Court Opinion

ID: 4560427
Source: CourtListenerOpinion
Date Created: 2020-08-26 21:02:10.817526+00
Date Added: 2024-06-11T08:46:09.165504
License: Public Domain

FILED
Aug 09, 2019
10:19 AM(CT)

TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS

 

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

AT GRAY
CHRISTOPHER TILSON, ) Docket No.: 2018-02-0062
Employee, )
Vv. ) State File No.: 7426-2018
HAYWORTH TIRE and AUTO )
SERVICE, ) Judge Brian K. Addington
Uninsured Employer. )

 

EXPEDITED HEARING ORDER

 

The Court held an Expedited Hearing on August 8, 2019, on Mr. Tilson’s request
for past, unpaid medical benefits. Before the hearing, the parties discussed the issues and
announced to the Court that they would state their stipulations on the record.

The parties stipulated that Mr. Tilson’s evidence was sufficient to prove he
sustained a right-knee injury and is entitled to past medical benefits. Further, the parties
stipulated Hayworth Tire and Auto Service (Hayworth) agreed to pay $13,761.19 in
medical expenses related to his injury incurred to date.

Based on the parties’ stipulations, the Court holds Mr. Tilson is likely to succeed
at a hearing on the merits in proving entitlement to medical benefits and orders Hayworth
to pay the incurred medical bills associated with Mr. Tilson’s work injury according to
the fee schedule.

The parties further agreed to continue this matter for two weeks to allow
Hayworth to obtain a medical records review. Following the records review, the parties
will determine whether Dr. Michael Wells will be designated the authorized treating
physician or if a panel would be appropriate. The parties agreed to file a new Request for
Expedited Hearing if they are unable to agree on continued medical treatment or an
agreed order if they reach an agreement on this issue.
IT IS, THEREFORE, ORDERED as follows:

1.

Hayworth shall pay the providers $13,761.19 for medical services incurred to date
for treatment of Mr. Tilson’s work injury.

. This case is set for a Status Hearing on October 22, 2019, at 2:00 p.m. Eastern

Time. You must call 855-543-5044 to participate. Failure to call may result in a
determination of the issues without your participation.

. Unless interlocutory appeal of the Expedited Hearing Order is filed, compliance

with this Order must occur no later than seven business days from the date of entry
of this Order as required by Tennessee Code Annotated section 50-6-239(d)(3).
The Insurer or Self-Insured Employer must submit confirmation of compliance
with this Order to the Bureau by email to WCCompliance.Program@tn.gov no
later than the seventh business day after entry of this Order. Failure to submit the
necessary confirmation within the period of compliance may result in a penalty
assessment for non-compliance.

. For questions regarding compliance, please contact the Workers’ Compensation

Compliance Unit via email at WCCompliance.Program(@tn.gov.

 

ENTERED August 9, 2019.

/S/ Brian K. Addington
Judge Brian K. Addington
Court of Workers’ Compensation Claims

APPENDIX

Exhibits:

1.
me

Affidavit of Josh Hoeppner
(Collective) Medical Bills

Technical record:

1.
2.

Petition for Benefit Determination
Dispute Certification Notice

3. Notice of Filing
4. Request for Expedited Hearing
5. Pre-Hearing Brief

CERTIFICATE OF SERVICE

I certify that a correct copy of this Order was sent as indicated on August 9, 2019.

 

 

 

 

 

 

 

Name Certified Email | Service sent to:
Mail
Josh Hoeppner, x josh@hoeppnerlaw.com
Employee’s Attorney
Jeff Luethke, x jeffluethke@gmail.com
Employer’s Attorney

 

F
f

J NAL Ati
Linny Wu

Penny Shru/} Clerk of Court

Court of Wo/kers’ Compensation Claims
WC.CourtClerk@tn.gov

 

 
 

Expedited Hearing Order Right to Appeal:

If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:

1. Complete the enclosed form entitled: “Expedited Hearing Notice of Appeal,” and file the
form with the Clerk of the Court of Workers’ Compensation Claims within seven
business days of the date the expedited hearing order was filed. When filing the Notice
of Appeal, you must serve a copy upon all parties.

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 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 the 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. If a transcript of
the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
it with the court clerk within ten business days of the filing the Notice of
Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
parties within ten business 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 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. If you wish to file a position statement, you must file it with the court clerk within ten
business days after the deadline to file a transcript or statement of the evidence. The
party opposing the appeal may file a response with the court clerk within ten business
days after you file your position statement. All position statements should include: (1) a
statement summarizing the facts of the case from the evidence admitted during the
expedited hearing; (2) a statement summarizing the disposition of the case as a result of
the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
argument, citing appropriate statutes, case law, or other authority.

For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
LB-1099

 

EXPEDITED HEARING NOTICE OF APPEAL
Tennessee Division of Workers’ Compensation
www. tn.gov/labor-wid/weomp.shtml
wce.courtclerk@tn.gov
1-800-332-2667

 

Docket #:
State File #/YR:

 

Employee

Vv.

 

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:

 

 

 

Additional Information
Type of Case [Check the most appropriate item]

L] Temporary disability benefits
L] Medical benefits for current injury
LC Medical benefits under prior order issued by the Court

List of Parties
Appellant (Requesting Party): At Hearing: LJEmployer LJEmployee

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 *

rev. 10/18 Page 1 of 2 RDA 11082
Employee Name: SF#: DOI:

Appellee(s)

Appellee (Opposing Party): At Hearing: L]JEmployer LJEmployee

 

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,
Expedited 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

, certify that | have forwarded a true and exact copy of this

[Signature of appellant or attorney for appellant]

 

LB-1099 rev. 10/18 Page 2 of 2 RDA 11082
 

Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667

AFFIDAVIT OF INDIGENCY

I, , having been duly sworn according to law, make oath that
because of my poverty, | 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 Ail Dependents:

Relationship:

 

 

Relationship:

 

 

Relationship:

 

 

Relationship:

 

 

6. lam employed by:

 

My employer’s address is:

 

My employer’s phone number is:

 

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

$

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

 

 

 

 

 

 

AFDC $ per month beginning
ssl $ per month beginning
Retirement $ per month beginning
Disability $ per month beginning
Unemployment $ per month beginning
Worker's Comp.$ per month beginning
Other $ per month beginning

 

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

 

 

 

Rent/House Payment $ permonth Medical/Dental $ per month

Groceries $ per month Telephone $ per month

Electricity $ per month School Supplies $ per month

Water $ per month Clothing $ per month

Gas $ per month Child Care $ per month

Transportation $ per month Child Support $ per month

Car $ per month

Other $ per month (describe: )
10. Assets:

Automobile $ (FMV)

Checking/Savings Acct. $

House $ __ (FMV)

Other $ Describe:

 

11. My debts are:

Amount Owed To Whom

 

 

 

 

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

 

APPELLANT

Sworn and subscribed before me, a notary public, this

day of , 20

 

NOTARY PUBLIC

My Commission Expires:

LB-1108 (REV 11/15) RDA 11082