Court Opinion

ID: 3164251
Source: CourtListenerOpinion
Date Created: 2015-12-21 16:05:56.954207+00
Date Added: 2024-06-11T12:02:11.222679
License: Public Domain

146 P.3d 801, 805 (2006) ("[T]his court affords no deference to the district
                  court's ruling in judicial review matters.").
                              We conclude that the appeals officer erred in his
                  interpretation of NRS 616C.495.      See City of N. Las Vegas v. Warburton,
                  127 Nev. 682, 686, 262 P.3d 715, 718 (2011) (stating this court reviews
                  questions of law, like statutory interpretation, arising out of
                  administrative appeals de novo). When a person seeks to reopen his or her
                  workers' compensation claim after accepting a permanent partial
                  disability (PPD) lump sum payment, NRS 616C.495 controls. Under NRS
                  616C.495(2)(a)(1)'s plain terms, a person can reopen his or her workers'
                  compensation claim after accepting a PPD lump sum payment if he or she
                  satisfies the requirements of NRS 616C.390.'
                              Here, Vela accepted a PPD lump sum payment, and then
                  sought to reopen her workers' compensation claim. However, instead of
                  looking only towards the requirements of NRS 616C.390, as instructed by
                  NRS 616C.495, the appeals officer relied on NRS 616C.495(2)'s language
                  that "Mlle claimant's acceptance of [the PPD lump sum payment]
                  constitutes a final settlement of all factual and legal issues in the case,"
                  and other appeal dates and waiver language which arose over the course
                  of Vela's workers' compensation claim. As a result, the appeals officer
                  precluded Vela from reopening her claim. This was error. In assessing
                  whether Vela could reopen her claim, the appeals officer should have
                  focused entirely on NRS 616C.390. See Day v. Washoe Cnty. School Dist.,

                        'All of the paperwork signed by Vela in accepting her PPD lump
                  sum payment mirrored the language of NRS 616C.495, and thus, aligns
                  with the statutory interpretation of NRS 616C.495 as set forth.

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                  121 Nev. 387, 390, 116 P.3d 68, 70 (2005) (explaining in a case featuring
                  similar facts that when an injured employee seeks to reopen his or her
                  workers' compensation claim, the pertinent analysis falls under NRS
                  616 C .390).
                                 Under NRS 616C.390, an insurer must reopen a claim if (1)
                  "[the] application to reopen a claim is made in writing within 1 year after
                  the date on which the claim was closed," (2) "[t]he application is supported
                  by medical evidence demonstrating an objective change in the medical
                  condition of the claimant," and (3) "[t]here is clear and convincing evidence
                  that the primary cause of the change of circumstances is the injury for
                  which the clam was originally made." NRS 616C.390(4).
                                 Vela satisfied NRS 616C.390's first requirement because she
                  filed her application to reopen her claim only 15 days after her claim had
                  closed. The appeals officer's factual findings support this, as he found that
                  Vela "requested reopening only two weeks after the closure of her claim."
                  While it is not clear what the appeals officer precisely found in regards to
                  the second element, his findings generally, along with evidence in the
                  record, support the conclusion that Vela's application to reopen was
                  supported by medical evidence demonstrating an objective change in her
                  medical condition. 2
                                 Finally, as to NRS 616C.390's third requirement, the appeals
                  officer found that Vela had "not shown that her worsening of condition is
                  primarily related to the industrial strain of her lumbosacral spine." We
                  conclude, based on the record as a whole, that this finding by the appeals

                        2 This conclusion is supported by Dr. Lynch's diagnosis and reliance
                  on an X-Ray and an MRI, and Dr. Hall's affirmation of that diagnosis.

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                   officer was clearly erroneous.   See Day, 121 Nev. at 389, 116 P.3d at 69
                   ("While this court will not substitute its judgment for that of the agency as
                   to the weight of the evidence, this court will reverse an agency decision
                   that is clearly erroneous in light of reliable, probative, and substantial
                   evidence on the whole record." (internal quotations omitted)). In making
                   his decision, the appeals officer gave more weight to office paperwork and
                   Dr. Hall's expert opinion (who only spent 30 minutes in total on the case),
                   over Dr. Lynch's expert opinion (a board-certified spinal neurosurgeon who
                   treated Vela), Dr. Rappaport's expert opinion (who treated Vela), and Dr.
                   Nagy's expert opinion (a board certified neurosurgeon). 3 Thus, we
                   conclude that Vela satisfied all the requirements necessary to reopen her
                   workers' compensation claim after the awardS of her lump sum payment.
                                We further conclude that CCMSI is equitably estopped from
                   limiting Vela to treatment for a lumbar strain because (1) CCMSI covered
                   her treatment by Dr. DeMordaunt even when he treated her for more than
                   a strain, (2) CCMSI's claim manager Hickson told Vela over the phone she
                   could reopen her claim for surgery, and (3) CCMSI never issued a letter to
                   Vela pursuant to NRS 616C.065(7) denying coverage of her spinal
                   conditions beyond a strain. See Dickinson v. American Medical Response,
                   124 Nev. 460, 467, 186 P.3d 878, 883 (2008) ("Equitable estoppel may be
                   invoked against a party who claims a statutory right in administrative

                         3 We have considered the parties remaining arguments and conclude
                   that they are without merit. Specifically, the argument CCMSI raised in
                   its answering brief that it cannot be held responsible for payment to Dr.
                   Lynch because Dr. Lynch was not on the insurer's panel of treating
                   physicians, as well as the argument that Vela never requested a change of
                   physician pursuant to NRS 616C.090, are not appropriate for this appeal.

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                    workers' compensation proceedings, when the invoking party has
                    reasonably relied on the other party's words or conduct to her detriment.")
                                 Accordingly, we
                                 ORDER the judgment of the district court REVERSED AND
                    REMAND this matter to the district court for proceedings consistent with
                    this order, and instruct the district court to enter an order reversing the
                    appeals officer's decision.

                                                       Gibbons

                                                                                    ,   J.

                    cc: Hon. James E. Wilson, District Judge
                         James Georgeson, Settlement Judge
                         Nevada Attorney for Injured Workers/Carson City
                         Attorney General/Carson City
                         Beckett, Yott, McCarty & Spann/Reno
                         Carson City Clerk

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