Court Opinion

ID: 4560389
Source: CourtListenerOpinion
Date Created: 2020-08-26 21:02:07.942574+00
Date Added: 2024-06-11T11:17:15.405559
License: Public Domain

FILED
                                                                                            Jun 06, 2019
                                                                                            01:18 PM(CT)
                                                                                          TENNESSEE COURT OF
                                                                                         WORKERS' COMPENSATION
                                                                                                CLAIMS

                TENNESSEE BUREAU OF WORKERS' COMPENSATION
               IN THE COURT OF WORKERS' COMPENSATION CLAIMS
                                AT JACKSON

LORI HILL,                                              )    Docket No. 2018-07-0411
                   Employee,                            )
v.                                                      )
COX OIL COMPANY,                                        )    State File No. 79342 2017
         Employer,                                      )
And                                                     )
ACCIDENT FUND INSURANCE                                 )    Judge Amber E. Luttrell
COMPANY OF AMERICA,                                     )
         Carrier.                                       )

                               COMPENSATION HEARING ORDER

        The Court held a Compensation Hearing on May 8, 2019, on Ms. Hill's request for
workers' compensation benefits for alleged injuries to her right foot and left knee. The
parties disputed whether Ms. Hill sustained permanent impairment for her compensable
right-foot injury and whether she suffered a compensable left-knee injury. For the reasons
below, the Court awards Ms. Hill permanent partial disability benefits and future medical
benefits for her foot injury; the Court awards no permanent partial disability benefits, but
does award limited medical benefits for the knee injury.

                                              History of Claim

       Ms. Hill works for Maverick Convenience Store, which is owned by Cox Oil
Company. On September 28, 2017, she worked in the deli, and a heavy container of
chicken fell on her right foot. She reported the injury and sought treatment at the
emergency room in Humboldt. 1 Cox Oil authorized treatment at Physicians Quality Care,
who then referred her to Dr. Douglas Haltom, an orthopedic specialist. Ms. Hill later
sought an independent medical evaluation with Dr. Samuel Chung. The parties took the
depositions of Dr. Haltom and Dr. Chung and introduced the following medical proof.

1
    The parties did not introduce the hospital records into evidence.

                                                        1
                                 Treatment and Physicians' Testimony
                                            Dr. Haltom 2

       Ms. Hill saw Dr. Haltom approximately five weeks after the injury for continued
foot pain. Following a normal x-ray, he diagnosed a foot contusion with neuropathic pain.
Dr. Haltom subsequently ordered an MRI, which revealed nondisplaced fractures at the
third and fourth metatarsals. He recommended she continue using a walking boot and
weight-bear as tolerated; he also prescribed crutches for use at home. After several
months of conservative treatment, Dr. Haltom concluded Ms. Hill reached maximum
medical improvement for her right-foot injury on January 9, 2018, and returned her to full
duty. He testified she had minimal swelling, no tenderness to palpation, and x-rays
indicated no bony abnormalities. Dr. Haltom assessed a zero-percent impairment rating
for her foot injury under Table 16-2 on page 504 of the American Medical Association's
Guides to the Evaluation of Permanent Impairment ("AMA Guides"). 3 Dr. Haltom
considered x-rays and Ms. Hill's most recent physical exam and functional history to
assess her impairment.

        During Ms. Hill's treatment for her foot injury, she reported the onset of left-knee
pain. Dr. Haltom testified her symptoms were secondary to wearing the walking boot. He
explained the boot had an uneven inch-and-a-half sole that can cause opposite-sided leg
pain and irritation from an uneven gait. He diagnosed inflammation of the joint lining of
the knee. Dr. Haltom provided conservative treatment for her complaints for two months
and she reported some improvement. He later ordered an MRI, which revealed a radial
tear to the medial meniscus and mild to moderate arthritis. Before her MRI, Dr. Haltom
noted that Ms. Hill reported that "she slipped the other day at work and had increase in
pain, but she has not had her MRI yet." Dr. Haltom did not address this incident further.

      Regarding causation for the knee, Dr. Haltom testified within a reasonable degree
of medical certainty that Ms. Hill's meniscus tear and arthritis were not primarily caused
by her work injury. He stated Ms. Hill did not have an injury mechanism to sustain a
traumatic radial tear of her meniscus. He believed the use of the walking boot had "some
impact" but determined that it exacerbated an underlying problem.

      On cross-examination, Dr. Haltom further explained the basis for his opinion that
her meniscus tear was not a work injury. He stated the basis for his opinion was "her
work injury mechanism and the fact that she had arthritic changes in her knee, and that
the vast majority of meniscus tears are degenerative . . . [b ]ut No. 1 would be her
mechanism that was reported to me."

          Regarding the impact of the walking boot, Dr. Haltom stated that "it could cause

2
    Dr. Haltom is a board-certified orthopedic surgeon.
3
    Both physicians testified they used the Sixth Edition of the AMA Guides.

                                                      2
an irritated and inflamed knee." Upon questioning regarding an aggravation or
exacerbation caused by the boot, Dr. Haltom stated, "I could state the aggravation of her
left knee, the complaints of left knee pain and swelling, would be primarily caused from
the boot wear on the opposite extremity."

       Cox Oil provided authorized treatment for Ms. Hill's left-knee complaints related
to the boot until the MRI indicated a radial tear of the medial meniscus and Dr. Haltom
recommended surgery to repair it. Cox Oil denied surgery based on Dr. Haltom's opinion
that the tear did not primarily arise out of her injury; therefore, Ms. Hill underwent
surgery under her personal health insurance.
                                                      4
                                          Dr. Chung

       Ms. Hill saw Dr. Chung one time for an independent medical evaluation. Dr.
Chung summarized Ms. Hill's history of her foot injury and later left-knee pain from
wearing the walking boot and her treatment. He testified Ms. Hill also reported that,
while undergoing conservative treatment for her left knee, she had an incident at work
where she slipped on water on the kitchen floor and twisted her left knee, causing
increased pain. Afterward, Ms. Hill had the MRI, and Dr. Haltom diagnosed the meniscal
tear.

        Dr. Chung reviewed the MRI report, and in addition to the tear, he noted it
revealed osteoarthritis with mild to moderate articular cartilage loss. He also noted Ms.
Hill underwent a left-knee arthroscopy with partial medial meniscectomy. Dr. Chung
testified Ms. Hill reported continued left-knee pain with squatting, walking, or climbing
stairs even after surgery. On exam of the right foot, Dr. Chung noted slight swelling and
mild pain in the dorsum of the foot and pain in the bottom of the right mid-foot. Dr.
Chung's left-knee exam indicated crepitus on flexion, which he stated sounded like
arthritis causing friction. He noted minimal tenderness in the medial joint line and
prepatellar area with palpation and some range of motion deficits. Dr. Chung obtained an
x-ray of Ms. Hill's left knee and stated he measured two millimeters of cartilage interval
between the medial patellofemoral joint line on the x-ray.

       Regarding causation for the knee, Dr. Chung testified, "the left knee injury clearly
was stemming from the subsequent weight-bearing on the left knee with wearing the
walking boot but also the incident that took place ... at her workplace where she slipped
and then twisted her left knee." He further stated her injuries to her right-foot and left-
knee were greater than fifty-percent caused by her work activities.

       Dr. Chung concluded Ms. Hill retained permanent impairment for her right foot

4
  Dr. Chung is an osteopath with board certifications in physical medicine and rehabilitation and
independent medical evaluations.

                                                3
injury and left knee. For the right foot, he used Table 16-2 on page 504 of the AMA
Guides and assessed a Class 1, Grade D, one-percent permanent impairment to the body
for a healed nondisplaced fracture with abnormal exam findings. Dr. Chung based his
impairment rating on his clinical findings and Ms. Hill's continued mild pain with
weight-bearing and ambulation. For the left knee, Dr. Chung used Table 16-2 on page
511 and rated Ms. Hill for the diagnosis of patellofemoral arthritis with two millimeter
cartilage interval. He assessed a Class 1, Grade C, four-percent permanent impairment to
the body.
                                   Additional Testimony

       Ms. Hill testified she returned to work for Cox after Dr. Haltom released her. She
currently works as a cashier and "works the floor," which consists of sweeping, mopping,
and stocking coolers.

        Ms. Hill continues to experience pain and swelling in her right foot if she stands
for longer than two or three hours. She further stated she has stiffness in her left knee
after sitting and knee pain while sleeping. She can no longer squat or sit on the floor to
play with her grandchildren.5

                           Findings of Fact and Conclusions of Law

       At a Compensation Hearing, the employee must establish by a preponderance of
the evidence that she is entitled to the requested benefits. Willis v. All Staff, 20 15 TN
Wrk. Comp. App. Bd. LEXIS 42, at *18 (Nov. 9, 20 15); see also Tenn. Code Ann. § 50-
6-239(c)(6) (2018).
                                        Right foot

        The parties stipulated Ms. Hill's foot injury arose primarily out of and in the
course and scope of her employment. Therefore, the Court holds Ms. Hill is entitled to
reasonably necessary future medical treatment recommended by Dr. Haltom under
Tennessee Code Annotated section 50-6-204. The issue the Court must address is
whether Ms. Hill sustained any permanent impairment that entitles her to permanent
partial disability benefits.

       The Court considers the competing impairment opinions to analyze whether Ms.
Hill successfully rebutted the statutory presumption afforded Dr. Haltom's zero-percent
rating by a preponderance of the evidence. See Tenn. Code Ann. §50-6-204(k)(l). For the
reasons below, the Court finds she did.

        Both Drs. Haltom and Chung used Table 16-2 for metatarsal fractures to assess

5
  Ms. Hill further testified she underwent surgery for a right knee meniscus tear several months after the
left knee. She maintained the left knee tear was related to her work injury.

                                                    4
Ms. Hill's impairment. However, they selected different classes for asstgnmg
impairment. Dr. Haltom assigned a zero-percent impairment under Class 0, which
requires a healed fracture with no objective deficits. He based his opinion on his exam
findings of a healed fracture, minimal swelling, and no tenderness on palpation.

       In contrast, Dr. Chung assigned a one-percent impairment under Class 1, which
requires a nondisplaced fracture with abnormal exam findings. He based his opinion on
his findings of mild swelling and pain on palpation on the dorsum of the foot and the
bottom of the mid-foot. He further based his impairment on Ms. Hill's continued mild
pain with weight-bearing and ambulation.

       Both physicians found swelling in Ms. Hill's foot on physical exam, eight months
apart, which was consistent with Ms. Hill's credible testimony regarding her ongoing
problems of swelling and pain in her foot. Tennessee law has long held that medical
proof is not to be "read and evaluated in a vacuum" but instead "must be considered in
conjunction with the lay testimony of the employee as to how the injury occurred and the
employee's subsequent condition." Thomas v. Aetna Life and Cas. Co., 812 S.W.2d 278,
283 (Tenn. 1991).

        The Court finds Dr. Chung's testimony regarding the foot impairment more
thorough than Dr. Haltom's and, when combined with Ms. Hill's testimony, was more
persuasive. Accordingly, the Court holds Dr. Chung's impairment opinion of one-percent
to the body to be the accurate anatomic rating for the foot.

                                         Left knee

       Turning to the knee, Ms. Hill must show her alleged injury arose primarily out of
and in the course and scope of her employment to establish a compensable injury.
Further, she must show "to a reasonable degree of medical certainty that [the injury]
contributed more than fifty percent (50%) in causing the death, disablement or need for
medical treatment, considering all causes." The term "reasonable degree of medical
certainty" means that "in the opinion of the physician, it is more likely than not
considering all causes, as opposed to speculation or possibility." See Tenn. Code Ann.
§50-6-102(14). Moreover, a compensable injury does not include an aggravation "unless
it can be shown to a reasonable degree of medical certainty that the aggravation arose
primarily out of and in the course and scope of employment." Tenn. Code Ann. § 50-6-
102(14)(A). Thus, causation must be established by expert medical testimony.

       Ms. Hill credibly testified regarding the details of her foot injury on September 28,
2017, and the resulting symptoms in her left knee while wearing the walking boot. Cox
Oil offered no contrary evidence. Cox Oil authorized treatment for Ms. Hill with Dr.
Haltom for the foot injury and knee complaints related to her wearing the boot. The issue
is whether Ms. Hill established that the work injury primarily caused the meniscus tear,

                                             5
the resulting surgery, and temporary disability.

        In denying compensability for Ms. Hill's meniscus tear, Cox Oil relied on Dr.
Haltom's opinion within a reasonable degree of medical certainty that the tear and
arthritis found on the MRI did not arise primarily out of her work injury. As the
authorized treating physician, Dr. Haltom's causation opinion is afforded a rebuttable
statutory presumption of correctness.

       To resolve this dispute, the Court considers Dr. Haltom's complete testimony
regarding the basis for his causation opinion. He testified that Ms. Hill did not have an
injury mechanism to sustain a traumatic radial tear of her meniscus. He explained that his
opinion was based on "her work injury mechanism and the fact that she had arthritic
changes in her knee, and that the vast majority of meniscus tears are degenerative ...
[b]ut No. 1 would be her mechanism that was reported to me."

       Regarding the impact of the walking boot, Dr. Haltom acknowledged that wearing
it could cause an "irritated and inflamed knee" and aggravated the knee by causing pain
and swelling. The Court finds he treated Ms. Hill for those symptoms aggravated by her
use of the boot; however, he never stated that Ms. Hill's use of the boot caused her
meniscus tear or the need for surgery.

        Considering Dr. Chung's causation testimony, the Court notes two troubling
aspects of his opinion. He testified generally that "the knee injury" stemmed from both
Ms. Hill's weight-bearing on her left knee while wearing the boot and a subsequent
incident at work when she slipped on water in the kitchen and twisted her knee. The
Court finds Dr. Chung's testimony insufficient to establish Ms. Hill's meniscus tear arose
primarily out of her September 28, 2017 work injury. First, Dr. Chung did not
specifically testify to causation for the meniscus tear. Instead, he generally referred to
"the knee injury." Second, his opinion is insufficient because he attributed causation, in
part, to the later incident at work where she slipped in water in the kitchen, which is not
the injury at issue in this claim. Moreover, the Court notes that in determining permanent
impairment for Ms. Hill's left knee, Dr. Chung did not rate Ms. Hill for her tom
meniscus. Instead, he rated her based on patellofemoral arthritis.

        "When faced with conflicting medical testimony, the Court must use its discretion
in accepting one expert opinion over another and, in so doing, may consider which
opinion contains the more probable explanation." Sanker v. Nacarato Trucks, Inc., 2016
TN Wrk. Comp. App. Bd. LEXIS 27, at *12 (July 6, 2016). Here, upon thorough
consideration of the preponderance of the evidence, the Court finds Dr. Haltom's
testimony more persuasive and holds Ms. Hill did not establish that her meniscus tear and
resulting surgery arose primarily out of her employment.

      However, the Court finds Ms. Hill did establish by a preponderance of the

                                             6
evidence, through Dr. Haltom's testimony, an aggravation of her knee resulting in pain,
irritation, and swelling, which primarily arose out of her wearing the boot; thus, she is
entitled to future medical benefits for treatment for that aggravation. Because the Court
finds Dr. Chung's causation opinion insufficient, the Court holds Ms. Hill is not entitled
to an award of permanent disability because of any left-knee injury.

       Finally, the Court holds Ms. Hill's attorney is entitled to a reasonable attorney's
fee. The statute provides attorney's fees shall be deemed reasonable if the fee "does not
exceed twenty percent (20%) of the award to the injury worker." Tenn. Code Ann. § 50-
6-226. Thus, the Court holds Ms. Hill's counsel is entitled to a twenty-percent fee.

IT IS, THEREFORE, ORDERED as follows:

   1. Ms. Hill shall recover from Cox Oil Company 4.5 weeks of permanent partial
      disability benefits at the stipulated compensation rate of $195.54, for a total
      amount of $879.93 for her right-foot injury.

   2. Ms. Hill shall receive future medical benefits for the right-foot injury.

   3. Ms. Hill shall receive future medical benefits for the left knee made reasonably
      necessary by the aggravation of her knee from wearing the walking boot.

   4. Ms. Hill's attorney is awarded a twenty-percent fee and any incurred expenses to
      be paid from Ms. Hill's award. If the parties are unable to reach an agreement
      regarding discretionary costs, Ms. Hill may file a post-trial motion.

   5. Costs of $150.00 are assessed against Cox Oil Company under Tennessee
      Compilation Rules and Regulations 0800-02-21-.07 (20 18), to be paid to the Clerk
      within five days of this order becoming final. Cox Oil Company shall prepare and
      file with the Clerk a statistical data form (SD2) within ten business days of the
      date of this order under Tennessee Code Annotated section 50-6-244.

   6. Absent an appeal of this order, it shall become final thirty days after issuance.

ENTERED June 6, 2019.

                                          Court of Workers' Compensation Claims

                                             7
                                        APPENDIX

Stipulated Findings of Fact:
    1. Ms. Hill's date of injury was September 28, 2017.
   2. She received authorized treatment from Dr. Haltom until he recommended knee
       surgery.
   3. The parties stipulated that if the Court finds compensability for the left-knee
       injury, Ms. Hill is entitled to eight weeks of temporary total disability, which totals
       $1,564.32.
   4. Ms. Hill returned to work for Cox Oil making the same or greater rate of pay.
    5. Ms. Hill's compensation rate is $195.54.

Exhibits:
   1. Dr. Chung's deposition
   2. Dr. Chung's IME report
   3. Dr. Haltom's deposition
   4. Dr. Haltom's records
   5. Physician's Quality Care records

Technical record:
   1. Petition for Benefit Determination
   2. Dispute Certification Notice
   3. Request for Scheduling Hearing
   4. Scheduling Order
   5. Order Granting Employer's Motion to Continue Mediation
   6. Order Granting Motion to Amend Scheduling Order
   7. Employee's List of Witnesses and Exhibits
   8. Employer's Exhibit List
   9. Employer's Witness List
   10. Pre-Compensation Hearing Statement
   11. Employer's Pre-Hearing Brief
   12. Post-discovery Dispute Certification Notice

                                              8
                             CERTIFICATE OF SERVICE
       I certify that a copy of the Compensation Hearing Order was sent to the following
recipients as indicated below on June 6, 2019.

Name                                       Email    Service sent to:
Edward L. Martindale, Jr.,                   X      edwardlmartindale@gmail.com
Employee's Counsel                                  rachalmwallace@}gmail.com
Gordon Aulgur,                                 X    gordon.aulgur@accidentfund.com
Employer's Counsel                                  christine.spear@accidentfund.com

                                        Penny Shrum, Clerk of Court
                                        Court of Workers' Compensation Claims
                                        WC.CourtClerk@tn.gov

                                           9
                        Compensation Hearing Order Right to Appeal:
     If you disagree with this Compensation Hearing Order, you may appeal to the Workers’
Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers’
Compensation Appeals Board, you must:
   1. Complete the enclosed form entitled: “Compensation Hearing Notice of Appeal,” and file
      the form with the Clerk of the Court of Workers’ Compensation Claims within thirty
      calendar days of the date the compensation hearing order was filed. When filing the
      Notice of Appeal, you must serve a copy upon the opposing party (or attorney, if
      represented).

   2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
      calendar days after filing of the Notice of Appeal. Payments can be made in-person at
      any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
      alternative, you may file an Affidavit of Indigency (form available on the Bureau’s
      website or any Bureau office) seeking a waiver of the filing fee. You must file the fully-
      completed Affidavit of Indigency within ten calendar days of filing the Notice of
      Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will
      result in dismissal of your appeal.

   3. You bear the responsibility of ensuring a complete record on appeal. You may request
      from the court clerk the audio recording of the hearing for a $25.00 fee. A licensed court
      reporter must prepare a transcript and file it with the court clerk within fifteen calendar
      days of the filing the Notice of Appeal. Alternatively, you may file a statement of the
      evidence prepared jointly by both parties within fifteen calendar days of the filing of the
      Notice of Appeal. The statement of the evidence must convey a complete and accurate
      account of the hearing. The Workers’ Compensation Judge must approve the statement
      of the evidence before the record is submitted to the Appeals Board. If the Appeals
      Board is called upon to review testimony or other proof concerning factual matters, the
      absence of a transcript or statement of the evidence can be a significant obstacle to
      meaningful appellate review.

   4. After the Workers’ Compensation Judge approves the record and the court clerk transmits
      it to the Appeals Board, a docketing notice will be sent to the parties. The appealing
      party has fifteen calendar days after the date of that notice to submit a brief to the
      Appeals Board. See the Practices and Procedures of the Workers’ Compensation
      Appeals Board.
To appeal your case directly to the Tennessee Supreme Court, the Compensation Hearing
Order must be final and you must comply with the Tennessee Rules of Appellate
Procedure. If neither party timely files an appeal with the Appeals Board, the trial court’s
Order will become final by operation of law thirty calendar days after entry. See Tenn.
Code Ann. § 50-6-239(c)(7).
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
                               Tennessee Bureau of Workers’ Compensation
                                      220 French Landing Drive, I-B
                                        Nashville, TN 37243-1002
                                              800-332-2667

                                          AFFIDAVIT OF INDIGENCY

I, ________________________________________, having been duly sworn according to law, make oath that
because of my poverty, I am unable to bear the costs of this appeal and request that the filing fee to appeal be
waived. The following facts support my poverty.

1. Full Name:                                            2. Address:

3. Telephone Number:                                     4. Date of Birth:

5. Names and Ages of All Dependents:

        ______________________________________ Relationship:

        ______________________________________ Relationship:

        ______________________________________ Relationship:

        ______________________________________ Relationship:

6. I am employed by:

        My employer’s address is:

        My employer’s phone number is:

7. My present monthly household income, after federal income and social security taxes are deducted, is:

$ ___________________

8. I receive or expect to receive money from the following sources:

        AFDC            $ ________ per month             beginning
        SSI             $ ________ per month             beginning
        Retirement      $ ________ per month             beginning
        Disability      $ ________ per month             beginning
        Unemployment $ ________ per month                beginning
        Worker’s Comp.$ ________ per month               beginning
        Other           $ ________ per month             beginning

LB-1108 (REV 11/15)                                                                               RDA 11082
9. My expenses are:

        Rent/House Payment $ ________ per month          Medical/Dental $ ___________ per month

        Groceries       $ ________ per month             Telephone       $            per month
        Electricity     $ ________ per month             School Supplies $            per month
        Water           $ ________ per month             Clothing        $            per month
        Gas             $ ________ per month             Child Care      $            per month
        Transportation $ ________ per month              Child Support   $            per month
        Car             $_________ per month
        Other           $ _______ per month (describe:                                      )

10. Assets:

        Automobile              $                        (FMV)
        Checking/Savings Acct. $
        House                   $                        (FMV)
        Other                   $                        Describe:

11. My debts are:

        Amount Owed                     To Whom

I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
and that I am financially unable to pay the costs of this appeal.

                                                                         _

APPELLANT

Sworn and subscribed before me, a notary public, this

_______ day of                                    , 20_______.

NOTARY PUBLIC

My Commission Expires:

LB-1108 (REV 11/15)                                                                             RDA 11082
                                         COMPENSATION HEARING NOTICE OF APPEAL
                                                 Tennessee Division of Workers’ Compensation
                                                     www.tn.gov/labor-wfd/wcomp.shtml
                                                            wc.courtclerk@tn.gov
                                                               1-800-332-2667

                                                                                                      Docket #:
                                                                                                      State File #/YR:

                       Employee

                       v.

                       Employer

          Notice
          Notice is given that
                                   [List name(s) of all appealing party(ies) on separate sheet if necessary]

          appeals the order(s) of the Court of Workers’ Compensation Claims at

                                                                 to the Workers’ Compensation Appeals Board.
           [List the date(s) the order(s) was filed in the court clerk’s office]

          Judge

          Statement of the Issues
          Provide a short and plain statement of the issues on appeal or basis for relief on appeal:

          List of Parties

          Appellant (Requesting Party):                          ___At Hearing: ☐Employer ☐Employee
          Address:
          Party’s Phone:                                                     Email:
          Attorney’s Name:                                                                       BPR#:
          Attorney’s Address:                                                                            Phone:
          Attorney’s City, State & Zip code:
          Attorney’s Email:
                                       * Attach an additional sheet for each additional Appellant *
LB-1103   rev. 10/18                                      Page 1 of 2                                                    RDA 11082
Employee Name: ____________________________________    SF#: ________________________________ DOI: __________________

Appellee(s)
Appellee (Opposing Party):____________________At Hearing: ☐Employer ☐Employee

Appellee’s Address:
Appellee’s Phone:                                                   Email:
Attorney’s Name:                                                                      BPR#:
Attorney’s Address:                                                                    Phone:
Attorney’s City, State & Zip code:
Attorney’s Email:
                         * Attach an additional sheet for each additional Appellee *

CERTIFICATE OF SERVICE

I,                                            , certify that I have forwarded a true and exact copy of this
Compensation Hearing Notice of Appeal by First Class, United States Mail, postage prepaid, to all
parties and/or their attorneys in this case in accordance with Rule 0800-02-22.01(2) of the Tennessee
Rules of Board of Workers’ Compensation Appeals on this the              day of         , 20 .

[Signature of appellant or attorney for appellant]

Attention: This form should only be used when filing an appeal to the Workers’ Compensation Appeals
Board. If you wish to appeal a case to the Tennessee Supreme Court, please utilize the form provided by
the Court which can be found on their website at the following address:
http://www.tncourts.gov/sites/default/files/docs/notice_of_appeal_-_civil_or_criminal.pdf

LB-1103   rev. 10/18                                  Page 2 of 2                                           RDA 11082