Court Opinion

ID: 5135862
Source: CourtListenerOpinion
Date Created: 2021-12-17 15:06:12.176259+00
Date Added: 2024-06-11T08:23:51.906053
License: Public Domain

RENDERED: DECEMBER 10, 2021; 10:00 A.M.
                  NOT TO BE PUBLISHED

           Commonwealth of Kentucky
                   Court of Appeals
                     NO. 2021-CA-0451-WC

CAMBRIAN HOLDING COMPANY,
INC.                                                 APPELLANT

             PETITION FOR REVIEW OF A DECISION
v.        OF THE WORKERS’ COMPENSATION BOARD
     ACTION NOS. WC-18-60509, WC-19-00595, AND WC-19-01095

L.D. SEXTON; APPALACHIAN
REHABILITATION TEAM; FUGATE
FAMILY CHIROPRACTIC; DR.
JAMES VARNEY; DR. JOHN
GILBERT; KENTUCKY MOUNTAIN
HEALTH; KENTUCKY PAIN
MANAGEMENT SERVICES;
MOUNTAIN COMPREHENSIVE
HEALTH CORPORATION;
HONORABLE PETER NAAKE,
ADMINISTRATIVE LAW JUDGE;
PIKEVILLE MEDICAL CENTER;
PIKEVILLE NEUROLOGY; SPINE
AND BRAIN NEUROSURGICAL; DR.
VAN BREEDING; WHITESBURG
ARH; AND WORKERS’
COMPENSATION BOARD                                   APPELLEES
                                            OPINION
                                           AFFIRMING

                                       ** ** ** ** **

BEFORE: ACREE, GOODWINE, AND JONES, JUDGES.

JONES, JUDGE: Cambrian Holding Company Inc. (“Cambrian”), has petitioned

this Court for review of a decision of the Workers’ Compensation Board (“the

Board”), which affirmed the October 9, 2020 opinion, order, and award rendered

by the Administrative Law Judge (“ALJ”). On appeal, Cambrian asserts the Board

erred as a matter of law when it held that the time limits for the submission of

medical bills set out in KRS1 342.020(4) and 803 KAR2 25:096 §11 apply only

after entry of an interlocutory or final award. Having reviewed the record and

being otherwise sufficiently advised, we affirm.

                                      I. BACKGROUND

                On October 9, 2018, while working as an underground coal miner for

Cambrian, Sexton struck his head on the mine roof. Sexton reported to the job site

the next day but was unable to work because he could not lift his arms. He sought

medical care from Dr. Van S. Breeding. Sexton’s chief complaint was neck pain.

After conservative treatment failed, Sexton was referred to Dr. John Gilbert, a

1
    Kentucky Revised Statutes.
2
    Kentucky Administrative Regulations.

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neurosurgeon. Dr. Gilbert recommended Sexton undergo a cervical fusion surgery.

Dr. Gilbert performed the surgery in January 2020.

             Sexton never returned to work and requested Cambrian to provide him

with temporary wage and medical benefits. However, Cambrian denied Sexton’s

claim. Sexton’s health insurance covered his surgery. Eventually, Sexton filed a

specific injury claim with the Department of Workers’ Claims as related to the

October 9, 2018 incident alleging cervical, thoracic, lumbar, and psychiatric

injuries. He also filed separate hearing loss and coal workers’ pneumoconiosis

(“CWP”) claims. Sexton’s claims were consolidated and assigned to a single ALJ

for adjudication.

             Following the submission of proof and a final evidentiary hearing, the

ALJ rendered an opinion, order, and award. Therein, the ALJ: (1) dismissed

Sexton’s CWP claim; (2) awarded only medical benefits for Sexton’s hearing loss

claim; (3) determined that the October 9, 2018 incident caused a temporary

psychological injury for which Sexton was entitled to medical benefits from the

date of injury through May 4, 2020, the date of maximum medical improvement;

(4) concluded that Sexton failed to demonstrate any permanent injuries to his

lumbar and thoracic spine and dismissed his claim for permanent partial disability

and future medical benefits for those alleged injuries; and (5) found that the

October 9, 2018 incident caused Sexton to suffer a cervical spine injury which left

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him 28% permanently impaired and rendered him totally and permanently disabled

entitling Sexton to temporary total disability benefits, permanent total disability

benefits, and past and future medical benefits, including compensation for the

cervical fusion surgery.

             Cambrian appealed the ALJ’s award to the Board. Before the Board,

Cambrian argued that the ALJ erred in failing to account for Sexton’s preexisting

active cervical spine issues and in finding him totally disabled. Cambrian also

asserted that the ALJ erred in concluding that it was responsible for past medical

expenses, which were not submitted in accordance with the time limits prescribed

by KRS 342.020(4) and 803 KAR 25:096 §11. After the Board affirmed the ALJ,

Cambrian petitioned this Court for further review. In this appeal, Cambrian

contests only the portion of the Board’s opinion which holds KRS 342.020(4) and

803 KAR 25:096 §11 do not apply pre-award.

                             II. STANDARD OF REVIEW

             The question before us is one of pure statutory and regulatory

interpretation. “As a reviewing court, we are bound neither by an ALJ’s decisions

on questions of law or an ALJ’s interpretation and application of the law to the

facts. In either case, our standard of review is de novo.” Bowerman v. Black

Equipment Co., 297 S.W.3d 858, 866 (Ky. App. 2009).

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                                    III. ANALYSIS

             In relevant part, KRS 342.020(4) states that “the provider of medical

services shall submit the statement for services within forty-five (45) days of the

day treatment is initiated and every forty-five (45) days thereafter, if appropriate,

as long as medical services are rendered.” Additionally, 803 KAR 25:096 §11

provides:

             Section 11. Request for Payment for Services Provided or
             Expenses Incurred to Secure Medical Treatment.

             (1) If an individual who is not a physician or medical
             provider provides compensable services for the cure or
             relief of a work injury or occupational disease, including
             home nursing services, the individual shall submit a fully
             completed Form 114 to the employer or medical payment
             obligor within sixty (60) days of the date the service is
             initiated and every sixty (60) days thereafter, if
             appropriate, for so long as the services are rendered.

             (2) Expenses incurred by an employee for access to
             compensable medical treatment for a work injury or
             occupational disease, including reasonable travel
             expenses, out-of-pocket payment for prescription
             medication, and similar items shall be submitted to the
             employer or its medical payment obligor within sixty
             (60) days of incurring of the expense. A request for
             payment shall be made on a Form 114.

             (3) Failure to timely submit the Form 114, without
             reasonable grounds, may result in a finding that the
             expenses are not compensable.

             Before the Board, Cambrian argued that the ALJ erred in ordering it

to provide compensation for the medical expenses not submitted in accordance

                                          -5-
with KRS 342.020(4) and 803 KAR 25:096 §11. The Board, however, concluded

that the ALJ correctly interpreted the submission requirements as applying only

after an award had been entered by an ALJ. Cambrian urges us to reverse on the

basis that the Board misinterpreted the statute and its accompanying regulations.

            This exact issue was recently decided by the Kentucky Supreme Court

in Wonderfoil, Inc. v. Russell, 630 S.W.3d 706 (Ky. 2021). In that case, the

claimant, Richard Russell, sustained an injury to his right arm while working for

Wonderfoil. Before the ALJ, Wonderfoil admitted the injury was compensable;

however, it argued that the ALJ should not order it to compensate Russell for past

medical expenses not submitted in accordance with KRS 434.020(4) and 803 KAR

25:096 §11. The ALJ agreed with Wonderfoil and ruled that Russell’s unpaid

medical expenses were not compensable based on the untimely submissions.

Russell appealed to the Board. The Board reversed holding that the submission

requirements apply only after an interlocutory decision or final award has been

entered by the ALJ. After this Court affirmed the Board, Wonderfoil sought

further review from the Kentucky Supreme Court.

            The Supreme Court first examined 803 KAR 25:096 §11(2)’s

requirement that “[e]xpenses incurred by an employee for access to compensable

medical treatment . . . shall be submitted to the employer or its medical payment

obligor within sixty (60) days of incurring of the expense.” The Court determined

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that the statute was ambiguous because it was impossible to tell whether it “applies

only post-award, during litigation but pre-award, or even before the potential

claimant files his claim.” Wonderfoil, Inc., 630 S.W.3d at 710. The Court then

examined 803 KAR 25:096 §11(2) in the context of the broader scheme

established by the Department of Workers’ Compensation’s administrative

regulations. In so doing, the Court noted that various other regulations required the

claimant to disclose and submit unpaid medical expenses prior to final adjudication

by the ALJ. See 803 KAR 25:010 §7; 803 KAR 25:010 §13(9)(a). It concluded

that interpreting 803 KAR 25:096 §11(2)’s sixty-day requirement to apply before

entry of an award would “result in a direct contradiction with 803 KAR 25:010 §

7(2)(f), which requires the claimant disclose unpaid medical bills within forty-five

days of filing his claim and within ten days of receiving new bills after the initial

forty-five days has passed.” Wonderfoil, Inc., 630 S.W.3d at 711. Ultimately, the

Court held that 803 KAR 25:096 §11 applies only post-award because this

interpretation was the only way to avoid a contradictory and absurd result. Id.

             The Court rejected Wonderfoil’s argument that interpreting KRS

342.020(4) and 803 KAR 25:096 §11(2) to apply only post-award would result in

unfair surprise and hardship to employers. It explained:

             Additionally, our interpretation does not offend due
             process by creating unfair surprise to employers, despite
             arguments made otherwise to this Court. Even under our
             interpretation of 803 KAR 25:096, § 11(2), a claimant is

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             still required to submit medical expenses they wish to
             have paid pursuant to 803 KAR 25:010, §§ 7 and 13.
             Those medical expenses must be included in the
             claimant’s notice of disclosure that must be filed within
             forty-five days of the issuance of the Notice of Filing of
             Application. 803 KAR 25:010, §7(2)(e)7. The claimant
             is then under a continuing obligation to turn over new
             medical expenses within ten days of receiving those
             expenses pursuant to 803 KAR 25:010, §7(2)(f). Further,
             a claimant is required to bring copies of unpaid medical
             bills and expenses to the benefit review conference. 803
             KAR 25:010, §13(9)(a). If he or she fails to do so and
             does not show good cause, such failure “may constitute a
             waiver to claim payment for those bills.” Id. These
             requirements prevent employers from being unfairly
             surprised by requested medical expenses and provide a
             mechanism by which claimants may be penalized for
             failure to comply.

Wonderfoil, Inc., 630 S.W.3d at 713.

             In keeping with the above explanation, the Court observed that

Wonderfoil “did not defend on the basis of Russell’s failure to submit his medical

expenses under any other regulation [such as 803 KAR 25:010, §7 or KAR 25:010,

§13(9)].” Id. It cautioned, however, that had Wonderfoil done so, the result may

have been different.

             In his opinion, order, and award, the ALJ explicitly stated that Sexton

“filed medical billing regarding all denied medical treatment, mileage, out-of-

pocket expenses and co-payments[.]” We presume the ALJ was referring to

Sexton’s filing requirements under 803 KAR 25:010 §7 and KAR 25:010 §13(9).

In any event, Cambrian did not argue before either the Board or this Court about

                                        -8-
any noncompliance with these regulations. Like Wonderfoil, Cambrian defended

solely on the basis that it should not have liability for medical expenses submitted

outside the time frames established by KRS 342.020(4) and 803 KAR 25:096,

§11(2). The Board properly rejected Cambrian’s argument since no award had

been entered prior to the ALJ’s October 9, 2020 opinion, order, and award.

Wonderfoil, Inc., 630 S.W.3d at 711.

                                 IV. CONCLUSION

             For the reasons set forth above, we affirm the Workers’ Compensation

Board.

             ALL CONCUR.

BRIEF FOR APPELLANT:                       BRIEF FOR APPELLEE L.D.
                                           SEXTON:
W. Barry Lewis
Hazard, Kentucky                           Emily Faith Wetmore
                                           Hazard, Kentucky

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