Opinion ID: 874037
Heading Depth: 2
Heading Rank: 1

Heading: Causation was necessarily put at issue before the Commission.

Text: Gomez argues on appeal that it was error for the Commission to ignore the issues regarding reasonableness of treatment as agreed to by the parties and instead focus on the issue of causation for its decision. Gomez argues that the Commission is required to rule on only those issues agreed to by the parties for the hearing and included in the written notice of the hearing from the Commission. Also, Gomez argues that once medical benefits are initially allowed, the question of causation is automatically settled. Because causation is an issue whenever entitlement to benefits is at question, we disagree.
This Court has said that administrative tribunals are unable to raise issues without first serving an affected party with fair notice and a full opportunity to meet such issues. Hernandez v. Phillips, 141 Idaho 779, 781, 118 P.3d 111, 113 (2005) (citing White v. Idaho Forest Indus., 98 Idaho 784, 786, 572 P.2d 887, 889 (1977)). Idaho Code § 72-713 is the legislature's codification of this rule, requiring the Commission to provide parties with a written notice of issues to be heard at a Commission hearing. Id. Idaho Code section 72-713 states that the commission shall give at least ten (10) days' written notice of the time and place of hearing and of the issues to be heard. . . . The issue of whether this notice required by I.C. § 72-713 needs to specifically state each individual issue in the text of the issues statement of the notice was answered in Hernandez. Id. at 781-82, 118 P.3d at 113-14. Further, the necessity of specifically listing the issue of causation in the issues statement was answered in Henderson v. McCain Foods, Inc., 142 Idaho 559, 564-65, 130 P.3d 1097, 1102-03 (2006). In Hernandez, the claimant was given proper notice of three issues regarding entitlement to medical benefits, temporary disability benefits, and attorney fees before the Commission. 141 Idaho at 781, 118 P.3d at 113. Yet, the claimant argued that the issues of impairment and maximum medical improvement (MMI), of which the Commission referee made findings, could not be at issue because they were not specifically listed in the notice's issues statement. Id. This Court disagreed, holding that the issue of MMI was necessarily at issue by virtue of his claim for additional temporary income benefits because whether the claimant was entitled to temporary income benefits turned on whether claimant had reached MMI. Id. If the claimant had reached MMI by a certain date, no additional temporary income benefits could be awarded, but if not, the claimant was entitled to the benefits. Id. Additional temporary income benefits could not be awarded without addressing the issue of MMI. Similarly in Henderson, this Court found that since the claimant had made a claim for further medical benefits, the unspecified issue of causation was put at issue by virtue of [the claimant's] claim. 142 Idaho at 564, 130 P.3d at 1102. Since prior decisions ha[d] made it clear that an employee seeking compensation for medical care must prove that there is a causal relationship between the industrial accident and the need for the medical care, the Commission was not required to specifically notice the issue of causation. Id. It was necessarily at issue to address the issue of entitlement to medical benefits sought in the case. Medical treatments could be the most reasonable available option for a claimant's symptoms, but if there is no causal connection, there will ultimately be no entitlement to benefits. Id. at 565, 130 P.3d at 1103 (Even though medical care is reasonable, it is still not compensable unless the care was due to the industrial accident.). In the present case, if there was no causal connection between Gomez's industrial injury and the treatment she received, the noticed issue of reasonableness is irrelevant. [2] Like in Hernandez, the issue specifically listed in the notice issues statement turned on another question that was not listed in the notice. In Hernandez, the issue before the Commission turned on MMI, here it turns on a causal connection between Gomez's industrial injury and the treatment she received. Therefore, we hold that I.C. § 72-713 does not require specific notice of causation. Causation is put on issue by virtue of any claim regarding the reasonableness of medical benefits arising from an industrial accident or disease; even if reasonableness is found without causation, there is no entitlement to benefits.
Similarly to the claimant in Henderson, Gomez contends that she was denied due process of law because she was not on notice that she would have to prove a causal connection between her industrial accident and her [medical treatment]. See id. at 563, 130 P.3d at 1101. This Court held that the claimant in Henderson was not denied due process by the failure to expressly state causation as one of the issues before the Commission. Id. at 564, 130 P.3d at 1102. Gomez argues that this holding in Henderson should not be applied to her case because causation was not addressed in a previous hearing before the Commission as it had been in Henderson. See id. at 563, 130 P.3d at 1101. Regardless of the factual differences, the holding in Henderson applies to Gomez's claim. There is no dispute that the claimant in Henderson had two hearings before the Commission. The first of these hearings found that various symptoms were not caused by the claimed industrial accident. Id. Upon the claimant's motion, the Commission allowed an additional hearing to address whether costs for a subsequent neck surgery and post-operative care could be recovered. Id. The notice for the second hearing did not state that causation would be addressed. Id. Nevertheless, the claimant in Henderson was still required to prove the causal relationship between the necessary surgery for a claimant's symptoms and the industrial accident. Id. at 564, 130 P.3d at 1102. Just because a particular treatment is necessary for the claimant's medical condition, that does not automatically lead to a determination that the claimant is entitled to workers' compensation benefits. See Fife v. Home Depot, Inc., ___ Idaho ___, ___, 260 P.3d 1180, 1184 (2011). The conclusion that the claimant's due process rights were not denied by an unspecified notice of issues did not rely on the fact that causation was at issue at a previous hearing before the Commission and therefore somehow the claimant was already on notice because of the subject matter addressed in the first hearing. The conclusion was based on the fact that causation was a necessary step along with reasonableness of care to prove to the Commission the claimant was entitled to medical benefits. See Henderson, 142 Idaho at 564, 130 P.3d at 1102. The notice in Henderson did not come from knowledge gained by participating in previous proceedings; the notice came from an understanding of the proof necessary to show entitlement to medical benefits. Specific notice of causation is not necessary prior to an initial hearing before the Commission as Gomez contends. Rather specific notice of causation is unnecessary when the specifically noticed issue before the Commission is reasonableness of treatment because causation is an element of the ultimate goal of entitlement to benefits. Id. at 565, 130 P.3d at 1103. Since Gomez was seeking to show she was entitled to medical benefits by showing reasonableness of the treatment received, this Court holds that she, like the claimant in Henderson, was on notice of the need to prove a causal connection between her industrial accident and the treatment she received.
Gomez sought an emergency hearing with the Commission to address the reasonableness of the treatment she received for back pain after her medical benefit payments were suspended. The Commission found that Gomez had not proven that the symptoms she had treated medically were caused by the occupational accident at question in this case. She now argues that since some benefit payments were made for her medical treatment, the question of causation could no longer be an issue. She believes I.C. § 72-432(1) infers the establishment of a presumptive causal connection once an employer or surety commences payment for a claimant's medical care and argues that the statute does not require causation be addressed before a physician is visited.
Idaho Code 72-432(1) states: Subject to the provisions of section 72-706, Idaho Code, the employer shall provide for an injured employee such reasonable medical, surgical or other attendance or treatment, nurse and hospital services, medicines, crutches and apparatus, as may be reasonably required by the employee's physician or needed immediately after an injury or manifestation of an occupational disease, and for a reasonable time thereafter. If the employer fails to provide the same, the injured employee may do so at the expense of the employer. The reasonableness of a required treatment is an analysis required by I.C. § 72-432(1). Hipwell v. Challenger Pallet & Supply, 124 Idaho 294, 298, 859 P.2d 330, 334 (1993). This analysis is unnecessary if the medical care is unconnected to an industrial accident. Henderson, 142 Idaho at 565, 130 P.3d 1097, 1103 (Even though medical care is reasonable, it is still not compensable unless the care was due to the industrial accident.). The Commission cannot make a meaningful Sprague reasonableness analysis without some consideration of causation involved because causation is at the root of all workers' compensation questions. Requiring the Commission to ignore causation simply because the employer or surety has commenced with providing benefits prior to a Sprague inquiry would be unwarranted. An employer or surety is allowed to stop payment of benefits or refuse payments altogether if the treatment is found to be unconnected to the industrial injury. Fife, ___ Idaho at ___, 260 P.3d at 1184 (An employer is not liable for medical expenses unrelated to an industrial accident.); Troutner v. Traffic Control Co., 97 Idaho 525, 528, 547 P.2d 1130, 1133 (1976) ([T]he employer or surety [is given] the opportunity to investigate the claim in order to assure itself that it was obligated by I.C. § 72-432 to provide the treatment.). Section 72-432(1) protects employees, mandating that employers provide necessary medical services for employees injured on the job. St. Alphonsus Reg'l Med. Ctr. v. Edmondson, 130 Idaho 108, 111, 937 P.2d 420, 423 (1997); Harrison v. Osco Drug, Inc., 116 Idaho 470, 473, 776 P.2d 1189, 1192 (1989). However, Idaho Code § 72-432(1) does not eliminate the need to show causation. Henderson, 142 Idaho at 565, 130 P.3d at 1103. Further, if I.C. § 72-432(1) were interpreted to presume causation, this would essentially lead to the employer or surety insisting on evidence as to causation before providing benefits, thus being against the claimant's interests and vastly restricting timely access to needed care. Therefore, causation cannot be presumed in a Sprague analysis.
An employee seeking medical benefits is required to show causation; this requirement is not the responsibility of a physician providing treatment. Id. To recover medical benefits, the employee must prove both that the need for the medical care was due to the accident and that the medical care was reasonable. Id. Physicians merely treat the symptoms before them. The statute does not presume that this medical treatment by the physician will be covered, it only mandates that an employer or surety will provide or reimburse for reasonable treatment related to an industrial injury. Fife, ___ Idaho at ___, 260 P.3d at 1184 ([A] determination that a particular treatment was required for a claimant's medical condition does not equate to a determination that the employer or surety is liable for the cost of that treatment.). If an employee wishes to be compensated for this treatment, the employee must show that the care was reasonable and that it was related to the industrial accident or disease. Henderson, 142 Idaho at 565, 130 P.3d at 1103. While Gomez is correct that I.C. § 72-432(1) does not include causation language, it is still a question that must be addressed along with the reasonableness of treatment before an entitlement to benefits can be reached. The Commission is not going to look to see if a physician has established causation before a treatment as Gomez contends, but will always analyze whether the treatment was reasonable under Idaho Code section 72-432(1) while mindful of the requirement that causation be proven before an employee's entitlement to benefits is found. Causation is a subsequent determination to the treatment itself. Troutner, 97 Idaho at 528, 547 P.2d at 1133. Idaho Code section 72-432(1) is not a tool that can be used by an employer or surety to deny benefits if a physician does not prove a causal connection, as Gomez contends, nor has it ever envisioned being so. Idaho Code section 72-432(1) merely ensures that an employer or surety is limited to compensating for only medical treatment related to an employee's industrial accident or disease. See Fife, ___ Idaho at ___, 260 P.3d at 1184. Should an employer or surety deny benefits, I.C. § 72-432(1) can still mandate later compensation if the treatment is necessary, reasonable, and related to the industrial accident or disease. See, e.g., Reese v. V-1 Oil Co., 141 Idaho 630, 634, 115 P.3d 721, 725 (2005) (I.C. § 72-432(1) authorizing treatment at employer's expense after employer denial; where surgery was reasonably required and was needed as a consequence of the claimant's work-related injury); Troutner, 97 Idaho at 528, 547 P.2d at 1133 (surety can be liable despite initial refusal to authorize treatment). This Court finds that I.C. § 72-432(1) does not presume causation, nor does it allow an employer or surety to deny medical care on every single physician visit.