Court Opinion

ID: 4677242
Source: CourtListenerOpinion
Date Created: 2021-04-14 16:05:59.006354+00
Date Added: 2024-06-11T08:03:37.102832
License: Public Domain

IN THE COURT OF APPEALS OF IOWA

                                  No. 20-0673
                              Filed April 14, 2021

APRIL ARLENE CLARK,
     Petitioner-Appellant/Cross-Appellee,

vs.

WINNEBAGO INDUSTRIES, INC.,
     Respondent-Appellee/Cross-Appellant.
________________________________________________________________

      Appeal from the Iowa District Court for Polk County, Paul D. Scott, Judge.

      April Clark appeals the denial of penalty benefits in a workers’

compensation dispute with her employer.          Winnebago cross-appeals the

commissioner’s award of permanent disability benefits, the benefit rate applied,

and the alternate medical care option. AFFIRMED IN PART AND REMANDED

FOR FURTHER PROCEEDINGS ON APPEAL; AFFIRMED ON CROSS-

APPEAL.

      Mark S. Soldat of Mark S. Soldat, PLC, West Des Moines, for appellant.

      Valerie A. Foote (until withdrawal) and Lindsey Mills of Smith Mills Schrock

Blades P.C., West Des Moines, for appellee.

      Considered by Bower, C.J., and Vaitheswaran and Greer, JJ.
                                        2

GREER, Judge.

      After sustaining a work injury to her right wrist in July of 2016, April Clark

received benefits under the workers’ compensation system.1 Now, Clark advances

a claim for additional entitlement to penalty benefits under Iowa Code section

86.13(4)(c) (2017).2     Winnebago      Industries   (Winnebago)    contends the

commissioner and district court properly denied her request because the company

1 The parties stipulated this was a work injury. Clark petitioned for benefits on
January 31, 2017.
2 Iowa Code section 86.13(4) provides:

              a. If a denial, a delay in payment, or a termination of benefits
       occurs without reasonable or probable cause or excuse known to the
       employer or insurance carrier at the time of the denial, delay in
       payment, or termination of benefits, the workers’ compensation
       commissioner shall award benefits in addition to those benefits
       payable under this chapter, or chapter 85, 85A, or 85B, up to fifty
       percent of the amount of benefits that were denied, delayed, or
       terminated without reasonable or probable cause or excuse.
              b. The workers’ compensation commissioner shall award
       benefits under this subsection if the commissioner finds both of the
       following facts:
              (1) The employee has demonstrated a denial, delay in
       payment, or termination of benefits.
              (2) The employer has failed to prove a reasonable or probable
       cause or excuse for the denial, delay in payment, or termination of
       benefits.
              c. In order to be considered a reasonable or probable cause
       or excuse under paragraph “b”, an excuse shall satisfy all of the
       following criteria:
              (1) The excuse was preceded by a reasonable investigation
       and evaluation by the employer or insurance carrier into whether
       benefits were owed to the employee.
              (2) The results of the reasonable investigation and evaluation
       were the actual basis upon which the employer or insurance carrier
       contemporaneously relied to deny, delay payment of, or terminate
       benefits.
              (3) The employer or insurance carrier contemporaneously
       conveyed the basis for the denial, delay in payment, or termination
       of benefits to the employee at the time of the denial, delay, or
       termination of benefits.
                                           3

had a reasonable basis for initially delaying benefit payments to Clark. Winnebago

cross-appeals over three issues it asserts were not supported by substantial

evidence: (1) error in finding permanent disability, (2) error in calculating the benefit

rate, and (3) error in awarding alternate medical care.

       While using a screwdriver at work, Clark noticed pain in her right hand and

wrist that traveled up her arm and into her right shoulder. Following the July 2016

injury, Clark treated with a general practitioner and a physician assistant until she

was referred to an orthopedic specialist, Dr. Timothy Gibbons. In October, Dr.

Gibbons evaluated Clark’s condition after taking diagnostic tests and noted:

       I had a comprehensive discussion with her about issues of causation.
       I think the x-ray implies she has [a] previous old trauma though she
       cannot recall when this occurred. I think this is a temporary agitation
       of a pre-existing condition as it stands today.

Then, after reviewing a November MRI, Dr. Gibbons declared Clark at maximum

medical improvement (MMI) and discharged her with restrictions in November

2016. Her November MRI showed an ununited ulnar styloid fracture, edema, and

triangular fibrocartilage perforation. He could not explain her wrist pain and could

offer her no further treatment. As for any permanency, Dr. Gibbons opined, “I do

not believe that she sustained any permanent partial impairment secondary to her

employment, but I do believe that she would benefit from a different work

assignment that she is more tolerant of, which would include avoiding power tools,

especially the power tools that cause a torque.”

       At Winnebago’s request, Dr. Joshua Kimelman performed an independent

medical examination (IME) in July 2017. After reviewing the medical records and

performing a physical exam, he diagnosed Clark with “[c]hronic wrist pain of
                                           4

unknown etiology.” Dr. Kimelman did not agree with Dr. Gibbons’s opinion that

Clark had a pre-existing condition with her wrist. But he causally related the wrist

condition and her need for care to her work activities at Winnebago. Yet, he opined

Clark was at MMI and recommended no further treatment. Zeroing in on her

complaints, Dr. Kimelman noted, “I do not believe the nonunion of her ulnar styloid

is in any way related to her complaint of dorsal wrist pain.” In response to a series

of questions in his report, Dr. Kimelman addressed Clark’s degree of permanent

impairment:

              Question 6: Do you believe that Claimant’s work injury caused
       her to sustain any degree of permanent impairment? What
       permanent impairment would you assign? Would any portion of
       Claimant’s impairment be attributable to pre-existing or personal
       condition?
              Answer: As regards to permanent impairment, that is difficult
       to determine as she demonstrates essentially full range of motion
       and while she does demonstrate relative atrophy of the right arm
       compared to the left, her measurement, particularly with pinch grip,
       was very variable, probably not indicative of organic disease.

Finding Clark should be on light lifting status, he recommended limited occasional

lifting of twenty pounds without repetitive work as “restrictions . . . secondary to her

job-related injury, although . . . unable to attribute an anatomic injury to her arm at

this point.”

       Next, at the request of Clark’s counsel, in August 2017, Dr. Sunil Bansal

examined Clark. He addressed several questions in his IME report. First, he found

Clark injured her right wrist at work and confirmed

       [t]he mechanism of injury of forceful wrist torqueing from tightening
       screws would lead to loaded ulnar deviation, making it highly
       pathognomonic for a triangular fibrocartilage complex tear. Given
       her immediate wrist pain and her lack of preexisting wrist pain, this
       is highly suggestive of an acute tear or the aggravation of a pre-
       existing tear to make it clinically relevant.
                                             5

(Emphasis added.) On the subject of permanency, Dr. Bansal found a permanent

loss of grip strength with no prior history of impairment of her right wrist. He found

her condition was consistent with outcomes attributed to a triangular fibrocartilage

complex tear. Dr. Bansal assigned Clark a 10% permanent impairment rating of

the right upper extremity, restricted her lifting to ten pounds and recommended

treatment with a Mayo Clinic specialist in triangular fibrocartilage complex (TFCC)

tears.

         In her September 2017 hearing before the deputy workers’ compensation

commissioner, Clark raised a number of issues including if she was entitled to

penalty benefits.3        With a stipulated hearing report before the deputy

commissioner, the parties discussed issues that were resolved and those that were

not.

                 DEPUTY: I have discussed the hearing report with the parties
         off the record and will go over that again on the record. The parties
         have stipulated as to the existence of an employer-employee
         relationship at the time of the alleged injury and that Ms. Clark
         sustained an injury on or about July 8, 2016. They agree the alleged
         injury caused temporary disability during a period of recovery, but
         dispute whether or not the injury caused a permanent disability, so
         extent of disability is at issue. I have discussed there are a number
         of weeks listed on the hearing report, and I’m not going to go through
         those again at this time, regarding temporary and healing period

3   The list of issues included:
                  1. Is the alleged injury a cause of permanent disability?
                  2. If the alleged injury is a cause of permanent disability, what
          is the extent of disability?
                  3. What is the rate?
                  4. Is Clark entitled to alternate medical care?
                  5. If the alleged injury is a cause of permanent disability, is
          Clark entitled to interest?
                  6. Should Clark be awarded penalty benefits?
                  7. Should costs be awarded to Clark?
                                          6

       benefits. There was a rate dispute, and a payment log has been
       provided in the case. Is that Exhibit D?
              EMPLOYER: Yes, Your Honor.
              DEPUTY: And the [employer] intends to pay the underpaid
       benefits before submitting their brief in this case; is that correct?
              EMPLOYER: Yes, your Honor.
              DEPUTY: So there’s really no dispute concerning what’s been
       underpaid at this time. You’ve agreed upon the rate, and you just
       need—the claimant needs to receive the payment?
              CLAIMANT: Yes, but to—
              DEPUTY: And interest?
              CLAIMANT: Yeah. To obtain that, you have to do the credit
       interest computation—
              DEPUTY: Right.
              CLAIMANT: —using the United States rule, so I can’t say how
       much at this point.
              DEPUTY: Sure, right. And that will be briefed by the parties?
              CLAIMANT: It would.
              DEPUTY: Unless you’re able to agree. The defendant does
       agree that it’s liable for those benefits and it has paid benefits.
       They’ve just underpaid them. And they also agree that the claimant
       was off work during this period of time. The defendant, are you
       alleging that the claimant is entitled to 37.5 weeks or is that the
       claimant’s contention?
              CLAIMANT: That’s my contention.

The parties also stipulated that the commencement date for permanent partial

disability benefits was July 19, 2016, but Winnebago contested any permanency

finding. After a hearing, the deputy commissioner awarded Clark benefits for a

10% permanent impairment of the right upper extremity and ordered alternate care

at the Mayo Clinic.4

4 The findings were 1) Clark sustained a 10% permanent disability of her right
upper extremity as a result of the stipulated workplace injury; 2) Clark’s
classification for calculation is married with three children, and the correct workers’
compensation rate is $372.30 per week; 3) Clark is not entitled to penalty benefits
for Winnebago’s non-payment of permanent partial disability benefits; and 4) Clark
is entitled to alternate medical care in the form of an evaluation with a specialist in
TFCC tears at the Mayo Clinic per Dr. Bansal’s recommendation.
                                          7

       Ultimately, both parties appealed the deputy’s decision, but Clark first

applied for a rehearing to address the penalty issue. On January 25, 2018, the

deputy denied the rehearing application. The appeal to the workers’ compensation

commissioner came next. On July 31, 2019, the commissioner affirmed the deputy

commissioner’s decision in all respects noting

       I find the deputy commissioner provided a well-reasoned analysis of
       all the issues raised in the arbitration proceeding. I affirm the deputy
       commissioner’s findings of fact and conclusions of law pertaining to
       those issues.

       The next month, Clark petitioned for judicial review to the district court.

Winnebago cross-petitioned. The district court affirmed the commissioner. Clark

appealed, and Winnebago cross-appealed.

Standard of review and preservation of error.

       Iowa Code chapter 17A governs judicial review of final decisions by the

workers’ compensation commissioner. Ramirez-Trujillo v. Quality Egg, L.L.C., 878

N.W.2d 759, 768 (Iowa 2016). “[W]e review the district court decision to decide if

our legal conclusions mirror those reached by the district court.” Meyer v. IBP, Inc.,

710 N.W.2d 213, 225 (Iowa 2006). “If we reach the same conclusions, we affirm;

otherwise we may reverse.” Watson v. Iowa Dep’t of Transp., 829 N.W.2d 566,

568 (Iowa 2013). We will uphold the commissioner’s factual findings if, after

reviewing the record as a whole, we determine substantial evidence supports the

findings. Iowa Code § 17A.19(10)(f). “Evidence is substantial if ‘the quantity and

quality of evidence . . . would be deemed sufficient by a neutral, detached, and

reasonable person, to establish the fact at issue when the consequences resulting

from the establishment of that fact are understood to be serious and of great
                                         8

importance.’” Gumm v. Easter Seal Soc’y of Iowa, Inc., 943 N.W.2d 23, 33 (Iowa

2020) (alteration in original) (quoting Iowa Code § 17A.19(10)(f)(1)).

       Both Clark and Winnebago challenge the findings of fact of the

commissioner and the application of law to those facts. Both agree that the other

preserved error on those issues appealed.

Clark’s appeal.

       Clark’s request for penalty benefits.

       The deputy commissioner held Clark was not entitled to penalty benefits

because the claims about her marital status and if she suffered a permanent injury

were fairly debatable issues. The commissioner and district court agreed. When

payment of benefits is delayed without reasonable or probable cause or excuse,

we consider the directive under Iowa Code section 86.13 to determine if an

employee is entitled to penalty benefits. Mannes v. Fleetguard, Inc., 770 N.W.2d

826, 831 (Iowa 2009). Clark advocates for a penalty award because (1) she was

underpaid based on her marital status, (2) there was no basis to deny her benefits

based upon her permanent injury, and (3) Winnebago underpaid her benefits after

she was placed on MMI status. Noting no legal venue addressed the issue, Clark

argues she was underpaid temporary partial benefits and temporary total disability

(healing period) from July 18 to November 26, 2016.

       The first issue involves the question of Clark’s marital status and whether

the marital weekly benefit rate of $372.30 or the single weekly benefit rate of

$363.86 applied. After hearing testimony from Clark and her boyfriend, Jeremy

Wilson, the deputy commissioner said: “I conclude that the issue of whether Clark

was married at the time of the work injury was fairly debatable. No penalty benefits
                                          9

should be awarded to Clark based upon the incorrect rate.” To bolster her position,

Clark emphasizes her testimony and that of her boyfriend confirming her existing

marriage to Joshua Clark. But she could not find her marriage license and offered

no tax returns confirming her marital status. In contrast, Winnebago relied upon

her W-4 tax filing at the time of her hire where she checked the box for “single” and

pointed to a 2015 medical report that noted Clark’s quote about her marital status

as “recently divorced.” The deputy commissioner found Clark credible on the

subject of her marital status. Based on her testimony, the thirty-nine year old Clark

confirmed her engagement to boyfriend Wilson at the same time she alleged she

was still legally married to Joshua Clark. Both Clark and Wilson testified that she

left her husband in September 2014 but he would not give her a divorce and she

could not afford one. At the hearing, Clark offered she had an appointment at

Legal Aid to pursue the divorce as well. The deputy commissioner considered the

question of marital status as one involving credibility and resolved the question in

Clark’s favor.

         Going into the arbitration hearing, the marital status of Clark remained an

issue.    Finding her W-4 and the medical record supported a single status,

Winnebago could rely upon that information, and did, to calculate an appropriate

benefit. Couple that documentary evidence with Clark’s inability to produce her

own documentation of her marital status, and it was reasonable for Winnebago to

contest the marital status. An employer can establish a “reasonable cause or

excuse” if the employer had a reasonable basis to contest the employee’s

entitlement to benefits. Christensen v. Snap-On Tools Corp., 554 N.W.2d 254,

260 (Iowa 1996). With divergent views and competing exhibits, we agree that the
                                         10

marital status question was fairly debatable and was an issue that needed

resolution at a hearing with witnesses. “A claim is ‘fairly debatable’ when it is open

to dispute on any logical basis.’ Whether a claim is ‘fairly debatable’ can generally

be determined by the court as a matter of law.” Rodda v. Vermeer Mfg., 734

N.W.2d 480, 483 (Iowa 2007) (citations omitted).          Clark failed to prove her

entitlement to penalty benefits on this issue.

       Clark’s second argument is more nuanced and is an attack on two fronts—

one involving nonpayment of permanency payments and the other involving under-

payment of late-paid temporary benefits. On the permanency benefits issue, the

deputy commissioner found the determination of permanent injury was a fairly

debatable question. Contending it had good cause, Winnebago points to the early

medical conclusions of Dr. Gibbons. Winnebago argues it could reasonably rely

on Dr. Gibbons’s opinion that Clark suffered no permanent injury in the work

accident. It summarized its position:

       As Clark continued to treat for her work injury beyond the
       commencement date of July 19, 2016, she was paid intermittent
       temporary partial disability benefits, but an assessment as to her
       permanent disability arising from the work injury was unable to be
       made until she concluded her treatment. Clark contends that “there
       was no evidence at all that Winnebago was conducting an
       investigation” during that time as to Clark’s potential permanent
       disability from the work injury, but that “investigation” is clearly
       evidenced by the medical records, as Winnebago was continuing to
       provide medical treatment for Clark. The treatment records did not
       provide any indication of permanent disability while Clark’s treatment
       was ongoing. Once Clark concluded her treatment, signaled by Dr.
       Gibbons assignment of MMI on November 17, 2016, he opined that
       Clark did not sustain any permanent impairment as a result of the
       work injury. Winnebago relied upon Dr. Gibbons’ opinion, the first
       opinion received with regard to permanency, and no permanent
       disability benefits were paid.
                                             11

       Clark argues that Dr. Gibbons’s opinion came after the stipulated July 19,

2016 date to commence the permanent partial disability benefits and that

Winnebago failed to show it had an excuse then to not pay the benefits. We look

to the applicable statute, which requires the commissioner to award penalty

benefits if both of the following are met:

              (1) The employee has demonstrated a denial, delay in
       payment, or termination of benefits.
              (2) The employer has failed to prove a reasonable or probable
       cause or excuse for the denial, delay in payment, or termination of
       benefits.

Iowa Code § 86.13(4)(b)(1)-(2).      But here, the question of permanency was

disputed based on the treating doctors’ opinions and the respective medical

opinions offered by both sides. The commissioner refused to award penalty

benefits for the delay in commencing permanent partial disability compensation.

And the first medical evidence supporting Clark’s claim of permanent injury was

not authored until Dr. Bansal’s August 2017 report.       Winnebago argues the

overwhelming medical evidence found no permanency and, thus, it could

legitimately contest whether Clark’s complaints were a permanent condition arising

from the work injury.     We think there is substantial evidence to support the

commissioner’s finding that there was a legitimate dispute as to the permanency

of Clark’s injury. See Burton v. Hilltop Care Ctr., 813 N.W.2d 250, 267 (Iowa 2012)

(noting the reasonableness of the employer’s denial does not turn on if the

employer was right).

       In a final swing at penalty benefits, Clark contends the issue of delayed

payments of temporary benefits was not considered even though she proved the

delay. Clark argues she was denied both temporary partial disability benefits and
                                        12

healing period benefits during the periods of July 19 to August 9, 2016, and from

September 22 to December 7, 2016.         Calling it a new argument on appeal,

Winnebago urges:

       [T]he issue of late-paid temporary benefits [was not addressed]
       because it was not raised by Clark’s counsel until well after the
       arbitration hearing, in her Application for Rehearing filed on January
       10, 2018. Again, the only issues with regard to interest and penalty
       timely raised by Clark and considered by the hearing deputy were
       whether Clark was entitled to penalty benefits for an underpayment
       of benefits, if one was found, and whether Clark was entitled to
       penalty benefits for Winnebago’s nonpayment of permanency
       benefits. The hearing deputy properly considered these issues and
       determined that Clark’s “claim was fairly debatable and she is not
       entitled to penalty benefits.”

Still, Clark directs us back to the record made about the pre-trial hearing report

and the parties’ stipulation. In a fair assessment of that record, Clark reminds us

that Winnebago agreed there was an underpayment when the deputy

commissioner asked, “So there’s really no dispute concerning what’s been

underpaid at this time. You’ve agreed upon the rate, and you just need—the

claimant needs to receive the payment?”

       Then, at the hearing, the calculation of interest or penalty was reserved for

later briefing after the deputy commissioner decided which benefit rate applied.

We agree that the issue of the penalty involving the underpayment of the

temporary benefits was not part of the deputy commissioner’s decision. Although

again raised in Clark’s rehearing application, the deputy commissioner summarily

denied the application. In the rehearing application, using the single benefit rate,

Clark calculated “47 days of principal payment delays in payment of $1,469.13 of

temporary partial benefits and healing period compensation.”            Clark then

requested a 35% penalty based on the temporary benefit underpayments. Further,
                                         13

Clark argues Winnebago failed to establish a reasonable cause for failing to timely

make the temporary benefit payments. Incorporating all arguments made in the

rehearing application, Clark appealed this penalty issue to the district court.

Winnebago notes:

       Claimant filed an Application for Rehearing on January 10, 2018,
       urging for the issues of penalty and interest to be reconsidered.
       Claimant failed to address the credit and interest computations of
       weekly compensation in her post-hearing brief as instructed by the
       court on pages 4 and 5 of the hearing transcript, and the Application
       for Rehearing was essentially an improper attempt to make
       additional arguments that were not addressed in Claimant’s post-
       hearing brief. Defendants responded, arguing that Claimant’s failure
       to address all of her arguments in her post-hearing brief should not
       give rise to an additional opportunity to do so.

Winnebago argues it is improper and untimely to consider now these arguments

made after the ruling on the issues.       Yet Winnebago does not dispute the

stipulation that it underpaid temporary benefits. Likewise, Clark quotes from her

post-hearing brief directly disputing Winnebago’s current theme:

       Likewise, the question of whether there have been underpayments
       of [healing period] compensation, [temporary partial disability
       benefits], and [permanent partial disability]compensation, which are
       subject to a section 86.13(4) penalty cannot be determined, until the
       weekly earnings and weekly compensation rate are known. All that
       can and should be determined is that Winnebago has failed to
       “satisfy all of the . . . criteria” in Iowa Code § 86.13(4)(c) with
       “evidence.”
                Accordingly, it is requested that after the weekly earnings and
       compensation rate is determined, Clark and Winnebago be given
       an opportunity to perform the credit/interest computations and either
       stipulate to them or submit any dispute to the deputy: “We agree
       that it is the commissioner’s obligation in the enforcement of section
       85.30 (‘to resolve the dispute . . . if the parties cannot agree on
       interest recoverable for late payments of weekly benefits.’”)

(Fourth and fifth alterations in original.) (Citations omitted.) We find the issue of

the delayed payment of temporary benefits appears to have been raised by
                                          14

Clark—both before the hearing and in her post-hearing brief—and we find the

issue was not addressed by the deputy commissioner. Without a decision to

review, the proper remedy is to remand for a determination of the penalty issue as

to the underpayment of temporary partial permanent benefits and healing period

compensation as stipulated by the parties. Thus, we remand to the district court

with directions to remand to the commissioner for further proceedings consistent

with this opinion. See Baker v. Bridgestone/Firestone, 872 N.W.2d 672, 684-85

(Iowa 2015).

       We otherwise affirm the rulings on the penalty question because the

determination of the marital status of Clark involved the credibility of witnesses, it

was not unreasonable to hold benefits until the hearing on the issue was held, and

the permanency determination was fairly debatable.

Winnebago’s cross-appeal.

       Substantial evidence of a permanent injury.

       All parties agree that Clark’s right wrist injury is a scheduled member injury

compensated based upon functional disability.            See Iowa Code § 85.34.

Functional disability is assessed solely by determining the impairment of the body

function of the employee. Simbro v. Delong’s Sportswear, 332 N.W.2d 886, 887

(Iowa 1983). “Functional disability is limited to the loss of physiological capacity of

the . . . body part.” Id. Where the parties part ways is on the permanency aspect

of Clark’s July 2016 injury. Finding the decision of the deputy commissioner to be

“illogical,” Winnebago argues the finding of full range of motion in Dr. Kimelman’s

report equates to a 0% impairment rating and no other finding makes sense.

Winnebago discounts the IME conclusions of Dr. Bansal by urging that Clark failed
                                          15

to establish her injuries were permanent by substantial evidence. Dr. Bansal found

and the commissioner accepted a 10% permanent disability determination of

Clark’s injury. Pointing to the omission of a permanency finding by all of Clark’s

treating doctors and Dr. Kimelman, the IME doctor, Winnebago contends the

weight of the evidence supports no permanency finding. Winnebago argues it was

illogical for the commissioner to find otherwise and for the district court to affirm.

       Physicians are the logical individuals to evaluate permanency of an injury.

See Schoenfeld v. FDL Foods, Inc., 560 N.W.2d 595, 598 (Iowa 1997).

Winnebago draws our focus to Dr. Kimelman’s opinions. It trumpets the deputy

commissioner’s “most persuasive” finding concerning Dr. Kimelman’s report. Still,

while the deputy commissioner did give great credence to the Kimelman report,

stating specifically, “I find the opinion of Dr. Kimelman most persuasive,” there was

no finding that the Dr. Bansal report had no persuasive effect. The deputy found

“the impairment rating issued by Dr. Bansal unrebutted.”            With no contrary

reference to the impairment rating assigned by Dr. Bansal, the deputy

commissioner accepted it. To be clear, no reference to an impairment rating might

mean a 0% rating, but when asked about permanency impairment, Dr. Kimelman

noted “it is difficult to determine” and then discussed Clark’s normal objective

findings. This could mean either he cannot formulate a firm opinion or that he

believes there is no impairment. Thus, we think the report is hardly as conclusive

as Winnebago would have us believe. We decline to speculate as to which opinion

Dr. Kimelman might voice.
                                         16

      Finally Winnebago attacks the findings contained in Dr. Bansal’s report by

comparing it to the findings of the treating doctors and Dr. Kimelman. Winnebago

addressed its view of the medical dichotomy

      Dr. Bansal did not review Clark’s MRI to determine whether the
      findings actually correlated to her area of pain in her wrist and
      therefore his conclusions are speculative, at best. The remaining
      physicians in the record did not assign any degree of permanent
      impairment because the MRI findings did not correlate with Clark’s
      area of pain in her wrist. Both Dr. Kimelman and Dr. Gibbons
      reviewed Clark’s MRI. While Dr. Kimelman and Dr. Gibbons had
      differing opinions with regard to whether Clark had a pre-existing
      condition in her wrist, both agreed that the nonunion of the ulnar
      styloid was not related in any way to Clark’s complaint of dorsal wrist
      pain. The finding on the MRI of an ulnar styloid avulsion in the TFCC
      lesion was away from Clark’s area of maximum tenderness, which
      was the dorsal area of her wrist.

But as is often the case, there were multiple opinions on the cause of Clark’s pain

and how that translated to a permanent condition related to the work injury. Dr.

Kimelman diagnosed Clark with chronic pain5 but found it “difficult to assess

specifically where her pain is coming from.” When asked if Clark’s right wrist

condition and subsequent need for care were causally related to her work activities

at Winnebago on July 8, 2016, Dr. Kimelman said “yes.”            And the deputy

commissioner could consider that when Dr. Kimelman was asked about any

permanent impairment, he did not affirmatively confirm there was zero impairment

but only opined “that is difficult to determine.” In contrast, Dr. Bansal expressed

firm opinions about Clark’s condition.

5 Winnebago also argued Clark had a pre-existing chronic pain syndrome, but we
found no evidence in this record that previous condition in any way related to her
right wrist.
                                        17

      To arrive at an answer, the deputy commissioner considered the expert

testimony together and found the unrefuted permanency rating of 10% calculated

by Dr. Bansal persuasive. See Evenson v. Winnebago Indus., Inc., 881 N.W.2d

360, 366 (Iowa 2016) (“An agency’s decision does not lack substantial evidence

because inconsistent conclusions may be drawn from the same evidence.”

(quoting Coffey v. Mid Seven Transp. Co., 831 N.W.2d 81, 89 (Iowa 2013))).

      The district court agreed, finding:

              The question in this instance is not whether the evidence
      might support a different finding, but whether the evidence supports
      the findings actually made. Viewing the record as a whole, there is
      substantial evidence to back up Deputy Palmer’s finding of facts as
      to the nature and extent of Clark’s 10% permanent disability as
      required by Iowa Code section [17A.19(10)]. There is no evidence
      to support the position that the deputy’s findings were irrational or
      illogical.

      Yet a disability determination presents a “mixed question of law and fact.”

See Larson Mfg. Co., Inc. v. Thorson, 763 N.W.2d 842, 856 (Iowa 2009). Factual

determinations are clearly vested in the discretion of the workers’ compensation

commissioner, so we defer to the commissioner’s findings “if they are based on

‘substantial evidence in the record before the court when that record is viewed as

a whole.’” Id. at 850 (quoting Iowa Code § 17A.19(10)(f)). Substantial evidence

is “the quantity and quality of evidence that would be deemed sufficient by a

neutral, detached, and reasonable person, to establish the fact at issue when the

consequences resulting from the establishment of that fact are understood to be

serious and of great importance.” Iowa Code § 17A.19(10)(f)(1). Although as fact

finder we might have decided this case differently, we conclude the evidence

provides substantial evidence supporting the findings actually made.          See
                                           18

Sherman v. Pella Corp., 576 N.W.2d 312, 320 (Iowa 1998). Winnebago argues it

is illogical to find Dr. Kimelman’s opinion to be the most persuasive but then follow

Dr. Bansal’s opinion on the permanency question.            But on the permanency

question, Dr. Bansal offered:

          Ms. Clark has a loss of grip strength, which is consistent with the
          medical literature of outcomes for [TFCC] tears treated six months
          past the injury date. In this case, Ms. Clark has not had treatment at
          all. Ms. Clark has about a 30% loss of grip strength. The study found
          an average loss of 17%. Based on Table 16-34 of the AMA Guides
          of Evaluation for Permanent Impaimnent, Fifth Edition, losses of 10
          to 30% are assigned an upper extremity impairment of 10%.

Applying law to fact, this opinion from Dr. Bansal provides substantial evidence of

a permanent disability. We affirm the commissioner’s ruling on the permanency

rating.

          Application of appropriate rate.

          At the hearing before the deputy commissioner, Winnebago argued Clark’s

weekly benefit rate is $363.86 based upon her status as single. Clark argued her

weekly rate is $372.30 based on her claim that she was married at the time of the

work injury. While there was evidence supporting both arguments, the deputy

commissioner found Clark to be married at the time of the injury. Rather than

questioning whether the evidence before us may support a different finding than

the one made by the commissioner, we ask whether the evidence supports the

finding actually made. See Larson Mfg. Co., 763 N.W.2d at 850.

          Because this issue relates back to the discussion in the penalty section, and

to be consistent, we find the appropriate benefit rate was the “married at the time

of the work injury” rate. We agree with the commissioner’s findings.
                                          19

       Alternate medical care award.

       On this last issue, Winnebago asserts the award of alternate medical care

is irrational, illogical, or wholly unjustifiable because Dr. Bansal is the only medical

expert who recommended this care. To recap, Bansal opined the tear to the TFCC

was consistent with the mechanism of injury, Clark had not had treatment for that

condition, and a Mayo Clinic specialist was required to assess her condition. By

contrast, Winnebago points to Dr. Gibbons’s opinion that the tear from a previous

older trauma was not consistent with the area of tenderness Clark identified and

to Dr. Kimelman’s finding that the tear did not explain the pain to the right forearm.

Winnebago argues Dr. Bansal did not personally review the MRI imaging, and

because other doctors found the tear incidental to the pain complaints, Dr. Bansal

misinterpreted the causation between the tear and the pain. But even the doctors

relied upon by Winnebago approached the causation question differently. And in

any question involving a battle of experts, the fact finder must glean from those

expert opinions medical conclusions supported by the evidence. See Grundmeyer

v. Weyerhaeuser Co., 649 N.W.2d 744, 752 (Iowa 2002) (“The commissioner, as

the fact finder, determines the weight to be given to any expert testimony. Such

weight depends on the accuracy of the facts relied upon by the expert and other

surrounding circumstances. The commissioner may accept or reject the expert

opinion in whole or in part.” (quoting Sherman, 576 N.W.2d at 321)).

       “We will reverse the commissioner’s application of the law to the facts ‘only

if the commissioner’s application [is] irrational, illogical or wholly unjustifiable.’”

Schutjer v. Algona Manor Care Ctr., 780 N.W.2d 549, 558 (Iowa 2010) (alteration

in original) (citation omitted). Here, the deputy commissioner could find the pain
                                         20

to the right wrist and forearm began after the July work injury and continued without

relief until the time of the hearing. The differing opinions of the medical providers

offered context and were noted in the arbitration decision. Although there were

differing medical opinions, Dr. Kimelman did confirm Clark had chronic right wrist

pain and her condition was causally related to her work activities at Winnebago

even though he could not explain her musculoskeletal pain in her right forearm

based on the MRI imaging.        We find it is not irrational, illogical, or wholly

unjustifiable for the deputy commissioner to rely on Dr. Bansal’s definitive

diagnosis of Clark’s condition while still respecting the concerns and questions Dr.

Kimelman raised.     Because the alternate medical care recommendation was

reasonable given Dr. Bansal’s opinions, we affirm the award.

Conclusion.

       We find no basis for an award to Clark of penalty benefits arising from the

appropriate benefit rate for a married injured worker. We find no basis for an award

to Clark for penalty benefits related to the failure to pay permanency benefits

because that issue was fairly debatable. On the other hand, we remand for a

determination on the applicability of a penalty for the underpayment of temporary

benefits.

       Substantial evidence supports the commissioner’s finding of a permanent

injury and the compensation rate calculated at the married rate.           With that

determination in hand and reviewing the record as a whole, we affirm the award of

alternate medical care.

       AFFIRMED IN PART AND REMANDED FOR FURTHER PROCEEDINGS

ON APPEAL; AFFIRMED ON CROSS-APPEAL.