursuant to this section." 

The Bureau's rules address the payment issue more specifically. Tennessee 

Compilation Rules and Regulations 0800-02-17-.1 0(1) (March 2014) provides that 

"[r]eimbursement for all health care services and suppliers shall be the lesser of (a) the 

provider's usual billed charges, [or] (b) the maximum fee calculated according the these 

rules[.]" The above rule also mandates that a provider "shall receive no more than the 

1 The Court is aware that the parties did not obtain certification of this issue by a mediator following their 

participation in post-discovery mediation. The Court will permit the parties to submit the payment issue for 

determination without certification because they negotiated in good faith and were successful in resolving all issues 

but the payment issue. See Tenn. Code Ann. § 50-6-239(b )(20 17). 

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maximum allowable payment, in accordance with these Rules, for appropriate health 

services rendered to a person who is entitled to health care services under the Act." Rule 

0800-02-17-.03(42) defines "maximum allowable payment", in part, by stating that, "[i]n 

no event shall [a provider's] reimbursement be in excess of the [Bureau's] Medical Fee 

Schedule." (Emphasis added.) 

The Bureau's rules also govern the methodology by which a provider of 

compensable treatment shall bill charges for payment under workers' compensation. 

Rule 0800-02-17-.05(1) provides that, "[s]ervices and medical supplies must be coded 

with valid procedure and supply codes of the Health Care Financing Administration 

Common Procedure Coding System[.]" An employer and/or its carrier may return 

incorrectly-billed charges to the provider and delay payment until the provider resubmits 

proper billing documentation. See Tenn. Compilation R. and Regs. 0800-02-17-.1 0( 17). 

Turning now to the positions of the parties, Mr. Girgis contended LaCosta's denial 

forced him to obtain treatment of his back injury outside the workers' compensation 

system. He argued that, under these circumstances, the Court should order LaCosta to 

pay him directly for the charges he incurred for unauthorized treatment. 

In support of this position, Mr. Girgis relied on two opinions decided long before 

the enactment of the 2013 reform act, N J. Zinc Co. v. Cole, 532 S.W.2d 246 (Tenn. 

1975), and Bituminous Casualty Corp. v. Smith, 200 Tenn. 13, 288 S.W.2d 246 (1956). 

While both of these opinions required employers to pay unauthorized medical charges in 

claims the employers initially denied, neither stands for the proposition that an employer 

must, or even should, pay unpaid charges directly to the employee, instead of to the 

uncompensated provider. 

Mr. Girgis also cited GAF Building Materials v. George, 47 S.W.3d 430 (Tenn. 

2001), in support of his position. However, this opinion involved an employee's 

exemption from the physician-selection statute in a claim initially denied by an employer. 

Nothing in the GAF opinion indicated that the Supreme Court intended to expand its 

ruling there past the specific facts before the court, and the Court will not so expand the 

ruling here.2 

LaCosta urged the Court to resolve the payment issue consistently with the 

Supreme Court's opinion in Staggs v. Nat'/ Health Corp., 924 S.W.2d 79 (Tenn. 1996). 

In Staggs, the court held that "an employee is not entitled to personally receive payment 

for medical expenses unless he or she personally paid the medical expenses and is due 

2 Mr. Girgis also asked for direct payment because LaCosta was guilty of "unclean hands" in denying his claim. 

LaCosta argued it validly denied the claim based on the information it had at the time of the denial. Mr. Girgis came 

forward with no evidence on the issue of why LaCosta denied Mr. Girgis' claim, thus the Court has no basis upon 

which to apply the "unclean hands" doctrine. 

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reimbursement. Instead, employers must pay the providers of medical care directly for 

incurred medical expense. "

3 /d. at 81. 

The Court holds the ruling in Staggs provides the clearest precedential authority 

applicable to the issue raised here. The ruling is consistent with Tennessee Compilation 

Rules and Regulations 0800-02-17-.11, which provides that: "[i]f an employee has 

personally paid for a health care service and at a later date a carrier is determined to be 

responsible for the payment, then the employee shall be fully reimbursed by the carrier." 

Thus, the Court holds that Mr. Girgis can only compel direct payment of a medical 

charge he incurred for treatment of his compensable injury if he shows he paid for the 

charge out-of-pocket. If he did not pay for the charge out-of-pocket, the Court holds that 

the provider of the subject charge must submit the charge to LaCosta or its carrier for 

payment under the applicable fee schedule. The Court will, however, require that 

LaCosta and/or its carrier immediately contact the providers who treated Mr. Girgis' 

spinal injury with instructions on how to submit their charges for payment. 

It is, therefore, ORDERED: 

1. That LaCosta and/or its carrier shall pay Mr. Girgis directly for any out-ofpocket payments he made toward the charges incurred for past reasonable 

and necessary treatment of his compensable injury; otherwise, LaCosta 

shall pay the charges incurred for past reasonable and necessary treatment 

of Mr. Girgis' injury after the providers of that treatment have presented 

their charges to LaCosta and/or its carrier upon appropriate billing forms; 

2. That LaCosta and/or its carrier shall immediately contact the providers of 

the past reasonable and necessary treatment of Mr. Girgis' injury with 

instructions on how to most expeditiously file for payment of their charges; 

3. That Dr. Dixit is the authorized treating physician for ongoing reasonable, 

necessary, and related medical treatment; 

4. That the parties shall schedule a telephonic hearing with the Court's Legal 

Assistant (J di.downs@tn.gov) within twenty days from the date of the 

entry of this order so that the Court can approve the terms to which the 

parties agreed in this claim. The parties shall utilize the standard settlement 

templates in presenting the agreed terms to the Court for approval; 

3 Both parties cited appellate opinions involving non-workers' compensation claims in support of their positions. 

Because workers' compensation is governed by statutory enactment, the Court holds those opinions are inapplicable 

here. 

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5. That LaCosta and/or its carrier shall pay taxed court costs of $150.00 

pursuant to Tennessee Compilation Rules and Regulations Rule 0800-02-

21-.07 (2016); 

6. That counsel for LaCosta shall prepare and submit a Statistical Data Form 

for this matter within ten calendar days of the date of this judgment; and 

7. That counsel for Mr. Girgis shall file a petition for approval of his 

attorney's fees and expenses. 

ENTERED this the 30th day of October, 2017. 

Judge Thomas Wyatt 

Court of Workers' Compensation Claims 

APPENDIX 

Technical record: The Court considered the following documents filed with the Clerk of 

the Court or Workers' Compensation Claims in making its decision in this claim: 

1. Petition for Benefit Determination; 

2. Dispute Certification Notice; 

3. Request for Expedited Hearing; 

4. Initial Hearing Order; 

5. Transfer Order; 

6. Order of Continuance; 

7. Order; 

8. Request for Admissions with attached billing records; 

9. Order Setting Forth Procedure on Compensation Hearing Decision on the 

Record; 

10. Agreed Order of Stipulation; 

11. Employer's Brief; and 

12. Employer's Response Brief. 

Exhibits: The parties submitted all evidence as attachments to the documents listed in the 

Technical Record. 

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CERTIFICATE OF SERVICE 

I hereby certify that a true and correct copy of this Compensation Hearing Order 

was sent to the following recipients by the following methods of service on this the 30th 

day of October, 2017. 

Name Certified 

Mail 

Thomas A. Travaglini, 

Employee Attorney 

Gordon Aulgar, 

Employer Attorney 

Via Service sent to: 

Email 

X Kaklegal13@aol.com 

X Gordon .aulgar@accidentfund.com 

---l. Penny~ e 11\ A~}~d"JW\ Court ----=-ftJ,~ Court of Workers' Compensation Claims 

WC.CourtCJerk@tn.gov 

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