Court Opinion

ID: 7820929
Source: CourtListenerOpinion
Date Created: 2022-09-07 17:54:32.075121+00
Date Added: 2024-06-11T16:30:44.221153
License: Public Domain

George Howard Jr., Judge, dissenting. I am persuaded that the evidence in this record supports the Administrative Law Judge’s finding that the delay on the part of appellee, Hartford Insurance Company, in paying a hospital bill of $19,943.65 constituted controversion, thus, entitling claimant’s attorney to a fee. The majority in affirming this case and concluding that there is substantial evidence to support the Full Commission’s holding that the appellee did not controvert the hospital bills made the following observation: The claim supervisor for the carrier testified he made the decision to withhold payment of the three hospital bills until they could obtain clarification as to whether the bills were injury related. The appellant’s attorney supplied the appellee insurance carrier with copies of hospital medical records on October 20,1978, only three working days prior to the hearing, and delivered the appellant’s medical information release to the appellee insurance carrier on the day of the hearing. Upon securing the medical information the appellee insurance carrier agreed to pay the three bills except for items totaling $121.00. Appellant’s attorney never offered any explanation for ignoring the request of the compensation carrier to be furnished medical release authorization except to assert at the hearing a medical release had previously been provided. The prior release had been filed with the hospital some two years earlier; however, for some reason the hospital was not acting pursuant to that request in providing information as to these bills. The evidence shows the hospital declined to provide hospital medical records to appellees without a new release authorization from appellant. But a careful scrutiny of the record reflects the following: The claim supervisor for the carrier testified: Q. Would it be a fair statement of fact to say that you are the person who is — makes the decision to pay or not to pay these bills? A. Yes, sir, that would be a fair statement. Q. Would it be a fair statement of fact to say that these bills weren’t paid as of September 18th, the date of requesting this hearing? A. That’s correct. Q. Could it be a fair statement of fact to say that you made that decision not to pay them? A. Yes, sir. While the claim supervisor for the carrier stated that he had received a call from the hospital stating that the hospital did not have a medical authorization on file and that he had requested his attorney (Mr. Coffman) to communicate with claimants’ attorney (Mr. Estes) for a medical authorization, the claim supervisor testified: Q. Did you tell Mr. Coffman that you needed a medical authorization because you didn’t have one the hospital would accept? A. No. Q. Did you tell Mr. Coffman that you needed a medical authorization because you didn’t have an up-to-date medical authorization that the hospital would accept? A. I believe that’s more in line with what I told him, that’s correct. Q. But you did have a medical authorization, didn’t you? A. I had a two-year-old medical authorization, that’s correct. Q. And that medical authorization has been used by The Hartford as recent as May 9th of 1978, hadn’t it? A. Evidently, it has. It is plain from the record that on March 2,1976, following claimant’s injury on January 19, 1976, the claimant executed the following medical authorization on a form supplied by Hartford Insurance Company: To whom it may concern: I hereby request and authorize you to disclose, whenever requested to do so by THE HARTFORD INSURANCE GROUP or its representative, any and all information you may have concerning John F. Turner, Jr. with respect to any illness or injury, medical history, consultation, prescription or treatment, including x-ray plates, and copies of all hospital records. A photostatic copy of this authorization shall be considered as effective and valid as the original. The claim supervisor testified further: Q. So, Mr. Scott, it’d be a fair statement of fact to say that you’ve had this medical release available to you, wouldn’t it? A. Well, it’s been maintained in our files, yes, sir. Q. You had it available to you, didn’t you, just answer my question. A. Yes. Q. And you could have used that medical release to determine whatever you wanted to determine about these bills, couldn’t you? A. I’m not sure if I could have or not. Q. Did you try — did you try to — A. I was advised by Sparks that I couldn’t get the requested information without an authorization. Q. Did you have an authorization? A. I had one dated probably over two years prior to the time I needed it. Q. Did you take that medical authorization to Sparks? A. No I did not. Q. Did you provide them with a copy through the mail ? A. No I did not. Q. Did you tell Mr. Coffman I don’t have a medical release? A. I don’t recall exactly what I said specifically, I was asking. Q. Let me ask you this what was your explanation to Mr. Coffman in requesting a medical release? A. That I didn’t have an authorization I felt that the hospital would accept. Q. Okay. So, you told Mr. Coffman that you didn’t have an authorization that the hospital would accept, is that right? A. That’s correct. It is clear that the claim supervisor merely assumed that the medical authorization given by claimant on March 2, 1976, was unacceptable to the hospital for there is no evidence that the hospital refused to accept this authorization. Consequently, the claim supervisor persisted in requiring a new medical authorization not because the hospital wanted an up-to-date one as found by the majority, but, on the contrary, on the assumption of the claim supervisor that the hospital would not honor the authorization in his possession. Another parallel paradox in this matter is the claim supervisor’s admission, in effect, that the hospital had honored the medical authorization of March 2, 1976, as late as May 9, 1978. Under these circumstances, I cannot support the posture taken by the majority in finding that the Commission’s holding is supported by substantial evidence — evidence possessing substance and authenticity which reasonable minds might accept as adequate to support a conclusion — therefore, I dissent.