Court Opinion

ID: 9958145
Source: CourtListenerOpinion
Date Created: 2024-04-08 13:51:46.139256+00
Date Added: 2024-06-11T08:17:57.844337
License: Public Domain

FILED
                                                                                           Apr 08, 2024
                                                                                          08:27 AM(CT)
                                                                                       TENNESSEE COURT OF
                                                                                      WORKERS' COMPENSATION
                                                                                             CLAIMS

             TENNESSEE BUREAU OF WORKERS’ COMPENSATION
            IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
                            AT COOKEVILLE

    ERNEST SOSA,                                      )   Docket No.: 2023-04-0865
             Employee,                                )
    v.                                                )
    COOKEVILLE REGIONAL                               )   State File No.: 84930-2021
    MEDICAL AUTHORITY,                                )
             Employer,                                )
    And                                               )
    PMA MGMT. CORP.,                                  )   Judge Robert V. Durham
             Insurer.                                 )

               EXPEDITED HEARING ORDER DENYING BENEFITS

       The Court held an Expedited Hearing on March 26, 2024, to determine whether Mr.
Sosa’s alleged low back injury primarily arose out of his work accident, and if so, the
benefits to which he is entitled. The Court holds Mr. Sosa did not establish that he is likely
to show his back injury primarily arose from his work, so the Court denies his requests for
future medical care and additional temporary disability benefits. 1

                                         History of Claim

     Mr. Sosa injured himself when his chair collapsed at work on November 3, 2021.
He was treated at the emergency room for a broken clavicle, and orthopedist James
McKinney later surgically repaired a torn rotator cuff in Mr. Sosa’s right shoulder.

       CRMC did not dispute the compensability of Mr. Sosa’s clavicle and shoulder
injuries, and Mr. Sosa reached maximum medical improvement from his shoulder and
clavicle injuries.

       However, CRMC denied Mr. Sosa’s contention that the accident also caused a low

1
 The parties agreed to a compensation rate of $420.19 and that CRMC stopped paying temporary disability
benefits on July 27, 2022. Mr. Sosa said he was not seeking past medical expenses at this hearing.
                                                  1
back injury. The following history will focus on the low back issue.

        On the day of the accident, Mr. Sosa wrote on an incident report that he injured his
“right shoulder.” He did not mention low back pain, nor did the emergency room report
document low back pain.

      Two days later, Mr. Sosa completed an intake form for Dr. McKinney, and on a
diagram where he marked the location of his pain, he only marked his right upper
extremity. Dr. McKinney’s office note reflected the same complaints without mention of
low back pain.

       Twelve days after his injury, Mr. Sosa saw his family doctor, Dr. J.D. Allred, about
severe pain from his collarbone fracture. The note does not mention back pain.

     Despite numerous visits from November through March to Dr. Allred and Dr.
McKinney, the records include no complaints of back pain.

       In mid-April, more than five months after the injury, Dr. Allred noted for the first
time that Mr. Sosa complained of “severe low back spasms” in his left low back for five
days but did not mention Mr. Sosa’s work injury. Mr. Sosa returned to Dr. Allred twice
complaining of continuing low back and left leg pain, but again the records do not refer to
his work injury.

        In May, Mr. Sosa reported left hip pain and left leg numbness at Dr. McKinney’s
office. He received a steroid injection to determine the source of the hip pain.

      Dr. Allred then ordered a lumbar MRI that showed “definite impingement” at L4-
L5 due to a disc protrusion. Dr. Allred noted that Mr. Sosa reminded him of the fall five
months earlier and asked if the nerve impingement might be related.

       In June, Mr. Sosa told Dr. McKinney that before his fall in November, he had never
had problems with his left leg, but now he had disabling pain that radiated down the leg.
He also told Dr. McKinney about the L4 nerve impingement and said he “hopes to get work
comp approval” to see a neurosurgeon. The record does not contain a neurosurgeon
referral.

       Mr. Sosa saw neurosurgeon Walter Jermakowicz, who is in practice with Dr.
McKinney, a few days later. While the note says that “his/her Workers’ Compensation
carrier” requested the visit, CRMC’s adjuster submitted a Rule 72 declaration specifically
denying that she ever authorized neurosurgical treatment.

       At the visit, Mr. Sosa described experiencing severe pain in the L4-5 distribution
for several months. He said that it waxed and waned but was progressively worsening. Dr.

                                             2
Jermakowicz described the herniated disc at L4-L5 as “quite large” and “undoubtedly
symptomatic.” When conservative treatment ultimately failed to relieve the symptoms, Dr.
Jermakowicz recommended a fusion.

       CRMC then sent Mr. Sosa to neurosurgeon Tarek Elalayli for an evaluation. Mr.
Sosa told Dr. Elalayli that he complained of low back pain at the emergency room and to
Dr. McKinney, but that he began experiencing increased left lower extremity symptoms
after his shoulder surgery. Dr. Elalayli then extensively outlined Mr. Sosa’s medical
records as to any mention of low back pain.

        He concluded that Mr. Sosa suffered from a disc herniation and required surgery.
He also said that if the history Mr. Sosa had relayed to him was correct, he would attribute
the herniation to his fall at work. However, Dr. Elalayli felt that Mr. Sosa’s history was
plainly inconsistent with medical records that do not report any low back pain “until well
after the work injury.” Thus, he could not attribute the herniation to the fall.

       In response, Mr. Sosa’s counsel wrote a letter to Dr. Jermakowicz. In the letter, he
said that Mr. Sosa recalled mentioning soreness in his low back at the emergency room and
to Dr. McKinney, but they did not record it. He also said that Mr. Sosa’s low back and left
leg symptoms increased after surgery, and Mr. Sosa could not recall any other incidents
that could have led to the herniation. He attached Dr. Elalayli’s report to his letter. He
concluded the letter by asking if, based on the stated information and Mr. Sosa’s history,
the disc herniation was more than 50% caused by the work accident.

       Dr. Jermakowicz responded by saying that the disc herniation was consistent with
the mechanism of injury and that “although rare,” symptoms were sometimes delayed until
weeks after. Thus, “based off his story and the imaging findings”, Dr. Jermakowicz
believed the work injury caused the herniation.

      Dr. Jermakowicz continued to treat Mr. Sosa and performed a lumbar fusion on
September 12, 2023. His last record kept Mr. Sosa off work until November 20, 2023,
“pending follow-up.”

       At the hearing, Mr. Sosa confirmed that he did not suffer from low back or left leg
pain before the fall. He said that he engaged in little physical activity after the accident
due to his upper extremity injury, and he did nothing that would have caused him to suffer
a herniated disc.

       Mr. Sosa maintained that he told emergency room personnel and Dr. McKinney
about his low back pain, but they did not document it. When questioned about the incident
form and the intake form that he completed himself, he said that he was focused on the
clavicle fracture and his shoulder pain. He also believed the pain medication for his
fracture and shoulder “masked” the pain in his back and leg. He testified that Dr.

                                             3
Jermakowicz has yet to release him to return to work.

                       Findings of Fact and Conclusions of Law

       To obtain benefits, Mr. Sosa must show a likelihood of prevailing at a hearing on
the merits. Tenn. Code Ann. § 50-6-239(d)(1) (2023). Here, the question is whether he
suffered a low back injury that primarily arose from his 2021 work accident. The Court
finds that while he proved the injury was consistent with his accident, he did not submit
enough evidence to overcome the fact that none of the documentary evidence submitted
references low back pain until several months after the accident. Thus, he is unlikely to
prove causation at trial, and the Court denies his requested benefits.

       To prove causation, Mr. Sosa must show to a reasonable degree of medical certainty
that he suffered an accidental injury due to a “specific incident, or set of incidents, that
arose primarily of and in the course and scope of employment…identifiable by time and
place of occurrence[.]” The injury or aggravation must have “contributed more than fifty
percent” in causing his disablement and need for treatment. “Reasonable degree of medical
certainty” means in a physician’s opinion “it is more likely than not considering all causes,
as opposed to speculation or possibility.” Tenn. Code. Ann. § 50-6-102(A)-(D).

       Tennessee Code Annotated section 50-6-102(12)(E) says that an authorized treating
physician’s causation opinion is presumed correct but may be rebutted by a preponderance
of the evidence. Although Mr. Sosa asserts that CRMC authorized Dr. Jermakowicz, the
adjuster submitted a Rule 72 Statement to the contrary. The Court finds the adjuster is the
better witness on this issue. Thus, the presumption does not apply to Dr. Jermakowicz’s
opinion over Dr. Elalayli’s.

        In this case, however, the doctors’ opinions are similar in most respects. They agree
that Mr. Sosa suffers from a herniated disc that requires surgery. They also agree that the
herniated disc is consistent with his fall from a collapsing chair. Where they differ is the
importance assigned to the lack of documentary evidence of low back pain in the months
after the accident. Dr. Elalayli says it is enough to deny causation; Dr. Jermakowicz
disagrees.

       After carefully considering the submitted evidence, the Court finds it agrees with
Dr. Elalayli. Neither the emergency room staff nor Dr. McKinney’s staff documented any
low back complaints despite Mr. Sosa’s insistence that he told them. Further, he had
multiple opportunities to tell both his family doctor and Dr. McKinney about his low back
pain, but there is no documented evidence he did so until more than five months after his
accident.

      Notably, not only do the medical records fail to mention low back pain, but two
forms completed by Mr. Sosa, the incident report and the intake sheet, do not refer to low

                                             4
back symptoms. In addition, when Dr. Allred’s records finally mention low back pain, it
only states that Mr. Sosa had been suffering back spasms for five days, and the records still
do not mention the work incident until May.

       Finally, the Court finds Mr. Sosa’s explanations for the lack of documentary
evidence to be inconsistent. On one hand, he said that he experienced immediate low back
pain severe enough to warrant telling both the emergency room staff and Dr. McKinney
about it. But on the other hand, he said his focus on his right upper extremity complaints
as well as his lack of activity and pain medication must have “masked” his low back
symptoms.

       The Court holds that Mr. Sosa’s unsupported testimony, when considering
documentary evidence to the contrary, is not enough to show he is likely to prevail at trial
in proving causation. Thus, the Court denies Mr. Sosa’s claim for benefits for his low back
injury at this time.

IT IS, THEREFORE, ORDERED:

       1. Mr. Sosa’s request for authorized treatment of his low back condition and
          additional temporary disability benefits is denied.

       2. This case is set for a Scheduling Hearing on May 8, 2024, at 10:30 a.m. Central
          Time. The parties must call 615-253-0010. Failure to appear might result in a
          determination of the issues without the party’s participation.

       ENTERED April 8, 2024.

                                   _____________________________________
                                   ROBERT DURHAM, JUDGE
                                   Court of Workers’ Compensation Claims

                                       APPENDIX

Technical Record:
          1. Petition for Benefit Determination
          2. Dispute Certification Notice
          3. Request for Expedited Hearing
          4. CRMC’s Pre-Trial Brief

                                             5
Exhibits:
            1. Mr. Sosa’s affidavit.
            2. Collective medical records attached to Request for Expedited Hearing
            3. Adjuster’s affidavit
            4. Dr. Jermakowicz’s response to causation letter
            5. CRMC’s incident report
            6. Emergency room records
            7. Initial visit record with Dr. McKinney
            8. Intake form
            9. Dr. Allred report
            10. Dr. McKinney’s collective medical records from November and December
            11. Additional Dr. Allred records
            12. Additional Dr. McKinney records
            13. Dr. Allred’s April 15 record
            14. Dr. McKinney’s April 25 note
            15. Dr. Worley’s medical record
            16. Dr. Allred’s May 31 note
            17. Dr. Jermakowicz note taking Mr. Sosa off work
            18, Dr. McKinney June 6 note
            19. Dr. Elalayli record

                            CERTIFICATE OF SERVICE

      I certify that a copy of the Order was sent as indicated on April 8, 2024.

  Name                      Certified Fax       Email   Service sent to:
                            Mail
  Timothy Roberto                                X      troberto@brownandroberto.com
  Frederick R. Baker                             X      fbaker@wimberlylawson.com

                                         _____________________________________
                                         PENNY SHRUM, Court Clerk
                                         WC.CourtClerk@tn.gov

                                            6
                                          Right to Appeal:
      If you disagree with the Court’s Order, you may appeal to the Workers’ Compensation
Appeals Board. To do so, you must:
   1. Complete the enclosed form entitled “Notice of Appeal” and file it with the Clerk of the
      Court of Workers’ Compensation Claims before the expiration of the deadline.
               If the order being appealed is “expedited” (also called “interlocutory”), or if the
                 order does not dispose of the case in its entirety, the notice of appeal must be filed
                 within seven (7) business days of the date the order was filed.
               If the order being appealed is a “Compensation Order,” or if it resolves all issues
                 in the case, the notice of appeal must be filed within thirty (30) calendar days of
                 the date the Compensation Order was filed.
      When filing the Notice of Appeal, you must serve a copy on 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 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 are responsible for ensuring a complete record is presented on appeal. If no court
      reporter was present at the hearing, you may request from the Court Clerk the audio
      recording of the hearing for a $25.00 fee. If you choose to submit a transcript as part of your
      appeal, which the Appeals Board has emphasized is important for a meaningful review of
      the case, a licensed court reporter must prepare the transcript, and you must file it with the
      Court Clerk. The Court Clerk will prepare the record for submission to the Appeals Board,
      and you will receive notice once it has been submitted. For deadlines related to the filing of
      transcripts, statements of the evidence, and briefs on appeal, see the applicable rules on the
      Bureau’s website at https://www.tn.gov/wcappealsboard. (Click the “Read Rules” button.)

   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.
      If neither party timely files an appeal with the Appeals Board, the Court Order
      becomes enforceable. See Tenn. Code Ann. § 50-6-239(d)(3) (expedited/interlocutory
      orders) and Tenn. Code Ann. § 50-6-239(c)(7) (compensation orders).

       For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
                                              NOTICE OF APPEAL
                                      Tennessee Bureau of Workers’ Compensation
                                        www.tn.gov/workforce/injuries-at-work/
                                        wc.courtclerk@tn.gov | 1-800-332-2667

                                                                                  Docket No.: ________________________

                                                                                  State File No.: ______________________

                                                                                  Date of Injury: _____________________

         ___________________________________________________________________________
         Employee

         v.

         ___________________________________________________________________________
         Employer

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

appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the
Workers’ Compensation Appeals Board (check one or more applicable boxes and include the date file-
stamped on the first page of the order(s) being appealed):

□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________
□ Compensation Order filed on__________________ □ Other Order filed on_____________________
issued by Judge _________________________________________________________________________.

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

Parties
Appellant(s) (Requesting Party): _________________________________________ ☐Employer ☐Employee
Address: ________________________________________________________ Phone: ___________________
Email: __________________________________________________________
Attorney’s Name: ______________________________________________ BPR#: _______________________
Attorney’s Email: ______________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
                           * Attach an additional sheet for each additional Appellant *

LB-1099 rev. 01/20                              Page 1 of 2                                              RDA 11082
Employee Name: _______________________________________ Docket No.: _____________________ Date of Inj.: _______________

Appellee(s) (Opposing Party): ___________________________________________ ☐Employer ☐Employee
Appellee’s Address: ______________________________________________ Phone: ____________________
Email: _________________________________________________________
Attorney’s Name: _____________________________________________ BPR#: ________________________
Attorney’s Email: _____________________________________________ Phone: _______________________
Attorney’s Address: _________________________________________________________________________
                              * Attach an additional sheet for each additional Appellee *

                                             CERTIFICATE OF SERVICE

I, _____________________________________________________________, certify that I have forwarded a
true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described
in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this
case on this the __________ day of ___________________________________, 20 ____.

                                                           ______________________________________________
                                                            [Signature of appellant or attorney for appellant]

LB-1099 rev. 01/20                                 Page 2 of 2                                        RDA 11082