Court Opinion

ID: 9912959
Source: CourtListenerOpinion
Date Created: 2023-12-26 16:37:12.1313+00
Date Added: 2024-06-11T13:06:42.371104
License: Public Domain

139 Nev., Advance Opinion

                          IN THE COURT OF APPEALS OF THE STATE OF NEVADA

                   BRETT GILMAN,                                         No. 84703-COA
                   Appellant,
                   vs.
                   CLARK COUNTY SCHOOL DISTRICT;
                   AND SIERRA NEVADA
                                                                               FIL
                   ADMINISTRATORS,
                   Respondents.

                               Appeal from a district court order denying a petition for judicial
                   review of an appeals officer's decision in a workers' compensation matter.
                   Eighth judicial District Court, Clark County; James M. Bixler, Senior Judge.
                               Reversed and remanded.

                   Berteldo Baker Carter Smith & Cullen and Javier A. Arguello, Las Vegas,
                   for Appellant.

                   Gilson Daub, LLP, and Matthew W. Smith and Jennifer Santana, Las Vegas,
                   for Respondents.

                   BEFORE THE COURT OF APPEALS, GIBBONS, C.J., and BULLA and
                   WESTBROOK, JJ.

                                                     OPINION

                   By the Court, BULLA, J.:
                               In this opinion, we consider the pUrpose and'application of NRS
                   61.-6C.065(7) in granting or denying the reopening of an industrial claim.
                   That subsection places the onus on the workers' compensation insurer to
                   expressly indicate acceptance or denial of 'coverage for a body part or
                   condi.tion, usually set forth in its notice of claim acceptance. In the absence
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                   of such indication, the statute provides that the insurer has neither accepted
                   nor denied coverage for that body part or condition. The legislative purpose
                   behind enacting this provision was to end the practice whereby an insurer
                   would accept an industrial claim but restrict its acceptance to a certain body
                   part or condition and then later use that restriction as a sword to deny
                   coverage for other injuries arising out of the same industrial accident.
                               In this case, the insurer's acceptance of coverage was restricted
                   to the claimant's cervical strain and thoracic sprain "only," but the insurer
                   did not expressly deny coverage for treatment to the claimant's lumber spine.
                   Therefore, the claimant was not required to appeal from either the
                   determination of claim acceptance or claim closure to preserve his right to
                   seek the reopening of his industrial claim under NRS 616C.390 for treatment
                   to his lumbar spine.
                                    FACTS AND PROCEDURAL HISTORY
                               In 2019, appellant Brett Gilman, an English teacher with
                   respondent Clark County School District, sustained injuries while diverting
                   a student altercation. According to the information Gilman provided in his
                   Incident Report/Form C-1, "Student was fleeing Administration, [r]unning at
                   breakneck speed. I stopped the student, by the straps of the backpack. They
                   threw a trash can between us to avoid capture, causing me to slip [and] fall."
                   Gilman reported his injuries as being "multiple" but "unknown" at the time
                   he completed the incident report. Soon after, Gilman requested workers'
                   compensation from the school district's industrial insurer, respondent Sierra
                   Nevada Administrators (Sierra), for injuries related to his "neck" and "back."
                   Several days later, Gilman was evaluated at Concentra Medical Center,
                   which diagnosed cervical strain and thoracic sprain. Gilman's treatment
                   records from Concentra did not mention any injury to his lumbar spine.

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                   Gilman was advised to return to full work and activity and referred for
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                      physical therapy.   The physical therapy records support that Gilman
                      complained of "low back pain," and his rehabilitation goals were to decrease
                      neck and back pain.
                                 Gilman's injuries reportedly continued to improve. Meanwhile,
                      Sierra advised Gilman in a notice of claim acceptance that it would be
                      accepting his industrial insurance claim for "Cervical Strain (Only) [and]
                      Thoracic Sprain (Only)." Sierra did not mention the lumbar spine in its claim
                      acceptance letter, and it did not issue either a written acceptance or a written
                      denial for treatment to the lumbar spine. Gilman did not appeal this
                      determination. A few months later, Sierra notified Gilman that all Workers'
                      compensation benefits had been paid and that his claim was being closed
                      without an award of permanent partial disability (PPD). Gilman did not
                      appeal this determination either, and his claim Was closed.
                                  Almost immediately after the closure of his claim, Gilman began
                      experiencing significant low back or lumbar pain, for which he sought
                      treatment. X-rays of Gilman's spine revealed degenerative disc disease. In
                      early 2020, well within one year of the closure of his workers' compensation
                      claim, Gilman requested that his claim be reopened for further evaluation
                      and treatment of injuries to his lumbar spine.' Sierra denied Gilman's

                             'Although Gilman had initially also requested reopening of the claim
                      for treatment to his cervical, thoracic, and lumbar spine, he testified at the
                      hearing before the appeals officer that he was only seeking to reopen his
                      industrial claim to cover treatment to his lumbar spine and: not for any
                      further treatment related to the cervical and thoracic spine. However, on
                      appeal, Gilman appears to assert that he is moving to reopen the entirety of
                      his claim, contrary to both his testimony before the appeals officer and the
                      record. For purposes of this appeal, we focus on Gilman's request to reopen
                      his industrial claim as it relates to the lumbar spine. On remand, the appeals
                      officer should confirm the scope of the claim Gilman is seeking to reopen.
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                   request because the lumbar spine was not a body part covered by the initial
                   acceptance of his claim. Gilman timely appealed Sierra's decision to a
                   hearing officer.
                               Before a decision was rendered, an MRI revealed that Gilman
                   had 'advanced degenerative disease of the spine with lumbar disc herniations.
                   Dr. Firooz Mashood opined that the disc herniations were not present prior
                   to the industrial injury and recommended that, "given the worsening of
                   patient's- symptomatology, physical examination findings and MRI study
                   findings[,} ....his case be reopened for further diagnostic workup and
                   treatment not limited to repeat MRI study of the lumbar spine and/or referral
                   to a spine orthopedic surgeon." br. Daniel Lee, the orthopedic surgeon to
                   whom Gilman was referred, noted disc ,herniations at L4-5 and L5-S,1,,which
                   he classified as being slightly Worše, Presumedly in comparison to a PriOr
                   study not clearlY identified in the record.
                                The hearing-officer issued two orders affirming Sierra's decision
                   to deny Gilman's request to reopen hiS claim. The hearing officer's first
                   decision and order identified the issue as an appeal from a "denial of
                   treatment" and affirmed Sierra's d.enial of additional medical treatment
                   based on the claim being closed. The hearing officer's second decision and
                   order identified the issue as an appeal from a "de facto denial" and a request
                   for claim reopening% In this second decision, the hearing officer denied
                   reopening because "the [workers] compensation claim was accepted. for the
                   cervical strain and thoracic sprain only." After reviewing Dr. Mashood's
                   consultation report, the hearing- officer concluded that, -"[a]s-Dr. Mashood is
                   recommending reopenin.g for lumbar spine treatment that is 'not included in
                   the original claim, [Sierra's] de facto denial of the reopening request is proper

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                   and is hereby AFFIRMED." Gilman timely administratively appealed the
                   hearing officer's decision.
                              While the matter was pending. Gilman continued to experience
                   low back pain and underwent selective nerve root blocks, which provided
                   some relief. Dr. Lee eventually diagnosed Gilman as having a lumbar disc
                   herniation with radiculopathy, noting that Gilman had "worsening foot drop
                   on the left [and] progressive weakness." Consequently, Dr. Lee performed a
                   posterior lumbar decompression and fusion surgery at L4-S1. Subsequently,
                   Dr. Mashood concluded that "Gilman's cervical, thoracic and lumbar have
                   worsened and the need of additional medical treatment, to a reasonable
                   degree of medical probability is priniarily related to the April 25, 2019
                   Industrial Injury."
                               The appeals officer issued a decision and order affirming Sierra's
                   denial of Gilman's request for additional medical treatment and his request
                   to reopen his claim. After noting that Sierra had "accepted the claim for the
                   following body parts: 'cervical strain only' and 'thoracic sprain only,' the
                   appeals officer found that Gilman's "lumbar spine was never accepted as part
                   of his industrial claim" and that he failed to appeal Sierra's claim closure
                   determination. In addition, the appeals officer found that Gilman did not
                   receive treatment to his lumbar spine until after his industrial claim was
                   closed and, therefore, equitable estoppel did not apply.2    In other words,

                         2 Gilman does not raise equitable estoppel as an issue on appeal.
                   Therefore, we need not address it further. See Powell v. Liberty Mut. Fire
                   Ins. Co., 127 Nev. 156, 161 n.3, 252 P.3d 668, 672 n.3 (2011) (providing that
                   issues not raised on appeal are deemed waived). Although Gilman's physical
                   therapy records are equivocal as to whether treatment was given for the
                   lower back or lumbar region, he testified at the hearing before the appeals
                   officer that he received treatment for low back pain before his claim was
                   closed.
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                   because the insurer did not pay for treatment to the lumbar spine, it could
                   not be equitably estopped from denying coverage Under Dickinson v.
                   American Medical Response, 124 Nev. 460, 186 P.3d 878 (2008). The appeals
                   officer also found that Gilman failed to comply with the requirements of the
                   reopening statute, NRS 616C.390, explaining, "[Mere, Mr. Gilman does not
                   satisfy the statute because the himbar was never an accepted body part."
                   The appeals officer ultimately concluded that "[Mr. Gilman] has not met his
                   burden to justify reopeni.ng his claim:" SubsequentlY, the 'district court
                   denied Gilman's petition for judicial reView. This appeal followed.3
                                                       ANALYSIS
                                  On appeal, Gilman argues that the appeals officer erred in
                   denying his motion to reopen his industrial claim.           Primarily, Gilman
                   contends that the appeals officer improperly considered Sierra's acceptance
                   letter to be a "denial" of coverage for injuries to the lumbar spine that Gilman
                   was obligated to appeal Under NRS 616C.220.4 Building on this assertion,
                   he argues that his failure to appeal did not preclude the reopening of his
                   industrial claim.      Gilman further argues that overwhelming evidence
                   supports reopening his industrial claim to include coverage for the low back
                   surgery performed by Dr. Lee pursuant to NRS 616C.390. Sierra, in turn,
                   argues that reopening the claim to include treatment to the lumbar spine

                         3   We hereinafter refer to respondents collectively as Sierra.
                         4Under NRS 616C.220(10), "[a]ny party aggrieved by a determination
                   to accept or • to- deny any claim" for industrial injury "may appeal that
                   determination, within 70 days after the • determination is rendered." The
                   parties agree that Gilman did not appeal after receiving either Sierra's
                   determination of claim acceptance or claim closure: The parties do, however,
                   dispute whether Gilman's failure to administratively appeal either
                   determination has any legal significance in resolving the issues before us.
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                   would have been improper because Gilman failed to appeal the "acceptance"
                   of his claim, which was limited to cervical strain and thoracic sprain only.
                   Sierra also argues that substantial evidence supports the appeals officer's
                   finding that Gilman failed to establish he was entitled to reopen his claim for
                   medical treatment to his lumbar spine. •
                               Generally, on appeal, the "standard for reviewing petitions for
                   judicial review of administrative decisions is the same for this court as it is
                   for the district court." City of Reno v. Bldg. & Constr. Trades Council of IV.
                   Neu., 127 Nev. 11.4, 119, 251 P.3d 718, 721 (2011) (internal citations omitted).
                   ThiS 'court reViews an administrative officer's construction of statutes de
                   novo. Holiday Ret, Corp. v. State, Div: of Indus. Relations, 128 Nev. 150, 153,
                   274 P.3d 759, 761 (2012). Further, We decide "pure legal questions without
                   deference to an agency determinatipn." City of Reno, 127 Nev. at 119, 251
                   P.3d at 721 (quoting Jones v. Rosner, 102 Nev 215, 217, 719 P.2d 805, 806
                   (1986)); see also Maxwell v. State Indus. Ins. Sys., 109 Nev. 327, 329, 849 P.2d
                   267, 269 (1993), ("The construction of a statute is a question of law, and
                   independent appellate review of an administrative ruling, rather than a niore
                   deferential standard of review, is appropriate.").
                               While we do not defer to administrative constructions of statutes,
                   "[wje review an administrative agency's factual findings for clear error or an
                   arbitrary abuse of discretion and will only overturn those findings if they are
                   not supported by substantial evidence."        City of North Las Vegas v.
                   Warburton, 127 Nev. 682, 686, 262 P.3d 715, 718 (2011) (internal quotation
                   marks omitted). "Substantial evidence exists if a reasonable person Could
                   find the evidenCe adequate to support the agency's conclusion." Law Offices
                   of Barry Levinson, P.C. v..Milko, 124 Nev. 355, 362, 184 P.3d 378, 384 (2008).
                   This court will not "reweigh the evidence or revisit an appeals officer'S
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                   credibility determination." Id. at 362, 184 P.3d at 383-84. And we do not
                   make factual determinations in the first instance. See Ryan's Express
                   Transp. Servs., Inc. u. Amador Stage Lines, Inc., 128 Nev. 289, 299, 279 P.3d
                   166, 172 (2012) ("An appellate court is not particularly well-suited to rnake
                   factual determinations in the first instance.").
                              The pivotal issue in this appeal is whether the appeals officer
                   misapplied NRS 616C.065(7) to find that the lumbar spine was not within
                   the scope of Gilman's accepted industrial claim and thus erred in denying
                   Gilman's request to reopen his claim for treatment to his lumbar spine on
                   that basis. The appeals officer reasoned that Gihnan could not move to
                   reopen his claim for a body part that was never accepted as part of the
                   original claim, asking rhetorically, "How can one have a worsening body part
                   that was never part of the claimr
                               We review the construction of NRS 616C.065(7) de novo. See
                   Holiday Ret. Corp., 128 Nev. at 153, 274 P.3d at 761. When interpreting a
                   statute, "the proper place to begin is with the plain text of the relevant
                   statute[s], and if those words are unambiguous, that is where our analysis
                   ends as well." In re Execution of Search Warrants, 134 Nev. 799, 801, 435
                   P.3d 672, 675 (Ct. App. 2018). However, "when a statute is susceptible to
                   more than one reasonable interpretation, it is ambiguous, and this court
                   must resolve that ambiguity by looking to the statute's legislative history and
                   construing the statute in a manner• that conforms to reason and public
                   policy." Zohar v. Zbiegien. 130 Nev. 733, 737, 334 P.3d 402, 405 (2014)
                   (internal quotations omitted).
                               Here, the language of NRS 616C.065(7) clearly states that "Nile
                   failure of the insurer to indicate the acceptance or denial of a claim for a part
                   of the body or condition does not constitute a denial or acceptance thereof."
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                   (Emphasis added.) And the acceptance or denial must be in writing. See
                   NRS 616C.065(5) ("The insurer shall notify the claimant or the person acting
                   on behalf of the claimant that a claim has been accepted or denied pursuant
                   to subsection 1. or 2 [by mailing or sending] its written determination . . .").
                   The plain language of these subsections of the statute unambiguously places
                   the responsibility on Sierra to either accept or deny coverage of a specific
                   body part or condition in writing when determining coverage for an
                   industrial claim.
                               Further, this plain language interpretation is supported by the
                   purpose of permitting claims to be reopened pursuant to NRS 616C.390. We
                   have "a duty to construe statutes as a whole, so that all provisions are
                   considered together and, to the extent practicable, reconciled and
                   harmonized." Orion Portfolio Servs. 2, LLC v. County of Clark ex rel. Univ.
                   Med. Ctr. of S. Nev.. 126 Nev. 397, 403, 245 P.3d 527, 531 (2010). And we
                   "will not render any part of [a] statute meaningless, and will not read [a]
                   statute's language so as to produce absurd or unreasonable results." Id.
                   Failure to give effect to the plain language of NRS 616C.065(7) would
                   frustrate the purpose of NRS 616C.390, which permits the reopening of a
                   claim and expanding the scope of coverage where, for example, an injury to
                   a body part manifests after a claim has been closed but is medically related
                   to the original industrial accident.
                               In this case, Sierra's acceptance letter did not address coverage
                   for the low back or lumbar pain that Gilman reported experiencing. Instead,
                   Sierra's letter simply identified the "Body Part(s)/Injury Diagnosis" as
                   "Cervical Strain (Only), Thoracic Sprain (Only)." Based on the statute's plain
                   language, since Sierra neither accepted nor denied coverage for treatment to
                   the lumbar spine, the letter cannot be interpreted to either accept or deny

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                   coverage for future treatment related to the lumbar spine. Thus, under NRS
                   616C.065(7), the appeals officer's determination that Sierra's failure to
                   expressly accept coverage for treatment to the lumbar spine was an implicit
                   denial of coverage for that body part is incorrect.5 Specifically, the appeals
                   officer, without considering the plain language of the statute, appears to have
                   found an implicit denial of Coveragefor the lumbar spine based on the explicit
                   acceptance of coverage for other body parts. But the denial of coverage for
                   the body part at issue—the lumbar spine—must be explicitly indicated in
                   writing in keeping With the plain meaning of NRS 616C.065(7) and the
                   requirements of NRS 61.6C.065(5) addressed above.           Thus, we are not
                   persuaded that the qualifier Of "only" aS related to the acceptance of the
                   injuries to the other two body parts, cervical strain and thoracic sprain,
                   supports the denial of coverage for the lumbar injury. By way of example, an
                   argument could be made that the qualifier of "only" listed after cervical strain
                   modifies the term strain, thereby limiting coverage to a cervical strain and
                   excluding other cervical conditions.
                               Further, without an expli.cit denial of coverage for treatment to
                   the lumbar spine, Gilman was not required to appeal within 70 days after
                   either receiving Sierra's determination of claim acceptance or claim closure.
                   See NRS 616C.220(10) (providing a right of appeal for "[a]ny ph:rty aggrieved

                         5To the extent Sierra relies. ofl NRS 616C.495 for the proposition that
                   "disputes concerning .the scope of. the claim do not survive claim closure,"
                   that statute is inapposite. Gilman did not dispute that his claim could be
                   closed without a PPD 'evaluation. And even if we looked to NRS 616C.495
                   for "guidance as to the issues of claim closure and the scope of the claim" as
                   suggested by Sierra, there was no "dispute" related to coverage for Gilman's
                   lumbar spine that existed prior to claim closure because Sierra never
                   expressly denied coverage for that claim in its claim acceptance letter. Cf.
                   NRS 616C.065(7).
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                     by a determination to accept or to deny any claim") and NRS 616C.315(3)
                     (providing a right of appeal from a deterrnination). In other words, since
                     Sierra had not yet denied coverage for treatment to Gilman's lumbar spine,
                     it would be illogical to require Gilman to appeal the lack of coverage for his
                     lumbar spine injury. Accordingly, the appeals officer's decision to deny the
                     reopening of Gilman's claim for failure to appeal Sierra's determination of
                     coverage disregarded the plain language of NRS 616C.065(7) and was in
                     error.
                                 Even though it is unnecessary to consider the legislative history
                     because of the plain language of the statute, we note that the history clearly
                     supports that NRS 616C.065(7) was intended to permit the reopening of a
                     claim to obtain treatment of a body or condition which was nOt specifically
                     denied by the insurer.6 During a subcommittee meeting of the Assembly
                     Committee on Commerce and Labor, Robert Ostrovsky, representing
                     Employers Insurance Group, explained the key legislative history:
                                   [the proposed amendment to S.B. 195(R1) adopting
                                   provisions of A.B. 178] includes nine major areas of
                                   consensus. The first area is the acceptance of a claim.
                                   There was a dispute that the letters sent to
                                   claimants, accepting a claim on a body part for
                                   example, were then used as a method for denying
                                   claims in the future—if the claimant had an arrn
                                   injury and had to add a hip injury if both body parts
                                   were injured during the same incident. There were
                                   issues that the acceptance letter was being used as a
                                   weapon to deny those claimants the right to expand

                              6We note that Gilman and Sierra dispute the timely disclosure of the
                     legislative history to the appeals officer. As we review the interpretation of
                     a statute de novo, we may consider the legislative history. See Zohar, 130
                     Nev. at 737, 334 P.3d at 405. We also note that Gilman brought the
                     legislative history to the attention of the appeals officer on reconsideration
                     and provided that same authority to the district court as well.
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                               their claim. To solve that problem, we added
                               language that would clearly indicate that the letter
                               of acceptance is not an exclusion, and not an
                               automatic deniai for other body parts. It does not
                               mean that they will automatically be accepted, but it
                               does mean you will get the opportunity to litigate
                               those rnatters before an appropriate appeals or
                               hearing officer, and/or discuss them with the parties.
                   Hearing on S.B. 195, Before the Assemb. Comm. on Commerce and Labor,
                   •75th Leg., at 3 (Nev., May 13, 2009).     Both the plain language of NRS

                   616C.065(7) and the statute's legislative history support our conclusion that
                   Sierra's failure to expressly. accept coverage for treatment to the lumbar
                   spine cannot be interpreted as a denial of coverage. Therefore, Gilman's
                   failure to appeal after receiving either Sierra's determination of claim
                   acceptance or claim closure did not preclude him from subsequently seeking
                   to reopen his claim under NRS 616C.390.
                               While the parties also dispute whether substantial evidence
                   supported the appeals officer's decision that Gilman failed to establish that
                   he was entitled to reopen his claim under NRS 616C.390 to seek medical
                   treatment for his lumbar spine, this issue does not provide a basis to affirm
                   the challenged decision. The appeals officer concluded that Gilman did not
                   satisfy the reopening statute, NRS 616C.390, for a single reason: "because
                   the lumbar was never an accepted body part." But as set forth above, the
                   appeals officer erred in reaching this decision because Sierra did not
                   explicitly deny coverage for injuries to the lumbar spine and, in any event,
                   the appeal officer's one-line conclusionary statement cannot be considered
                   substantial evidence supporting the denial of Gilman's request to reopen his
                   industrial claim.

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                                                    CONCLUSION

                                Because the appeals officer erred in denying Gilinan's request to

                   reopen his industrial claim by misapplying NRS 616C.065(7) and without
                   properly considering whether he satisfied the requirements of NRS
                   616C.390, we reverse and remand the matter to the district court with
                   instructions to remand the matter to the appeals officer for further
                   proceedings consistent with this opinion.

                                                         Bulla

                   We concur:

                                                ,   C.j.

                                                    J.
                   Westbrook

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