Court Opinion

ID: 1064808
Source: CourtListenerOpinion
Date Created: 2013-10-09 19:18:57.541806+00
Date Added: 2024-06-11T08:52:17.712909
License: Public Domain

COURT OF APPEALS OF VIRGINIA

Present: Judges Willis, Elder and Annunziata
Argued at Richmond, Virginia

DEVIN MICHAEL COFFEY, AN INFANT,
 BY DANIELLE MARIE TRIVETTE COFFEY,
 HIS MOTHER AND NEXT FRIEND
                                               OPINION BY
v.   Record No. 0529-01-4             JUDGE JERE M. H. WILLIS, JR.
                                            JANUARY 29, 2002
VIRGINIA BIRTH-RELATED NEUROLOGICAL
 INJURY COMPENSATION PROGRAM

        FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION

          Ann LaCroix Jones (William O. Snead, III;
          Gary B. Mims; Mark A. Towery; Snead & Mims,
          on briefs), for appellant.

          John J. Beall, Jr., Senior Assistant Attorney
          General (Randolph A. Beales, Sr., Acting
          Attorney General; Richard L. Walton, Jr.,
          Senior Assistant Attorney General, on brief),
          for appellee.

     On appeal from a decision of the Workers' Compensation

Commission denying him benefits under the Birth-Related

Neurological Injury Compensation Act, Code § 38.2-5000, et seq.,

Devin Michael Coffey, an infant, who sues by Danielle Marie

Trivette Coffey, his mother and next friend, contends (1) that

the commission erred in assuming jurisdiction and deciding his

claim without affording him legal counsel; and (2) that the

commission erred in holding that the Birth-Related Neurological

Compensation Program (the Program) had successfully rebutted the
presumption set forth in Code § 38.2-5008(A)(1).    We affirm in

part, reverse in part, and remand.

                           I.   BACKGROUND

     Danielle Marie Trivette Coffey gave birth to Devin

following a forty-one to forty-two week pregnancy.    The

pregnancy was marked by increasing signs of pregnancy induced

hypertension (preeclampsia).    The labor involved slow cervical

dilation and increasing signs of preeclampsia in the mother,

including swelling, muscle spasms, and increased blood pressure.

Fetal heart tracings ranging from seventy to one-hundred-eighty

beats per minute and light meconium stained amniotic fluid

indicated a distressed infant.    The delivery was complicated by

the child's large size and the mother's small stature.      Two

attempted forceps deliveries failed.     A fourth-degree episiotomy

was performed.    The child was finally delivered after

application of forceps to his head.

     At one minute of life, Devin's APGAR score was two out of a

possible ten.    He was not breathing.   His body was limp.   He

made no sounds.   He gave no response to stimuli.   His color was

blue to pale.    He was resuscitated with stimulation and his

airways were suctioned.   He received oxygen by mask and

endotracheal tube.

     At two minutes of life, Devin's arterial chord blood gases

were critically low.   They remained low for almost two hours

                                 - 2 -
after his birth.   He had notable molding of the head with

bruising, edema and abrasions.

     For three hours following birth, Devin displayed audible

respiratory grunting with nasal flaring and blueness and

coldness of the extremities.   He had difficulty feeding and had

to be fed.   He displayed increased oral secretions and a slight

decrease in tone in his right arm.

     Devin was discharged on his third day of life, only to be

rushed back to the hospital the same evening for breathing

difficulty with gagging and choking.   His color changed to red

and blue, and he had mucus in his nose and throat.   He was

examined and discharged.   Over the course of the next two

months, he continued to experience difficulty with secretions,

gagging and choking for no apparent reason.   He would curl up,

jerk, and then relax.

     On March 28, 1993, Devin was seen in the emergency room for

sleeping excessively without waking to eat, not crying, and

generally feeling limp.    Four days later, he was rushed to the

emergency room where he demonstrated jerking motions and apnea

spells.   At this point, he was diagnosed with a seizure disorder

and infantile spasms, confirmed by EEG testing.

     When Devin was four months old, his mother moved with him

to Nebraska, where his care was assumed by staff at Creighton

University Medical Center.   His records from that institution

describe seizures ranging from simple staring episodes to full
                              - 3 -
flexor spasms with back arching, excessive salivation and

choking.

     Devin has undergone numerous tests to determine the cause

of his condition.    A workup for sepsis was unremarkable.    A

differential diagnosis of tuberous sclerosis suggested by an

early MRI of the brain was ruled out by a follow-up EKG.      Long

chain fatty acid and metabolic studies failed to demonstrate

metabolic disorder.    Testing of diminished deep tendon reflexes

demonstrated no specific etiology.     He displayed no progressive

decline in cognitive function.     Perinatal asphyxia could not be

ruled out.

     Devin is now seven years old.     He is profoundly retarded,

quadriplegic, and cannot speak.     His condition renders him

permanently in need of assistance in all activities of daily

living.

                         II.   LEGAL ASSISTANCE

     Code § 38.2-5009 directs the commission to enter an award

in favor of an infant determined by it to have sustained a

birth-related neurological injury, see Code § 38.2-5001,

resulting from obstetrical services delivered by a participating

physician or rendered in a participating hospital.

     Code § 38.2-5001 defines a claimant under the Act as:

             [A]ny person who files a claim . . .   for a
             birth-related neurological injury to   an
             infant. Such claims may be filed by    any
             legal representative on behalf of an   injured
             infant . . . .
                                 - 4 -
Thus, a claim may be filed by the infant or on his behalf by his

legal representative.    Code § 38.2-5004 sets forth the

requirements for filing a claim under the Act.

     On March 1, 2000, Danielle Marie Trivette Coffey filed in

the commission on Devin's behalf a petition setting forth the

information required by Code § 38.2-5004.    She did so as his

mother.   She is not a licensed attorney-at-law and has no

professional legal training.    She noted on the petition that

Devin had "no legal representation."    The claim proceeded

through the commission with no legal representation on Devin's

behalf, with Ms. Coffey acting as his next friend.    On appeal,

Devin argues (1) that the commission should have appointed legal

counsel to represent him in the prosecution of his claim or a

guardian ad litem to defend his interests, and (2) that by

failing to ensure that he had legal representation in the

prosecution of his claim, the commission denied him due process.

These positions were not asserted before the commission.       See

Rule 5A:18.    However, Devin contends that the failure to afford

him these rights denied the commission jurisdiction to decide

his claim, a position that can be raised at any time.

          A.   APPOINTMENT OF COUNSEL TO PROSECUTE THE CLAIM

     Devin first argues that his disability as an infant

entitled him to the appointment of legal counsel to prosecute

his claim.     He cites no authority in support of that contention,

and we have found none.    Indeed, express statutory provision and
                                - 5 -
longstanding practice in this Commonwealth are to the contrary.

Code § 8.01-8 provides:

          Any minor entitled to sue may do so by his
          next friend. Either or both parents may sue
          on behalf of a minor as his next friend.

This statute contains no provision either requiring or

authorizing the appointment of legal counsel for a minor who

sues by his next friend.

     In Womble v. Gunter, 198 Va. 522, 95 S.E.2d 213 (1956), the

Supreme Court said:

               Code § 8-87 [now § 8.01-8] authorizes
          an infant to sue by his next friend. The
          practice in Virginia is for such suits to be
          instituted in the name of the infant by one
          of the parents or other near relative
          without formal appointment. If the suit or
          action proceeds without objection, it is a
          recognition by the court that the infant is
          a party to the proceeding. . . . In numerous
          cases we have held that in absence of fraud
          an infant is as much bound by a decree or
          judgment of a court as is an adult. The law
          recognizes no distinction between a decree
          against an infant and a decree against an
          adult, and, therefore, an infant can impeach
          it only upon grounds which would invalidate
          it in case of an adult party.

Id. at 530, 95 S.E.2d at 219.   The record in this case contains

no evidence of fraud.   Rather, it reveals that the commission

investigated and decided Devin's claim fairly and

conscientiously.

     The commission's failure to appoint legal counsel to

prosecute Devin's petition did not deny it jurisdiction to

decide his claim.
                                - 6 -
           B.   FAILURE TO APPOINT A GUARDIAN AD LITEM

     Devin next argues that the commission should have appointed

a guardian ad litem to defend his interests.   Code § 8.01-9(A)

provides, in pertinent part:

          A suit wherein a person under disability is
          a party defendant shall not be stayed
          because of such disability, but the court in
          which the suit is pending, or the clerk
          thereof, shall appoint a discreet and
          competent attorney-at-law as guardian ad
          litem to such defendant . . . and it shall
          be the duty of the court to see that the
          interest of the defendant is so represented
          and protected.

The statute specifically provides for the appointment of a

guardian ad litem for an infant party defendant, not for an

infant party plaintiff.   The Supreme Court considered this very

question in Cook v. Radford Community Hospital, 260 Va. 443, 536
S.E.2d 906 (2000), and held:

          [Code § 8.01-9] is not concerned with the
          capacity of a person under a disability to
          sue but with the protection of such person
          when named as a defendant in a lawsuit. One
          who institutes litigation is in a posture
          completely different than one against whom
          suit is filed. The filing of a lawsuit is
          an affirmative act on the part of a
          plaintiff and does not carry with it the
          need for the type of court-initiated
          protection which may exist when a person
          with a disability is required to defend
          himself . . . .

Id. at 449, 536 S.E.2d at 909.

                                 - 7 -
        Devin relies on our decision in Commonwealth ex. rel. Gray

v. Johnson, 7 Va. App. 614, 376 S.E.2d 787 (1989), wherein we

said:

             The child . . . not adequately represented
             may not receive his or her day in court, and
             the fundamental due process right to be
             heard may be a abridged.

              *      *      *        *       *     *      *

                  The strong public policy of this
             Commonwealth posits that the paramount
             concern where children are concerned are
             their best interests. . . . The courts of
             the Commonwealth have a long history of
             protecting the interests of minor children
             and have expressed that careful concern by
             ensuring that the rights and interests of
             the minors are safeguarded. Code §§ 8.01-9
             and 16.1-266 require that guardians ad litem
             or counsel be appointed to represent a
             child's interests when the child is involved
             in court proceedings.

Id. at 623, 376 S.E.2d at 791-92.        This statement in Johnson was

dictum.     Johnson turned not on whether a guardian ad litem

should have been appointed, but rather on whether a child whose

interests were affected had been made a party to the proceeding.

The quoted passage from Johnson relied upon Moses v. Akers, 203
Va. 130, 122 S.E.2d 864 (1961), and Kanter v. Holland, 154 Va.
120, 152 S.E. 328 (1930).       Those cases turned on the failure to

appoint guardians ad litem for infant defendants against whom

judgment had been rendered.      Both cases were decided in the

context of former Code § 8-88, which required appointment of a

guardian ad litem for an infant who "is a party."       The present

                                   - 8 -
statute provides only for the appointment of a guardian ad litem

for an infant who "is a party defendant."

     The commission's failure to appoint a guardian ad litem to

protect Devin's interests did not deny it jurisdiction to decide

his claim.

                           C.   DUE PROCESS

     Devin has identified no failure by the commission to comply

with the requirements of the Act.    He notes that his mother and

next friend did not pursue all avenues of discovery that might

have been available and might have been pursued by professional

counsel.   However, he has demonstrated no fraud or unfairness

and no failure of the commission to consider his claim fully and

fairly.    In short, he has not demonstrated that the proceedings

before the commission failed to comply with the established law

of the Commonwealth or failed to afford him a fair disposition

of his claim.   He has demonstrated no denial of due process.

     We hold that the commission properly afforded Devin his

procedural rights under the Act and that it had jurisdiction to

decide his claim.

                                 - 9 -
    III.     REBUTTAL OF THE CODE § 38.2-5008(A)(1) PRESUMPTION

                          A.   THE PRESUMPTION

     The Act 1 provides monetary relief to claimants who have

sustained a "[b]irth-related neurological injury," which is

defined as

             injury to the brain or spinal cord of an
             infant caused by the deprivation of oxygen
             or mechanical injury occurring in the course
             of labor, delivery or resuscitation in the
             immediate post-delivery period in a hospital
             which renders the infant permanently
             motorically disabled and (i) developmentally
             disabled or (ii) for infants sufficiently
             developed to be cognitively evaluated,
             cognitively disabled . . . [and which]
             disability [causes] the infant to be
             permanently in need of assistance in all
             activities of daily living.

Code § 38.2-5001.    Recognizing the difficulty in proving when

such an injury was sustained, the legislature enacted a

presumption to assist potential claimants in obtaining benefits.

Code § 38.2-5008(A)(1) provides, in pertinent part, as follows:

             A rebuttable presumption shall arise that
             the injury alleged is a birth-related
             neurological injury where it has been
             demonstrated, to the satisfaction of the
             Virginia Workers' Compensation Commission,
             that the infant has sustained a brain or
             spinal cord injury caused by oxygen
             deprivation or mechanical injury, and that
             the infant was thereby rendered permanently
             motorically disabled . . . .

                  If either party disagrees with such
             presumption, that party shall have the

     1
       Birth-Related Neurological Injury Compensation Act, Code
§ 38.2-5000, et seq.

                                 - 10 -
          burden of proving that the injuries alleged
          are not birth-related neurological injuries
          within the meaning of the chapter.

This is a "Morgan theory" presumption, which shifts "'both the

burden of production and the burden of persuasion on the factual

issue in question to the party against whom the presumption

operates.'"   Virginia Birth-Related Neurological Injury

Compensation Program v. Young, 34 Va. App. 306, 311, 541 S.E.2d
298, 301 (2001).

     Questions regarding the application of this type of

presumption frequently arise concerning claims for benefits

under Code § 65.2-402 of the Workers' Compensation Act.    That

code section provides, inter alia, that respiratory diseases

suffered by firefighters, and hypertension or heart diseases

suffered by firefighters and certain law enforcement personnel,

          shall be presumed to be occupational
          diseases, suffered in the line of duty, that
          are covered by [the Workers' Compensation
          Act] unless such presumption is overcome by
          a preponderance of competent evidence to the
          contrary.

Code § 65.2-402(A),(B).   Addressing this presumption in the

workers' compensation context, the Supreme Court has held that

an employer seeking to overcome the presumption must

          show, by a preponderance of the evidence,
          both that 1) the claimant's disease was not
          caused by his employment, and 2) there was a
          non-work-related cause of the disease. . . .
          [I]f the employer does not prove by a
          preponderance of the evidence both parts of
          this two-part test, the employer has failed
          to overcome the statutory presumption.
                              - 11 -
Bass v. City of Richmond Police Dep't, 258 Va. 103, 114, 515
S.E.2d 557, 562-63 (1999).   Evidence that a claimant's disease

was not caused by his employment, suggesting by inference that

the disease must, therefore, have had a non-work-related cause,

is insufficient to prove the second prong of the test.

               The obvious purpose of the rebuttable
          presumption is to establish by law, in the
          absence of evidence, a causal connection
          between death or disability from certain
          diseases and the occupation of a
          firefighter. The effect of the presumption
          is to eliminate the necessity for proof by
          the claimant of causal connection. . . . In
          the absence of evidence, the statutory
          presumption prevails and controls. The
          presumption shifts the burden of going
          forward with the evidence from the claimant
          to his employer.

               Even if the negative finding . . . of
          no evidence of causal connection is equated
          arguendo with an affirmative finding that
          there was no causal connection, the rebuttal
          evidence is still insufficient. We hold
          that to rebut the statutory presumption the
          employer must adduce competent medical
          evidence of a non-work-related cause of the
          disabling disease, and there is no such
          evidence in the record before us.

Page v. City of Richmond, 218 Va. 844, 847-48, 241 S.E.2d 775,

777 (1978).   See also Fairfax County Fire & Rescue Services v.

Newman, 222 Va. 535, 538-39, 281 S.E.2d 897, 899-900 (1981).

The employer must identify one or more specific non-work-related

causes of the subject injury.

     The Code § 38.2-5008(A)(1) presumption is stated in

essentially the same terms as the Code § 65.2-402(A), (B)

                                - 12 -
presumption.   It serves the same purpose, to provide a claimant

a vehicle for recovery upon a prima facie showing of condition,

casting upon the party resisting recovery the burden of proving

non-entitlement.   Therefore, we will apply with respect to the

Code § 38.2-5008(A)(1) presumption the test adopted by the

Supreme Court for application of the Code § 65.2-402(A), (B)

presumption.   Thus, we hold that to defeat the Code

§ 38.2-5008(A)(1) presumption, the Program must prove, to a

reasonable degree of medical certainty, see Augusta County

Sheriff's Dep't v. Overbey, 254 Va. 522, 527, 492 S.E.2d 631,

634 (1997), both (1) that the claimant's brain or spinal cord

injury did not occur "in the course of labor, delivery or

resuscitation in the immediate post-delivery period in a

hospital" and (2) that there was a specific, non-birth-related

cause of the injury.

     The Program concedes that the Code § 38.2-5008(A)(1)

presumption applies in this case.   Thus, to avoid liability, the

Program bore the burden of proving by the preponderance of the

evidence, to a reasonable degree of medical certainty, both (1)

that Devin's brain or spinal cord injury did not occur "in the

course of labor, delivery or resuscitation in the immediate

post-delivery period in a hospital" and (2) that a specific,

non-birth-related cause produced the injury.

                              - 13 -
                        B.   THE EVIDENCE

     The medical evidence consists of the opinions of Dr. Duncan

C. MacIvor, an obstetrician; Dr. Lawrence D. Morton, a pediatric

neurologist; and a panel of three obstetricians specializing in

high risk obstetrics, Dr. James E. Ferguson, Dr. Giancarlo Mari,

and Dr. William N.P. Herbert, appointed pursuant to Code

§ 38.2-5008(B).

     Dr. MacIvor concluded as follows:

          Devin's delivery was technically difficult
          with evidence of transient deprivation of
          oxygen. His later neurological development,
          however, seems more consistent with
          unrelated degenerative neurological disease,
          and it is noteworthy that several pediatric
          neurologists . . . who have followed Devin
          for extended periods have been aware of his
          difficult birth yet have never inferred a
          causal relationship to his present
          condition.

           *      *      *      *        *    *      *

          All his neurologists have seemed well
          acquainted with his history. Although there
          is occasional confusion in the later records
          over details of his perinatal history, none
          of the neurologists has made any connection
          between Devin's difficult delivery and his
          current status. His seizure disorder has
          been attributed to infantile spasms,
          possible tuberous sclerosis, and to rare and
          subtle metabolic derangements. None of
          these has ever been proven, and the records
          often state that the etiology of his problem
          is simply unknown. Conspicuously absent in
          the neonatal and neurologic records are
          references to intracranical hemorrhage or
          hypoxic ischemic encephalopathy such as
          would be expected if the neurologic deficits
          were due to obstetric mechanical injury or
          significant deprivation of oxygen. A baby
                              - 14 -
          that was injured at birth should not have
          had a several week interval of apparently
          normal function and development only to
          deteriorate later, and the initial findings
          in the newborn nursery should have been more
          striking.

          It is understandably tempting for concerned
          lay people . . . who experienced and
          witnessed Devin's difficult delivery, to
          link his birth with his current status. In
          my own opinion, the two simply do not fit
          together. It might be useful to have these
          records reviewed by an independent pediatric
          neurologist -- specifically addressing the
          question whether either birth trauma or
          oxygen deprivation could possibly have
          produced the picture that developed in
          Devin's early infancy. My own feeling is
          that no link exists, despite the clearly
          difficult delivery and undeniable (though
          brief) deprivation of oxygen, and that
          unfortunately, Devin does not qualify for
          the Program.

     Dr. Morton reported his review of Devin's birth and medical

records and concluded as follows:

          In summary, while there was some evidence of
          the infant being depressed and some degree
          of hypoxia with depressed one minute APGARs,
          this was not sustained. The chart
          information provided does not exclude the
          possibility of this being causal in the
          child's development, but certainly does not
          allow me to say this is the most likely
          cause and in fact, another underlying
          process is suggested by some of the notes in
          the chart. The seeming prosperity early
          goes against a marked injury occurring at
          the time of birth.

     Drs. Ferguson, Mari and Herbert reported as follows:

          In carefully reviewing the clinical case
          involving this child in light of the
          Virginia Birth-Related Neurological Injury
          Compensation Act, it is our opinion that the
                             - 15 -
          criteria for "birth-related neurological
          injury" are not met by the evidence
          presented in this case.

               . . . [D]espite the difficult vaginal
          delivery, young Devin's prompt response to
          resuscitation and his early neonatal course
          are inconsistent with birth-related
          neurological injury.

          [O]nly a small percentage of babies with
          cerebral palsy have [sic] as its origin
          events during the labor and delivery
          process. The majority have been thought to
          occur either early in the ante-natal or
          neonatal periods, and we feel that this
          young child's tragic situation falls into
          one of these other categories.

     The deputy commissioner found that the foregoing evidence

was credible and constituted a preponderance.   The full

commission agreed.

          [W]hether the Program rebutted the
          presumption is a question to be determined
          by the commission as fact finder after
          weighing the evidence produced by both
          parties. . . . "On appeal from this
          determination, the reviewing court must
          assess whether there is credible evidence to
          support the commission's award."

Young, 34 Va. App. at 317, 541 S.E.2d at 304 (quoting Bass, 258
Va. at 114, 515 S.E.2d at 563).

     Applying the two-part test we adopt for use in determining

whether the Program has rebutted the Code § 38.2-5008(A)(1)

presumption, we hold as a matter of law that the Program's

evidence, though credible and preponderating, fails to rebut the

presumption.

                             - 16 -
     1.   WHETHER THE INJURY OCCURRED IN THE COURSE OF LABOR,
                  DELIVERY OR RESUSCITATION, ETC.

     No physician concluded, to a reasonable degree of medical

certainty, that Devin's injuries did not occur at birth.

Dr. MacIvor opined that certain things "should" or "should not

have" occurred had Devin's injuries been birth-related.    He

noted that several pediatric neurologists who had treated Devin

and were aware of his difficult birth "[had] never inferred a

causal relationship to his present condition."   He stated his

own "feeling" "that no link exists."   None of these opinions was

stated to a reasonable degree of medical certainty.   Dr. MacIvor

suggested reservation by concluding that "[i]t might be useful

to have these records reviewed by an independent pediatric

neurologist" regarding "whether either birth trauma or oxygen

deprivation could possibly have produced" Devin's injuries.

     The pediatric neurologist, Dr. Morton, reported that

Devin's "seeming prosperity early goes against a marked injury

occurring at the time of birth" and that the evidence did not

allow him to say that the circumstances surrounding Devin's

birth were the most likely cause of Devin's injuries, but he

could not exclude the possibility that Devin's birth trauma was

"causal in the child's development."

     Finally, although the three-physician panel concluded that

Devin's "prompt response to resuscitation and his early neonatal

course are inconsistent with birth-related neurological injury,"

                              - 17 -
it did not state this opinion to a reasonable degree of medical

certainty.   The panel's statement that it "feel[s] [Devin's]

tragic situation" is not birth-related because "only a small

percentage of babies with cerebral palsy have [sic] as its

origin events during the labor and delivery process" and that

"[t]he majority [of such injurious events] [are] thought to

occur early in the ante-natal or neonatal periods" reinforces

the conclusion that its opinion regarding "inconsisten[cy]" was

not a finding, stated to a reasonable degree of medical

certainty, that Devin's condition is not birth-related.

              2.   WAS THERE A SPECIFIC, NON-BIRTH-RELATED
                           CAUSE OF THE INJURY

     Assuming arguendo that the evidence supports a finding that

Devin's injuries did not occur at birth, it fails to prove, to a

reasonable degree of medical certainty, a specific,

non-birth-related cause.   Thus, it fails to rebut the Code

§ 38.2-5008(A)(1) presumption.   Dr. MacIvor identified no

non-birth-related cause of Devin's condition.   He stated that

Devin's "later neurological development . . . seems more

consistent with unrelated degenerative neurological disease,"

but he did not state this opinion to a reasonable degree of

medical certainty, and he noted that Devin had received numerous

possible diagnoses, "[n]one of [which] has ever been proven."

Dr. Morton did not identify, to a reasonable degree of medical

certainty, a non-birth-related cause of Devin's condition.    He

                               - 18 -
stated that "another underlying process [rather than a

birth-related injury,] is suggested by some of the notes in the

chart," but he did not identify that "underlying process" and

did not opine to a reasonable degree of medical certainty that

it was a non-birth-related cause of Devin's condition.    Finally,

the three-doctor panel gave no opinion regarding the specific

cause of Devin's condition.   It stated only that it "[felt]"

Devin's condition originated "either early in the ante-natal or

neonatal periods."   It did not state this opinion to a

reasonable degree of medical certainty.

     The evidence failed, as a matter of law, to support the

commission's holding that the Program had rebutted the Code

§ 38.2-5008(A)(1) presumption.   Thus, the presumption carried

Devin's burden of proof, and he is entitled to an award of

benefits under the Act.   We reverse and remand this case to the

commission for entry of an appropriate award.

                                                 Affirmed in part,
                                                 reversed in part,
                                                     and remanded.

                              - 19 -