Court Opinion

ID: 4560221
Source: CourtListenerOpinion
Date Created: 2020-08-26 21:01:53.737612+00
Date Added: 2024-06-11T11:14:59.743308
License: Public Domain

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

DAVID LEATHERWOOD,                         )   Docket No. 2017-03-0758
         Employee,                         )
v.                                         )
MAYFIELD DAIRY FARMS, LLC,                 )
         Employer,                         )   State File No. 30692-2017
and                                        )
LIBERTY MUTUAL INSURANCE                   )
COMPANY,                                   )
          Carrier.                         )   Judge Pamela B. Johnson

                             COMPENSATION ORDER

       This matter came before the Court for a Compensation Hearing on November 6,
2018. The issue is whether Mayfield Dairy Farms, LLC is liable for unauthorized
medical expenses and, if so, for Mr. Leatherwood's attorney's fees and expenses. For the
reasons below, this Court holds that Mr. Leatherwood established by a preponderance of
the evidence that Mayfield is liable for the requested medical expenses but reserves the
attorney's fees issue.

                                   History of Claim
                                     Stipulations

        David Leatherwood sustained an injury by accident arising out of the course and
scope of his employment with Mayfield on April 21, 2017. He provided timely notice of
his injury and received authorized medical treatment with Dr. Audrey Smith at American
Family Clinic (AFC).

       On April 24, Dr. Smith released Mr. Leatherwood without restrictions, and he
returned to work for Mayfield for a period of time earning the same or greater wages as
he earned before the injury. His average weekly wage was $348.84 resulting in a weekly
compensation rate of $232.57.

                                           1
                                   Factual Allegations
                                         Injury

       Mr. Leatherwood worked part-time for Mayfield as a merchandiser. On April 21,
2017, he fell while stocking product, striking his back on a plastic crate and cutting his
head. The same day, he reported the injury to his supervisor, Shawn McGuire, who
instructed him to seek medical care at AFC. He denied receiving a panel of physicians.

       Mayfield disputed Mr. Leatherwood's claim that he was not provided a panel. To
support its contention, it introduced a panel containing the names of three physicians and
three medical centers. The unsigned, undated panel listed neither Mr. Leatherwood's
name, injury date, or contact information nor Dr. Smith or AFC as providers. Moreover,
Mayfield introduced a Notice to Report for Drug Specimen Collection, which instructed
him to report immediately to AFC for a post-accident drug screen.

                              Authorized Medical Treatment

        The same day, Mr. Leatherwood went to AFC and saw Dr. Audrey Smith. He
reported that he fell while pushing a cart of empty milk crates. He indicated he fell on his
bottom but scratched his right ribcage on the edge of another cart and a falling milk crate
scratched his forehead, but he denied loss of consciousness. On physical exam, Dr.
Smith noted that he suffered a superficial laceration to his right forehead, anterior right
rib tenderness with a large abrasion from the scapular area to the lumbar area, and
parascapular erythema. X-rays showed, "Questionable nondisplaced fracture lateral
aspect right eighth rib." She diagnosed an open head wound, right rib fracture, and open
wound of the right thoracic back. Dr. Smith assigned restrictions and told him to return
in three days.

        He did so and reported improvement. Dr. Smith noted his head and side wounds
were "almost completely healed." She indicated that she no longer believed he fractured
his rib, since he was pain free and had free range of motion. Dr. Smith released him to
work without restrictions.

                        Unauthorized Emergency Room Treatment

        On May 2, eleven days after the injury, Mr. Leatherwood sought emergency care
at Parkwest Medical Center (PMC). He reported he fell and struck his right forehead,
right ribs, and mid-back. He also stated he briefly lost consciousness when he fell and
suffered confusion since the fall. The intake sheet noted admitting diagnoses of chest
pain and shortness of breath. After an examination and numerous diagnostic tests, the
physician diagnosed back contusion and concussion injury from the fall and confirmed
"TESTS ALL GOOD. NO SDH OR SKULL FX. NO RIB FRACTURE, PNEUMO.

                                             2
NO ABD INJURY. LABS ALL GOOD." (Emphasis in original). Mr. Leatherwood
incurred charges totaling $9,341.92 for this visit.

                                     Disputed Issue

        The parties dispute Mr. Leatherwood's unauthorized medical treatment and
expenses incurred at PMC. Mr. Leatherwood claimed the treatment was necessitated by
his fall at work, and thus Mayfield was liable for the expenses. Mayfield disagreed,
asserting the treatment was unauthorized and unrelated to the work injury. It focused on
AFC's April 24 release of Mr. Leatherwood to full duty with no follow-up and his return
to work. It further asserted his explanation for seeking unauthorized care varied and
lacked credibility.

                        Mr. Leatherwood's Recorded Statement

        In his recorded statement taken by Mayfield's carrier, Mr. Leatherwood explained
his reasons for seeking emergency care. He said he was very concerned that he suffered
a possible concussion, and he remained worried about his lingering right-side pain. He
was not confident that the clinic was going to provide him with answers, and he was
closer to PMC than the clinic. He acknowledged that Mr. McGuire wanted him to return
to Mayfield to complete paperwork and then go to the clinic, but he stated he was having
difficulty driving and performing his job, and that he felt it better to seek treatment at
PMC.

       Additionally, Mr. Leatherwood discussed his April24 release to full duty. He said
AFC informed him that his type of injury took time to heal and nothing more could be
done. He stated he remained open to returning to work, but within three to four days of
doing so, he began having significant trouble working and he felt he needed additional
treatment.

                              Mr. Leatherwood's Affidavit

        In Mr. Leatherwood's affidavit supporting his Request for Expedited Hearing, he
stated, "On May 2, 2017, I called my supervisor to report my severe pain and other
developing issues and to tell him I was seeking further treatment immediately." He
indicated his supervisor told him to report to the clinic. Consistent with his recorded
statement, he declined because he believed it was in the best interest of others on the
roads and himself to seek treatment at the closer emergency room. He did not feel he
could safely drive to the clinic. He was concerned that he might have suffered a
concussiOn.

                                            3
                              Mr. Leatherwood's Deposition

       In his deposition, Mr. Leatherwood addressed his AFC release to work full duty.
He stated the AFC physician asked him how he was doing, and he responded, "[I]t hurt."
He told her, "I don't feel that I can't go back to work or try to go back to work." The
AFC physician replied, "Well, if you think you can do the job ... let's go ahead and get
you back."

       After he returned to work, he testified that each day he began feeling more tired,
his side hurt more, and he experienced difficulty driving and blackouts. On May 2, 2017,
he experienced shortness of breath and pain in his chest and right side. He called his
supervisors and told that he experienced confusion, had problems driving, and felt faint
and weak. His supervisors asked if he could finish his route and return to Mayfield. He
responded that he did not think he could make it back to the office and told Mr. McGuire
he thought he should go to a closer hospital.

        He denied experiencing these symptoms or missing work at his other employment.
He also denied seeking treatment following his emergency room visit. However, he
testified he continued to experience rib pain.

                          Mr. Leatherwood's Hearing Testimony

        At the hearing, Mr. Leatherwood testified that he sought emergency care because
he felt faint, short of breath, fatigued, and increasing right-side pain, and he experienced
difficulty driving. He indicated that he left Mr. McGuire a voicemail advising that he
needed to discuss his route. In the voicemail, he referenced his side where he struck his
rib, stated it was hard for him to catch his breath, and indicated he needed help. When he
spoke with his supervisor, Mr. McGuire asked him to return to Mayfield and then go to
AFC. Mr. Leatherwood testified that, at the time of the telephone call, he believed he
was closer to PMC than AFC. He again explained he sought treatment at PMC because
he was overwhelmed by his symptoms and concerned that he suffered internal injuries.
He thought if he went to AFC, then he would be required to wait and fill out paperwork.
In the couple of days leading up to May 2, he stated he had driven off the road and
blacked out.

        On cross examination, Mr. Leatherwood admitted the PMC sign-in sheet noted
that his primary reason for seeking treatment was "Can't Breath - hurting[.]" He
acknowledged the intake sheet noted shortness of breath and chest pain, but he countered
that different individuals completed the paperwork, and the same document noted that his
symptoms were employment-related.

       Mr. Leatherwood also admitted that he saw his primary care physician (PCP) on
April 27, 2017, for a three-month follow up regarding unrelated conditions. The notes

                                             4
reflected he told his PCP that he fell at work, hurt his back, and fractured a rib, but he
was doing well otherwise.

       He further admitted that he attended a previously scheduled sleep consultation on
May 3. At the consultation, he reported he snored and experienced excessive daytime
sleepiness for many years but his symptoms were worsening. He additionally reported he
worked two jobs and experienced more difficulty focusing at work and some difficulty
breathing. He advised the sleep center that he went to the emergency room the previous
evening but he did not report the recent work injury and no acute abnormalities were
shown.

      Mayfield's counsel presented Mr. Leatherwood with copies of two Facebook posts
dated April 29. One post depicted a wooded lot with a caption, "Our new home with so
much to do. Hugh (sic) wooded lot and chainsaw running today[.]" The second post
showed a large pile of cut tree branches and captions stating, "Cleaning up the
backyard!" He explained his wife posted the photos and captions and performed the yard
work.

                           Mr. McGuire's Hearing Testimony

       Mr. McGuire testified that Mr. Leatherwood worked every day after his April 24
release. He denied that Mr. Leatherwood called him to report his symptoms; he only
received the May 2 voicemail. On cross examination, Mr. McGuire acknowledged
Mayfield's policy would not allow an employee to operate a vehicle while on the clock if
that employee were experiencing symptoms similar to those reported by Mr.
Leatherwood. Mr. McGuire responded, "To answer your question on company policy,
no, we would not want an employee working under those conditions."

                                  Medical Testimony
                                    Dr. Kennedy

       At Mr. Leatherwood's request, Dr. William Kennedy reviewed the AFC and PMC
records to determine whether Mr. Leatherwood's emergency room visit was reasonable,
necessary, and caused by the work injury. Dr. Kennedy determined, "[I]t was both
appropriate and reasonable and necessary for Mr. Leatherwood to seek treatment in the
emergency department ... arising from and attributable to the work-related injuries that
he suffered[.]" Considering other potential causes, Dr. Kennedy testified, "[I]t was my
opinion that the necessity of that testing and treatment ... was primarily caused, with
greater than 50 percent contribution, to that cause by the work-related incident of April
21, 2017."

      Dr. Kennedy testified that he was familiar with the charges of emergency
departments in east Tennessee, regularly sees charges by other emergency physicians in

                                            5
the some locality, and routinely testifies as to the reasonableness and necessity of these
charges. Regarding the PMC charges and treatment, Dr. Kennedy testified, "[T]hey were
both reasonable and necessary and they were also caused by [the] work-related incident
of April 21, 2017." Dr. Kennedy explained that it was appropriate to conduct the CT
scans due to Mr. Leatherwood's history of the work injuries to his head and right side and
the potential subdural hematoma and/or hemopneumothorax.

       He testified that he readily reached the conclusion that the head CT scan was
appropriate due to the possibility of an evolving subdural hematoma from the trauma.
(Dr. Kennedy Depo, p. 21). He detailed further the importance of the CT scan of the
chest, abdomen, and pelvis, stating a hemopneumothorax, pulmonary embolus, or post-
traumatic congestive heart failure can evolve over time following a trauma. He
concluded that these tests were ordered not only on Mr. Leatherwood's complaints but
also on the objective findings of a blow to the head and the injury to the right side of his
chest. (!d., pp. 59-61).

        Dr. Kennedy admitted that he did not physically examine or interview Mr.
Leatherwood. Similarly, he admitted that he did not review records from his primary
care physician, and he had no knowledge of his other employment, medical conditions,
treatment, or medications. When asked whether he considered causes other than the
work injury necessitating emergency care, Dr. Kennedy testified, "That is the only cause
that I considered simply because that was the only cause that came to my attention in the
records that were available to me[.]"

                                        Dr. Smith

       Dr. Audrey Smith testified concerning her examinations of Mr. Leatherwood on
April 21 and 24 and offered her opinions concerning the reasonableness, necessity, and
causal need for his May 2 emergency care. She testified that Mr. Leatherwood stated at
the April 24 visit that he was better and ready to return to work. She additionally said he
did not complain of back, rib or chest pain, shortness of breath, headaches, or confusion.
She stated, "I released him to full duty, and my opinion was he did not need any further
medical treatment."

       Concerning the emergency care, Dr. Smith testified she reviewed the PMC records
and determined that Mr. Leatherwood's work injury did not primarily cause the
complaints that he presented with at PMC. She likewise stated that the work injury did
not primarily cause the need for the tests conducted at the emergency room. However,
she admitted she did not examine Mr. Leatherwood on May 2, and she could not testify
as to what Mr. Leatherwood's condition was on that date.

       Dr. Smith admitted that she neither practiced emergency medicine nor was she
licensed in it. Similarly, she confirmed she was not qualified to testify whether the PMC

                                             6
physicians performed Mr. Leatherwood's care within the recognized standards of
emergency care. She also denied any criticism of the PMC physicians for the care and
treatment provided to Mr. Leatherwood. Dr. Smith also confirmed that a doctor should
not merely rely upon prior exams of the patient when determining what is reasonable and
necessary for diagnosis and treatment at the patient's later presentation. She agreed it
was the duty of a doctor to consider all potential conditions and their differential
diagnoses and then consider the most serious conditions to rule out first.

                                      Attorney's Fees

       In addition to seeking payment of his bills for the emergency care, Mr.
Leatherwood asked the Court to award attorney's fees under Tennessee Code Annotated
section 50-6-226(d)(l)(B). The Court grants the parties' request that it defer deciding the
issue until they submit post-trial briefs and affidavits and the Court schedules the matter
for oral argument.

                        Findings of Fact and Conclusions of Law

        Mr. Leatherwood has the burden of proof on all essential elements of his claim.
Scott v. Integrity Staffing Solutions, 2015 TN Wrk. Comp. App. Bd. LEXIS 24, at *6
(Aug. 18, 2015). "[A]t a compensation hearing where the injured employee has arrived
at a trial on the merits, the employee must establish by a preponderance of the evidence
that he or she is, in fact, entitled to the requested benefits." Willis v. All Staff, 2015 TN
Wrk. Comp. App. Bd. LEXIS 42, at *18 (Nov. 9, 2015); see also Tenn. Code Ann.§ 50-
6-239(c)(6) (2017). Here, the benefits sought are for unauthorized medical treatment.

        Tennessee's workers' compensation law does not impose liability upon the
employer for unauthorized medical treatment unless the employee proves: "(1)
justification, i.e. a 'reasonable excuse,' for not consulting with h[is] employer before
incurring medical expenses, and (2) the 'necessity and reasonableness' of the
unauthorized medical care." Gray v. Wingfoot Cammer. Tire Sys., No. W2017-00380-
SC-WCM-WC, 2018 Tenn. LEXIS 239, at *19-20 (May 21, 2018) (internal citations
omitted). Additionally, Tennessee Code Annotated section 50-6-204 "makes it clear that
the intent [of the Legislature] . . . was for the employee to certainly do no less than
consult his employer before incurring the expenses called for by that statute if the
employee expects the employer to pay for it. The opposite would seem to be against
public policy." Buchanan v. Mission Ins. Co., 713 S.W.2d 654, 658 (Tenn. 1986)
(internal citations omitted).

      Applying these principles, the Court first addresses whether Mr. Leatherwood
demonstrated by a preponderance of the evidence that he consulted with Mayfield before
seeking emergency care or otherwise proved a justification for seeking unauthorized care.

                                             7
       The Court finds Mr. Leatherwood consistently testified by affidavit, deposition,
and at the hearing, that he informed Mr. McGuire on May 2 that he experienced difficulty
focusing and driving, and increased pain in his side. When his supervisor asked him to
come to Mayfield and then go to AFC, he explained that he was worried and believed it
was wiser to seek emergency care at the closer PMC than at AFC. In contrast, Mr.
McGuire denied that Mr. Leatherwood spoke to him concerning his condition on May 2
with the exception of the voicemail. However, he admitted that Mayfield's policy would
not permit an employee working who was experiencing the symptoms Mr. Leatherwood
alleged. The Court holds Mr. Leatherwood satisfied his burden and established that he
consulted Mayfield before seeking care at PMC. The Court further holds that Mr.
Leatherwood's decision to seek emergency care was justified considering the severity of
the symptoms he experienced on May 2.

        The Court next addresses whether his emergency care was reasonable, necessary,
and related to the work injury. The PMC records reflect Mr. Leatherwood reported he
fell and struck his forehead, ribs, and mid-back and suffered confusion since the fall. The
intake sheet noted an admitting diagnosis of chest pain and shortness of breath related to
his employment. After an examination and numerous diagnostic tests, the physician
diagnosed back contusion and concussion injury from the fall.

       Both parties submitted the PMC records for physician review to determine the
reasonableness and necessity of the emergency care as well as to address the causal
relationship to the work injury. Dr. Kennedy testified that Mr. Leatherwood's treatment
and resulting charges were reasonable, necessary, and caused by [the] work-related
incident. Dr. Kennedy explained that it was appropriate to conduct the CT scans due to
Mr. Leatherwood's history of the work injuries to his head and right side in light for the
potential subdural hematoma and/or hemopneumothorax. Dr. Kennedy found the
diagnostic testing was ordered not only on Mr. Leatherwood's subjective complaints but
also on the objective findings of a blow to the head and the injury to the right side of his
chest. When asked whether he considered causes other than the April21 work injury, Dr.
Kennedy testified, "That is the only cause that I considered simply because that was the
only cause that came to my attention in the records that were available to me[.]"

       In contrast, Dr. Smith determined that Mr. Leatherwood's work injury did not
primarily cause the complaints he presented with at PMC or the need for its testing.
However, she admitted that she was neither qualified to testify whether the PMC
physicians performed Mr. Leatherwood's care within the recognized standards of
emergency care nor offered criticism of the PMC physicians for the treatment they
provided. Of importance, she agreed it was the duty of a doctor to consider all potential
conditions and their differential diagnosis and then to consider the most serious
conditions to rule out first.

                                             8
       It is within the Court's discretion to conclude that the opinion of one expert should
be accepted over that of another expert as having more probable explanation of a disputed
issue. Ledford v. Mid Georgia Courier, Inc., 2018 TN Wrk. Comp. App. Bd. LEXIS 28,
at *7-8 (Jun. 4, 2018) (internal citations omitted). In evaluating expert medical opinions,
the trial court may consider, among other things, the qualifications of the experts, the
circumstances of their evaluation, the information available to them, and the evaluation of
the importance of that information by other experts. !d. No presumption of correctness
attaches to Dr. Smith's opinion because Mr. Leatherwood did not select her from a panel
under Tennessee Code Annotated section 50-6-204.

       Regarding the experts' qualifications, the Court finds this factor favors Dr.
Kennedy. He is board-certified as an orthopedic physician and independent medical
examiner. He testified he had experience in emergency care and with its customary
charges. In comparison, Dr. Smith testified she is board-certified in family practice, and
her curriculum vitae reflected her experience was limited to family practice and
occupational medicine. Additionally, she testified she was not qualified to testify
whether the PMC physicians performed Mr. Leatherwood's care within the recognized
standards of emergency care.

       The Court finds the circumstances of their evaluations do not favor either doctor.
Both reviewed similar information and focused on the PMC records. Both were asked to
review the PMC records to determine whether the treatment was reasonable, necessary,
and causally related to the work injury.

        Here, the case turns on the information available to the physicians and the
importance of that information. The Court finds Dr. Kennedy's opinion more persuasive.
He provided detailed explanation concerning the reasonableness and necessity of the
treatment and charges and the causal relationship to Mr. Leatherwood's work injury. He
explained with great specificity the rationale behind PMC's testing. Dr. Smith admitted
she had no criticism of the PMC physicians' treatment of Mr. Leatherwood and agreed
that it was a physician's duty to consider all potential conditions and their differential
diagnosis and then to consider the most serious conditions to rule out first.

      Accordingly, the Court holds Mr. Leatherwood satisfied his burden and
demonstrated the care at PMC was reasonable, necessary, and related to his work injury.
Therefore, the Court holds Mayfield is liable for these charges.

 IT IS, THEREFORE, ORDERED as follows:

   1. Mayfield shall pay Mr. Leatherwood's charges totaling $9,341.92.

   2. The issue of Mr. Leatherwood's attorney's fees is reserved at this time. The
      parties may file additional briefs and supporting affidavits limited to this issue

                                            9
      within the following deadlines: Mr. Leatherwood's deadline is ten business days
      from entry of this order, or no later than January 4, 2019; and Mayfield's deadline
      is fifteen business days following entry of this order, or no later than January 11,
      2019. The parties shall appear by telephone (toll-free 855-543-5041) for argument
      on January 17, 2019, at 10:00 a.m. Eastern Time.

   3. This Order shall not become final until the order on attorney's fees is entered.

      ENTERED December         l~                      ~
                                  kb12Jk~~
                                  PAMELA B. JOHNSON, JUDGE
                                  Court of Workers' Compensation Claims

                                      APPENDIX

Technical record:
 1. Petition for Benefit Determination
 2. Dispute Certification Notice
 3. Request for Expedited Hearing
 4. Order to Comply with 0800-025-21-.16(5)(c)
 5. Docketing Notice for on-the-Record Determination
 6. Employer's Position Statement
 7. Employer's Notice of Objection to Admissibility ofMedical Expenses
 8. Expedited Hearing Order
 9. Scheduling Hearing Order
 10. Agreed Order to Extend Discovery Deadlines
 11. Employee's Notice ofFiling Deposition Transcript of Dr. William Kennedy
 12. Employer's Notice of Filing Deposition of Dr. Audrey Smith
 13. Joint Pre-Compensation Hearing Statement
 14. Employer's Compensation Brief
 15. Employer's Witness and Exhibit List
 16. Post-Discovery Dispute Certification Notice
 17. Employee's Motion to Accept Employee's Table of Contents of Medical Records
      and Billing Records
 18. Subpoena served on Lori Leonard, Department of Health
 19. Subpoena served on Medical Records Custodian, Parkwest Medical Center
 20. Employer's Objection to Admissibility of Medical Bills
 21. Employee's Response to Employer's Objection to Admissibility of Medical Bills
 22. Employer's Response to Affidavit of Attorneys' Fees
 23. Employee's Reply to Employer's Objection to Employee's Fee Application

                                            10
    The Court did not consider attachments to Technical Record filings unless admitted
into evidence during the Compensation Hearing.            The Court considered factual
statements in these filings or any attachments to them as allegations unless established by
the evidence.

Exhibits:

 1.    Employer's Exhibits
           • Medical Records- American Family Care
           • First Report of Work Injury
           • Workers' Compensation File
           • Attendance Records
           • David Leatherman's Affidavit
           • David Leatherman's Recorded Statement
 2.    PMC Medical Records
 3.    Photographs of Injury
 4.    Wage Statement
 5.    David Leatherwood Deposition Transcript
 6.    Dr. William Kennedy Deposition Transcript
 7.    Dr. Audrey Smith Deposition Transcript
 8.    Tennessee Department of Health Dr. Audrey M. Smith Records
 9.    Voicemail Recording
 10.   Late-Filed Affidavit of Attorneys' Fees and Costs
 11.   University of Tennessee Medical Center April27, 2017 Office Visit Note
 12.   PMC Emergency Sign-In Sheet
 13.   May 3, 2017 Sleep Consultation
 14.   Facebook posts
 15.   David Leatherwood's Discovery Responses

                                            11
                           CERTIFICATE OF SERVICE

       I certify that a true and correct copy of the Compensation Order was sent to the
following recipients by the following methods of service on December 17,2018.

          Name              Certified Fax      Email   Service sent to:
                            Mail
Joshua Bond                                      X     jbond@hdclaw.com
Employee's Attorney

Laurenn S. Disspayne,                            X     ldisspayne@manierherod.com
Employer's Attorney

                                          12
                                        COMPENSATION HEARING NOTICE OF APPEAL
                                                Tennessee Division of Workers' Compensation
                                                    www.ln.gov/labor-wfd/wcomp ,shm11
                                                           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:0Employer0Employee
          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#: _ _ _ _ _ __ _ __          DOl: - - -- - -

 Appellee lsi
 Appellee (Opposing Party):      _ _ _ _ _ __ _ .At Hearing: 0Employer0Employee

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.t ncourts.gov/sites/d efau lt/files/docs/notice of appea l - civi l or criminal.pdf

LB-1103   rev. 10/18                               Page 2 of 2                                    RDA 11082
                          ompensation HearingO rd er Ri ght to API ea l:

     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:

    I. 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 lndigency 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 fi.fleen 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, 1-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 b y : - - - - - - - - -- - - - - - - - - - - - - - - - - -- -

        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-11 08 (REV 11/15)                                                                              RDA 11082
9. My expenses are:

        Rent/House Payment $              per month     Med icai/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

____ dayof _ _ _ _ _ _ _ _ _ _ _ ,20 _ __

NOTARY PUBLIC

My Commission Expires:_ _ _ _ _ _ __

LB-1108 (REV 11/15)                                                                          RDA 11082