Opinion
W.C. No. 3-113-588
January 7, 2002
FINAL ORDER
The claimant seeks review of an order of Administrative Law Judge Martinez (ALJ Martinez) which denied her claim for medical benefits. The claimant contends the ALJ's findings compel the conclusion that the requested medical treatment was reasonably necessary to treat the injury and, therefore, was compensable. We affirm.
The ALJ's findings may be summarized as follows. The claimant sustained a compensable left knee injury in May 1994. Thereafter, the claimant underwent arthroscopy in 1994, two scar removal procedures in 1997, one in 1998, and one on January 26, 2000. The respondents disputed liability for the January 2000 procedure, arguing it was not reasonable and necessary. In an order dated December 20, 2000, ALJ Jones determined the surgery was not reasonable and necessary, and the respondents were not liable for it.
Prior to the January 2000 surgery, the claimant used two crutches. She testified that after the January 2000 procedure, her knee pain was diminished and she began walking with only one crutch. Shortly thereafter, she began developing shoulder, back, and neck pain. In June 2001, the claimant's treating physicians prescribed physical therapy for treatment of these symptoms, and the claimant sought an order requiring the respondents to pay for the therapy.
However, ALJ Martinez concluded the claimant failed to carry her burden of proof to establish the "shoulder, back and neck symptomatology after January 26 2000 is causally related to for May 12, 1994 admitted injury." Instead, the ALJ found the evidence proved the claimant's symptoms were caused "by postural changes that occurred when claimant began using one crutch after the January 26, 2000 surgery instead of the two crutches she had been using prior to the surgery." The ALJ concluded that "were it not for the improvement in claimant's condition" resulting from the noncompensable surgery, the claimant would not have developed the symptoms and the consequent need for physical therapy. Therefore, ALJ Martinez denied the claim for physical therapy benefits.
On review, the claimant contends the ALJ applied an incorrect legal standard in denying the claim. The claimant asserts that because the January 2000 surgery "improved" her condition and "reduced" her use of crutches, the respondents are liable for the treatment because it was "reasonable and necessary" to treat the effects of the industrial injury. We disagree.
Respondents are not liable for medical treatment unless it is rendered for an injury "proximately caused by an injury or occupational disease arising out of and in the course of the employee's employment." Section 8-41-301(1)(c), C.R.S. 2001. Similarly, the statute provides respondents are liable for reasonable and necessary medical treatment to cure or in relieve the employee "from the effects of the injury." Section 8-42-101(1)(a), C.R.S. 2001. (Emphasis added).
The question of whether the claimant has proved the need for treatment was caused by the industrial injury is generally one of fact for determination by the ALJ. Faulkner v. Industrial Claim Appeals Office, 12 P.3d 844 (Colo.App. 2000); City of Durango v. Dunagan, 939 P.2d 496 (Colo.App. 1997). To the extent the issue of causation is one of evidentiary fact, we must uphold the ALJ's determination if supported by substantial evidence in the record. Section 8-43-301(8), C.R.S. 2001. This standard of review requires us to defer to the ALJ's resolution of conflicts in the evidence, the credibility determinations, and the plausible inferences drawn from the record. Wal-Mart Stores, Inc. v. Industrial Claims Office, 989 P.2d 251 (Colo.App. 1999). However, determination of causation may also involve mixed questions of law and fact. To the extent reasonable minds can draw but one inference from established facts, the issue is one of law for the court. See Schreiber v. Brown Root, Inc., 888 P.2d 274 (Colo.App. 1993).
Here, substantial evidence supports the evidentiary finding that the claimant's need for physical therapy treatment of her neck, back, and shoulder symptoms was caused by the sequalae of the surgery in January 2000. The claimant herself testified that prior to the January surgery, she used two crutches. It was only after the surgery, when she experienced diminished knee pain, that she began to use a single crutch and developed the other symptoms. Moreover, the respondents' medical expert, Dr. Olsen, reported the claimant's medical records are devoid of any reports of similar symptoms prior to June 2000. Thus, insofar as the claimant may be understood to dispute the ALJ's factual findings, there is no basis for interfering with the order.
Further, ALJ Martinez correctly applied the law to these facts. Under the quasi-course of employment doctrine, injuries received while undergoing authorized medical treatment for the industrial injury are considered compensable even though they occur outside the ordinary time and place limitations of "normal employment." Excel Corp. v. Industrial Claim Appeals Office, 860 P.2d 1393 (Colo.App. 1993). The rationale for this doctrine is that because the employer is required to provide reasonable and necessary medical treatment, and the claimant is required to submit to it or risk suspension or termination of benefits, treatment by the physician becomes an implied part of the employment contract. See Employers Fire Insurance Co. v. Lumbermens Mutual Casualty Co., 964 P.2d 591 (Colo.App. 1998); Schreiber v. Brown Root, Inc., supra.
However, in Schreiber, the court held injuries sustained in an automobile accident which occurred while the claimant was obtaining unauthorized treatment were not compensable under the quasi-course of employment doctrine. The court reasoned that even though the claimant may have acted reasonably in seeking the medical treatment, the fact the treatment was not authorized removed it as "an implied condition or expectation of the claimant's employment." 888 P.2d at 278. Consequently, as a matter of law, the injuries could not have been proximately caused by an injury arising out of and in the course of the claimant's employment.
Applying these principles here, ALJ Jones found the January 2000 surgery was not reasonable and necessary to treat the claimant's industrial injury. ALJ Martinez found as a matter of fact that the effects of the January 2000 surgery caused "postural changes" associated with the use of a single crutch, which in turn caused the claimant to develop shoulder, neck and back symptoms. ALJ Martinez also found these changes would not have occurred if the claimant had not undergone the January 2000 surgery.
It follows that the development of the symptoms and the consequent need for therapy were not proximately caused by the industrial injury. Here, as in Schreiber, the claimant underwent medical treatment which was not compensable under the Act. Consequently, the surgery did not constitute an implied condition or expectation of the claimant's employment contract. It follows the symptomatic sequalae of the surgery were not compensable under the quasi-course of employment doctrine, and the ALJ's findings of fact fully support his conclusion.
We recognize that ALJ Martinez found the January surgery afforded some symptomatic relief from the claimant's injury-related knee pain. However, this finding did not purport to set aside ALJ Jones' finding that the surgery was not reasonable and necessary, and we infer no such intention on the part of the ALJ Martinez. In fact, an ALJ might find that particular treatment is not "reasonable and necessary" to treat the claimant's condition even if the treatment is expected to afford some symptomatic relief. Determining the reasonableness and necessity for treatment may involve various considerations including assessment of the risks associated with the procedure, the cost of the treatment when compared to the expected benefit, and the duration of expected symptomatic relief. Indeed, the courts have held the question of whether particular treatment is reasonable and necessary is one of fact for determination by the ALJ. See City of Durango v. Dunagan, supra.
IT IS THEREFORE ORDERED that the order of ALJ Martinez dated July 10, 2001, is affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
________________________________ David Cain
________________________________ Dona Halsey
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. 2001. 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 January 7, 2002 to the following parties:
Phyllis Kroupa, 140 Etta Pl., Durango, CO 81301
Guy Walton, Mercy Medical Center, 375 E. Park Ave., Durango, CO 81301
Stacy Strickland, Catholic Health Initiatives, 1115 Elkton Dr., #1400, Colorado Springs, CO 80907
Elizabeth E. Salkind, Esq., 572 E. 3rd Ave., Durango, CO 81301 (For Claimant)
Gregory K. Chambers, Esq., 3900 E. Mexico Ave., #1300, Denver, CO 80210 (For Respondents)
BY: A. Pendroy