Opinion ID: 6472356
Heading Depth: 2
Heading Rank: 1

Heading: Employer/Insurer’s Right to Choose a HCP for Worker

Text: {18} Claimant argues that the WCJ erred by allowing Employer/Insurer a right to select Worker’s initial HCP because Employer/Insurer denied Worker’s claim for benefits. Claimant contends that Employer/Insurer did not have any rights under Section 52-1-49, because Worker did not have any rights under Section 52-1^49 prior to adjudication. Furthermore, Claimant argues the WCJ erred by allowing Dr. Shadoff to testify because he was neither a “treating” HCP nor authorized to provide an IME pursuant to Section 52-l-51(C). {19} Section 52-1-28 requires a worker to establish a causal connection between “an alleged disability” and an accidental injury when causation is denied by expert testimony of a health care provider. Section 52-1-51(0 provides that “[o]nly a health care provider who has treated the worker pursuant to Section 52-1-49 NMSA 1978 or the health care provider providing the independent medical examination pursuant to this section may offer testimony” at a worker’s compensation hearing. We believe the record in this case illustrates a circumstance the Legislature did not foresee. The WCJ and the Court of Appeals attempted to resolve the issue within the existing statutes, and so do we. We conclude that the Legislature intended to limit the use and number of experts in workers’ compensation cases, but also to ensure medical treatment was not postponed. See §§ 52-1-49, -51; see also Banks v. IMC Kalium Carlsbad Potash Co., 2003-NMSC-026, ¶ 28, 134 N.M. 421, 77 P.3d 1014 (“The Act limits testimony at the compensation hearing to a treating physician or a health care provider who has provided an independent medical examination pursuant to the Act.”). The purpose of the workers’ compensation administration was articulated in NMSA 1978, Section 52-5-1 (1990). It is the intent of the legislature in creating the workers’ compensation administration that the laws administered by it to provide a workers’ benefit system be interpreted to assure the quick and efficient delivery of indemnity and medical benefits to injured and disabled workers at a reasonable cost to the employers who are subject to the provisions of the Workers’ Compensation Act____ Id. The Legislature appears to have authorized both employer and worker an initial HCP selection, and then limited further selection to situations in which there was a disagreement about the proper treatment. See §§ 52-1-49, -51; see also 11.4.4.11 NMAC. The statutes and regulations do not directly address whether an employer has the right to make a HCP selection after it has denied coverage to a worker. {20} The Court of Appeals believed that the pivotal issue was whether Dr. Shadoff was a properly authorized HCP under Section 52-1-49. Grine, 2005-NMCA-075, ¶ 9, 137 N.M. 649, 114 P.3d 329. If he was not, then his testimony concerning Worker’s heart attack was not admissible under Section 52-1-51(0), and the WCJ could only rely on the testimony of expert Dr. Orchard. Id. The Court of Appeals held that Section 52-1-49 authorized Employer/Insurer to select a HCP for Worker, despite the fact that they denied Worker’s claim. Id. ¶ 13. The Court of Appeals agreed with Claimant “that neither the Act nor our case law specifically states whether a denial of a claim prohibits an employer from selecting a health care provider.” Id. After reviewing Section 52-1-49 and the workers’ compensation regulations, the Court of Appeals concluded that “Section 52-1-49 must be read to allow the employer and the worker each to make a selection of a health care provider at some point in a case. The employer’s right to make this selection would be eliminated if we were to adopt Worker’s interpretation of the statute.” Id. {21} We agree that Section 52-1^49 does not preclude an employer from selecting a HCP after it has denied a worker’s claim for benefits. Nevertheless, assuming Employer/Insurer received proper notice of Worker’s accident, we would reverse the Court of Appeals’ determination that Employer/Insurer made the initial HCP selection for Worker by requiring him to consult with Dr. Shadoff. We conclude that to be consistent with the Legislature’s intent expressed in Sections 52-1-49 and 52-1-51, we should hold Dr. Shadoff was not authorized to testify under Section 52-1-51(C). See Jurado v. Levi Strauss & Co., 120 N.M. 801, 907 P.2d 205 (Ct.App.1995) (holding that a doctor’s written impairment report was inadmissible in a worker’s compensation proceeding because the doctor neither treated the worker nor provided an IME). {22} The Court of Appeals agreed with the WCJ and concluded that Dr. Shadoff was Employer/Insurer’s initial HCP selection, while Dr. Orchard’s treatment was “authorized health care.” Grine, 2005-NMCA-075, ¶ 13, 137 N.M. 649, 114 P.3d 329; see also 11.4.4.11(C)(2)(c) NMAC (“Medical treatment provided to the Worker prior to the Employer’s written decision to either select the HCP, or to permit the Worker to select the HCP, shall be considered authorized health care, the cost of which is to be born by the Employer.”). According to the Court of Appeals, 11.4.4.11(C)(2)(e) NMAC “contemplates allowing an employer to exercise its rights under Section 52-H9(B), even though the worker may have already obtained medical treatment before the employer makes its choice under the statute.” Grine, 2005-NMCA-075, ¶ 13, 137 N.M. 649, 114 P.3d 329. The distinction between a qualified HCP under Sections 52-1-49 and 52-1-51(C), and authorized health care under 11.4.4.11(C)(2)(c) NMAC is not clear. We are not persuaded that authorized health care is equivalent to treatment by a qualified HCP. Rather, the regulations seem to serve the purpose of ensuring prompt medical attention for a work-related injury. Because neither party argues that Dr. Orchard’s testimony was inadmissible, however, we need not address this distinction. {23} Claimant argues that the WCJ and the Court of Appeals erred in allowing Dr. Shadoffs testimony. According to Claimant, Worker initially selected Dr. Orchard as his treating physician and the WCJ erred by concluding that Dr. Shadoff was the initial treating physician. Moreover, Dr. Shadoff was not properly authorized as a treating physician under Section 52-1-49, through either an initial or second selection process. Similarly, he was not authorized to conduct an IME under Section 52-l-51(A). Claimant argues, therefore, Dr. Shadoffs testimony was inadmissible under Section 52-l-51(C). We agree with Claimant that Dr. Shadoff was neither a “treating” physician under Section 52-1-49, nor authorized to provide an IME under Section 52-l-51(A). {24} If Employer had notice of the accident, it was required to “provide the worker in a timely manner reasonable and necessary health care services from a health care provider.” Section 52-l-49(A). In doing so, Employer was entitled to make the initial HCP selection or to permit Worker to make the selection. Section 52 — 1—49(B). “If the decision of the employer is not communicated in writing to the worker, the employer shall be presumed, absent other evidence, to have selected the HCP initially.” 11.4.4.11(C)(2)(b) NMAC. If Employer had notice and failed to communicate its HCP selection to Worker within a reasonable period of time, Dr. Orchard was Employer’s initial selection. Under these circumstances, Dr. Shadoff was not a qualified HCP under Section 52-1-49, and his deposition testimony would have been inadmissible. On this record, we need not decide whether Dr. Orchard was Employer’s initial selection. {25} We cannot classify Dr. Shadoff as a “treating” physician within the meaning of Section 52-l-51(C) when he only met with Worker on one occasion for a total of ten minutes on February 15, 2002, more than sixteen months after Worker’s heart attack. While we recognize that Dr. Shadoff was given Worker’s medical records, deposition, and job description to review, we believe Dr. Shadoffs ten minute consultation with Worker falls short of “treatment,” especially given the fact that this consultation occurred after Worker’s claim for benefits had been denied and after Worker filed a complaint with the WCJ. We reiterate that “[t]he expertise of a treating physician is the training, experience and familiarity with the patient whom he or she is treating. The ‘expert’ testimony required by Section 52-l-28(B) refers to testimony based on this training, experience and familiarity.” Banks, 2003-NMSC-026, ¶ 22, 134 N.M. 421, 77 P.3d 1014. Dr. Shadoff may have been a well-trained and experienced cardiologist, but he lacked familiarity with Worker as a patient. Dr. Shadoff met with Worker for ten minutes and immediately concluded that Worker’s heart attack was not work-related. Employer/Insurer’s selection of Dr. Shadoff appears to be an attempt to rebut Dr. Orchard’s opinion regarding causation, rather than an effort to treat Worker for his post-heart attack condition. Dr. Shadoff was not a treating HCP for purposes of Section 52-1-51(0). {26} Dr. Shadoff also did not provide an IME pursuant to Section 52-l-51(C). The WCJ properly denied Employer/Insurer’s request for an IME, because at the time of the request, there was no conflict between authorized medical providers as required by Section 52-1-51(A). See Ramirez v. IBP Prepared Foods, 2001-NMCA-036, ¶ 16, 130 N.M. 559, 28 P.3d 1100 (“disputes regarding medical issues must be between health care providers”). Additionally, prior to the 2005 amendment, an IME was not authorized to resolve an issue of causation. Id. ¶ 17. In Ramirez, the Court of Appeals stated: We do not believe that causation is a medical issue as contemplated by the IME statute. Causation involves medical opinion only when the employer denies causation. Then the worker is required to establish the causal connection by expert testimony of a health care provider. See NMSA 1978, § 52-1-28(B) (1987). Here, Employer denied causation, but sought the WCJ’s assistance in getting its own expert to negate Worker’s medical testimony. We do not believe that the legislature intended the IME statute to provide Employer with a medical expert to battle an existing medical provider on the issue of causation. Id.; but see NMSA 1978, § 52-1-51(A) (2005) (“In the event of a dispute between the parties concerning ... the cause of an injury or any other medical issue, if the parties cannot agree upon the use of a specific independent medical examiner, either party may petition a workers’ compensation judge for permission to have the worker undergo an independent medical examination.”) (Emphasis added.) Because Dr. Shadoff was neither a treating physician, nor authorized to provide an IME, his testimony was inadmissible.