Opinion
W.C. No. 3-113-338
October 5, 2001
FINAL ORDER
The claimant seeks review of an order of Administrative Law Judge Martinez (ALJ) which denied medical benefits after maximum medical improvement (MMI). We modify the ALJ's order and, as modified, affirm it.
In 1994 the claimant suffered an admitted back injury. On October 18, 1999, the respondents filed an Amended Final Admission of Liability. The claimant timely objected and filed an application for hearing dated July 7, 1999, on the issues of temporary disability benefits and penalties.
At the commencement of the hearing on November 6, 2000, the parties agreed the issues were future medical benefits as provided by Grover v. Industrial Commission, 759 P.2d 705 (Colo. 1988), and the suspension of benefits for confinement under § 8-42-113(1), C.R.S. 2001. No testimony was presented.
The ALJ found the claimant failed timely to object to the "position taken" by the respondents in the Amended Final Admission on the issue of Grover-type medical benefits. Therefore, the ALJ determined that the issue of Grover-type medical benefits beyond admitted liability was closed. Further, the ALJ found the claimant failed to prove the respondents failed to pay any admitted liability. Consequently, the ALJ denied the claim for additional medical benefits.
On August 11, 2000, the claimant was sentenced to the Colorado Department of Corrections for 4 years. Therefore, the ALJ suspended all further medical benefits pursuant to § 8-42-113(1).
On review the claimant first contends he had no notice the respondents contended the issue of Grover-type medical benefits was closed. Therefore, the claimant contends the ALJ's order was a denial of due process of law. We disagree.
Initially, we note that the claimant's Designation of Record includes the "entire Division of Labor file." The record transmitted to us on appeal apparently does not include the entire Division of Labor file. However, our review is limited to the evidentiary record before the ALJ, and there is no evidence in the record which tends to suggest the claimant requested the ALJ to consider the entire Division of Labor file as part of the evidentiary record for the hearing. See City of Boulder v. Dinsmore, 902 P.2d 925 (Colo.App. 1995); Rules of Procedure, Part VIII(A)(7), 7 Code Colo. Reg. 1101-3 at 22. Consequently, we have restricted our review to the record made at the hearing.
Due process contemplates advance notice of both the legal and factual issues to be litigated. Hendricks v. Industrial Claim Appeals Office, 809 P.2d 1076 (Colo.App. 1990). The issue of future medical benefits was endorsed in the claimant's Application for Hearing dated July 28, 2000. In their Response to the Application for Hearing the respondents asserted the "claimant failed to timely object to Respondents' prior Final Admission of Liability regarding maintenance medical benefits." ( See Response August 4, 2000). Further, at the commencement of the hearing the respondents' attorney argued the claimant did not timely object to the Amended Final Admission concerning Grover-type medical benefits. Under these circumstances, the record does not support the claimant's assertion that he was deprived of advance notice that the respondents intended to defend the claim on grounds the issue of medical benefits was closed.
Nevertheless, we agree with the claimant that the ALJ erred in finding the issue of Grover-type medical benefits was closed. The respondents are obligated to provide treatment which is "reasonably needed" to cure and relieve the claimant from the effects of the injury. Section 8-42-101(1)(a), C.R.S. 2001. Ordinary medical benefits terminate at MMI, but the claimant is entitled to medical benefits after MMI where there is substantial evidence in the record to support a determination that future medical treatment will be reasonable and necessary to relieve the effects of an industrial injury or prevent further deterioration of the claimant's condition. Stollmeyer v. Industrial Claim Appeals Office, 916 P.2d 609 (Colo.App. 1995) ; Milco Construction v. Cowan, 860 P.2d 539 (Colo.App. 1992). However, the claimant need not prove he requires a specific course of treatment at the time of MMI to receive a general award of future medical benefits. Rather, Grover contemplates that once the claimant has proven his entitlement to future medical benefits, there be a general admission or a general award requiring the respondent to pay the costs of future medical treatment, subject to the respondents' right to contest liability for any specific treatment modality on grounds the treatment is not reasonable or necessary. See Grover v. Industrial Commission, supra; Holly Nursing Care Center v. Industrial Claim Appeals Office, 992 P.2d 701 (Colo.App. 1999).
Section former § 8-43-203(2)(b)(II), C.R.S. 2000 [amended 2001 Colo. Sess. Laws, ch. 23 at 49 for admissions filed after March 11, 2001], provides that a claim is automatically closed as to the issues admitted in the final admission if the claimant does not timely object and requests a hearing on any disputed issues that are ripe for hearing. Dalco Industries, Inc. v. Garcia, 867 P.2d 156 (Colo.App. 1993).
Here, the respondents concede their Amended Final Admission of Liability admitted liability for Grover-type medical benefits. Because liability was admitted, and because the respondents did not seek to withdraw their admission for Grover-type medical benefits, the issue of Grover-type medical benefits remained open, and the claimant was only required to apply for a hearing in cases where the respondents refused payment for specific treatment deemed unreasonable or unnecessary. See § 8-43-203(2)(d), C.R.S. 2001 (once any liability is admitted, payments shall continue according to admitted liability). In other words, because no specific medical benefits were "ripe" for adjudication at the time of the final admission, the claimant's failure to apply for a hearing on the general issue of Grover-type medical benefits following the respondents' Amended Admission for Grover-type medical benefits did not "close" the issue. Indeed one of the purposes of the admissions process is to secure voluntary payment where there is no legitimate controversy. HLJ Management Group, Inc., v. Kim, 804 P.2d 250 (Colo.App. 1990). Consequently, we see no purpose in requiring a claimant to object specifically to portions of admission with which he agrees.
Nevertheless, we perceive no basis to interfere with the ALJ's order denying specific Grover-type medical benefits. The question of whether the claimant sustained his burden to prove entitlement to particular medical benefits is one of fact for resolution by the ALJ. Stollmeyer v. Industrial Claim Appeals Office, supra. We must uphold the ALJ's determinations if supported by substantial evidence in the record and plausible inferences drawn from the evidence. Section 8-43-301(8), C.R.S. 2001; Suetrack USA v. Industrial Claim Appeals Office, 902 P.2d 854 (Colo.App. 1995). Under this standard, it is the ALJ's sole prerogative to assess the sufficiency and probative weight of the evidence. Rockwell International v. Turnbull, 802 P.2d 1182 (Colo.App. 1990). Insofar as the medical evidence is subject to conflicting inferences, we may not substitute our judgment for that of the ALJ concerning the inference to be drawn. See City of Durango v. Dunagan, 939 P.2d 496 (Colo.App. 1997).
The claimant presented evidence he had several follow-up medical appointments with the authorized treating physicians after MMI and had received additional prescription medication. However, there is substantial evidence to support the ALJ's finding that the claimant failed to prove the need for specific medical treatment which had not already been paid by the respondents. This finding supports the order denying additional medical benefits.
Finally, the claimant contends the ALJ erroneously determined § 8-42-113 barred his right to medical benefits during his incarceration. The claimant argues the statute is ambiguous and should not be construed to apply to "medical" benefits. We disagree.
Section 8-42-113 provides that:
"Notwithstanding any other provision of law to the contrary, any individual who is otherwise entitled to benefits under articles 40 to 47 of this title shall neither receive nor be entitled to such benefits for any week following conviction during which such individual is confined in a jail, prison, or any department of corrections facility."
Relying on Wood v. Beatrice Foods Co., 813 P.2d 821 (Colo.App. 1991) the claimant points out the purpose of § 8-42-113 is to relieve the employers of payment benefits for lost earning capacity to persons who have no earning capacity because imprisonment removed them from the work force. The claimant argues the purpose is not furthered by construing the statute to ban Grover-type medical benefits. We reject these arguments.
In Woods v. Beatrice Foods Co., supra, the issue was the claimant's entitlement to permanent partial disability payments during incarceration. Applying the rules of statutory construction, the court determined that the plain meaning of the statute was unambiguous and that the statute "suspends all benefits." The Woods court concluded that only permanent disability benefits assigned to the claimant's dependents are exempt from the provisions of § 8-42-113. We and the ALJ are bound by published decisions of the Court of Appeals. C.A.R. 35(f).
We also note that under the Workers' Compensation Act (Act) the general term "benefits" includes "medical" treatment and disability payments. See § 8-40-102 C.R.S. 2001. Further, medical treatment is one of the "Benefits" provided for in Article 42 of the Act. See Section 8-42-101 C.R.S. 2001. Therefore, the ALJ did not err in determining § 8-42-113 required him to suspend the claimant's entitlement to Grover-type medical benefits during his incarceration.
The cases relied upon by the claimant are not authority to the contrary. In Wild West Radio Inc. v Industrial Claim Appeals Office, 886 P.2d 304 (Colo.App. 1994), the issue was whether the fifty percent reduction of "compensation" provided by former § 8-42-112(1), C.R.S. 1993, for injuries caused by the claimant's intoxication applies to medical benefits. The court concluded that the terms "benefits" and "compensation" are only synonymous in the context of the reopening statute. Further, the court held that the purpose of the statute was to deter misconduct and to achieve that purpose it was sufficient to apply the 50 percent reduction against the claimant's entitlement to indemnity benefits. Therefore, the court concluded "medical benefits" were not a form of "compensation" in the context of § 8-42-112(1). The General Assembly subsequently adopted the court's reasoning by amending § 8-42-112(1) to expressly limit the intoxication penalty to "nonmedical benefits." 1999 Colo. Sess Laws, ch. 174, § 8-42-112.5 at 580.
Relying on Wild West, the court in Support, Inc., v. Industrial Claim Appeals Office, 968 P.2d 174 (Colo.App. 1998), held that the language in § 8-43-402 C.R.S. 2001, which provides that a claimant who makes a false statement in a workers' compensation claim forfeits all right to "compensation" does not apply to medical benefits. Here, unlike Wild West and Support Inc, the applicable statute suspends "benefits," not "compensation." Consequently, Wild West and Support Inc., are legally distinguishable from the issue in this case.
Moreover, the purpose of § 8-42-113 is not to deter misconduct. Rather, it is to avoid injustice to the employer. That purpose is furthered by relieving the employer of liability for medical treatment of the industrial injury where the state is providing for the claimant's basic needs during incarceration. Therefore, we reject the claimant's contrary construction.
However, section 8-42-113 only suspends benefits while the claimant is incarcerated. Consequently, the ALJ erred insofar as his order is construed as a permanent bar to Grover-type medical benefits, and we modify the ALJ's order accordingly.
IT IS THEREFORE ORDERED that the ALJ's order dated December 18, 2000, is modified to provide that the claim for specific Grover-type medical benefits is denied and the claimant's right to Grover-type medical benefits is suspended during his incarceration.
INDUSTRIAL CLAIM APPEALS PANEL
____________________________________ David Cain
____________________________________ Kathy E. Dean
NOTICE
This Order is final unless an action to modify or vacate this Order is commenced in the Colorado Court of Appeals, 2 East 14th Avenue, Denver, CO 80203, by filing a petition for review with the Court, within twenty (20) days after the date this Order is mailed, pursuant to § 8-43-301(10) and § 8-43-307, C.R.S. 2000. The appealing party must serve a copy of the petition upon all other parties, including the Industrial Claim Appeals Office, which may be served by mail at 1515 Arapahoe, Tower 3, Suite 350, Denver, CO 80202.
Copies of this decision were mailed October 5, 2001 to the following parties:
James G. Eddy, 471 Carsen Lake, Clifton, CO 81520
Toby's Vacuum Truck Service, P.O. Box 515, Parachute, CO 81635-0515
Rhonda Norris, State Farm Insurance Companies, P.O. Box 266004, Littleton, CO 80163
J. Keith Killian, Esq., and Amy K. Eaton, Esq., P.O. Box 4859, Grand Junction, CO 81502 (For Claimant)
Kim D. Starr, Esq., 2629 Redwing Road, #330, Fort Collins, CO 80526 (For Respondents)
BY: A. Pendroy