Opinion
W.C. No. 4-796-464.
January 22, 2010.
FINAL ORDER
The respondents seek review of an order of Administrative Law Judge Stuber (ALJ) dated September 17, 2009, that found the claimant had suffered a compensable injury and ordered the respondents to pay for dental treatment. We affirm.
The ALJ made the following pertinent findings of fact. On June 8, 2009, the claimant while walking to get materials tripped over a grate, fell and struck his mouth on the corner of a worktable, fracturing a tooth as a result. The tooth was identified by his dental records as number 27. The claimant reported his injury to his employer and the employer's safety office transported the claimant to a dentist, Dr. Autobee. Dr. Autobee pulled the remaining portion of the fractured tooth and gave the claimant a prescription for an antibiotic. The employer filled the prescription and gave the medication to the claimant. The employer discussed with the claimant that Dr. Autobee had not done a good job and that the employer would be responsible for restoring the tooth. However, the respondents did not refer the claimant to any dental provider for the additional dental treatment. The claimant was laid off on June 17, 2009. In July 2009, the claimant sought treatment from Dr. Crosby who pulled the claimant's remaining lower teeth and prepared a new half denture. The claimant paid Dr. Crosby $1,000 for these services. The claimant had preexisting dental problems, but the injury aggravated his preexisting condition by fracturing the anchor tooth for his partial plate.
The ALJ concluded that the treatment by Dr. Autobee and Dr. Crosby were authorized and reasonably necessary to cure or relieve the effects of the work injury. The ALJ ordered the insurer to pay all of the claimant's reasonably necessary medical treatment by authorized providers for the work injury including reimbursing the claimant in the amount of $1,000 for out-of pocket expenditures.
On appeal the respondents contend that because there was no medical evidence in the record to support a finding that the treatment was reasonably needed to cure and relieve the effects of the claimant's injury, the ALJ erred in ordering payment for the dental treatment. As we read the respondents' brief, they only object to the treatment provided by Dr. Crosby and the portion of the order directing reimbursement of the $1,000.
Section 8-42-101(1), C.R.S. 2009, requires the employer to provide medical benefits to cure or relieve the effects of the industrial injury. See Snyder v. Industrial Claim Appeals Office, 942 P.2d 1337 (Colo. App. 1997). Consequently, compensability of the requested dental treatment is dependent on proof that the treatment is reasonably necessary to cure or relieve the effects of the industrial fall. See Snyder v. Industrial Claim Appeals Office, supra.
Where the claimant's entitlement to benefits is disputed, the claimant has the burden to prove a causal relationship between the work-related injury or disease and the condition for which benefits or compensation are sought. Snyder v. Industrial Claim Appeals Office, supra. Whether the claimant sustained his burden of proof is a factual question for resolution by the ALJ. City of Durango v. Dunagan, 939 P.2d 496 (Colo. App. 1997). Because these questions are factual in nature, we are bound by the ALJ's determinations in this regard if they are supported by substantial evidence in the record. 8-43-304(8), C.R.S. 2009; City of Durango v. Dunagan, supra. Substantial evidence is probative evidence, which would warrant a reasonable belief in the existence of facts supporting a particular finding, without regard to the existence of contradictory testimony or contrary inferences. See F.R. Orr Construction v. Rinta, 717 P.2d 965 (Colo. App. 1985). The substantial evidence standard also requires that we view evidence in the light most favorable to the prevailing party, and defer to the ALJ's assessment of the sufficiency and probative weight of the evidence. Thus, the scope of our review is "exceedingly narrow." Metro Moving Storage Co. v. Gussert, 914 P.2d 411 (Colo. App. 2003).
Initially, we note that a report from Dr. Crosby dated September 28, 2009 with attachments was received by us on December 21, 2009. However, our review is restricted to the record before the ALJ, and the factual assertions made in this document may not substitute for evidence, which was not in the record. See City of Boulder v. Dinsmore, 902 P.2d 925 (Colo. App. 1995); Subsequent Injury Fund v. Gallegos, 746 P. 2d 71 (Colo. App. 1987); Voisinet v. Industrial Claim Appeals Office, 757 P.2d 171 Colo. App. 1988); See Lewis v. Scientific Supply Co. 897 P.2d 905 (Colo. App. 1995). Consequently, we have not considered Dr. Crosby's report.
We reject the respondents' assertion that the claimant was required to prove his entitlement to medical benefits by medical evidence. See Lymburn v. Symbios Logic, 952 P.2d 831 (Colo. App. 1997); Apache Corp. v. Industrial Commission, 717 P.2d 1000 (Colo. App. 1986). Medical evidence is neither necessary nor conclusive in determining causation. Rockwell International v. Turnbull, 802 P.2d 1182 (Colo. App. 1990); Colorado Fuel and Iron Corp. v. Industrial Commission, 152 Colo. 25, 380 P.2d 28 (1963). Rather, a finding of causation may be based upon circumstantial evidence, including lay evidence, pointing to a relationship between the industrial injury and the need for treatment. Savio House v. Dennis, 665 P.2d 141 (Colo. App. 1983); Villanueva v. Marriott City Center, W.C. 3-954-848 (December 28, 1993). The claimant's testimony, if credited, may be sufficient to establish the requisite nexus between the industrial injury and the need for medical benefits. Savio House v. Dennis, supra; Westendorf v. Jackson Jackson, W. C. No. 4-598-193 (October 25, 2005). Regardless of the state of the medical evidence, it is always the case under the Act that the question of whether a proposed medical expense is reasonable and necessary is one of fact for determination by the ALJ. Kroupa v. Industrial Claim Appeals Office, 53 P.3d 1192 (Colo. App. 2002); Wal-Mart Stores, Inc. v. Industrial Claims Office, 989 P.2d 251 (Colo. App. 1999); Ontiveros v. Gallegos Corporation July 21, 2006, W.C. No. 4-575-790.
The respondents next contend that the ALJ did not identify any evidence that supported his finding that the treatment by Dr. Crosby was reasonably necessary to cure and relive the effects of the work injury. We disagree.
Here we note that the respondents did not appear at the hearing and therefore the claimant's testimony was the only evidence. As noted above, the ALJ recited in some detail the testimony of the claimant, which is not in dispute. We summarize the following additional portions of the claimant's testimony. The claimant stumbled over a piece of grating in his work area, fell and struck his face on the corner of a table, breaking a tooth. Tr. at 8 17-18. The employer representative took the claimant to a dentist who pulled the remaining part of the tooth. Tr. at 18-19. The dentist put in a temporary partial. Tr. at 19. However, the claimant already had a permanent partial plate and the tooth that was broken held in the partial plate. Tr. at 20. Therefore because the tooth was now broken and removed it no longer acted as an anchor for the plate. Tr. at 20. The claimant went to Dr. Crosby because his partial plate would no longer stay in. Tr. at 25. A partial plate would no longer work because the claimant did not have enough teeth left. Tr. at 26. Therefore, Dr. Crosby had to make a full half denture, which required all the teeth on the bottom to be pulled. Tr. at 26. The claimant paid Dr. Crosby $1,000 for the teeth pulling and making the new denture. Tr. at 27. The claimant's testimony was the only evidence offered at the hearing. The ALJ concluded that the treatment the claimant had received was reasonably necessary to cure and relieve the effects of the work injury.
In our view, the record reveals an uninterrupted chain of treatment for medical complications caused by the industrial injury extending from the date of injury to the treatment by Dr. Crosby. The ALJ could reasonably infer from the lay evidence concerning the physical impact of the fall on the claimant's tooth and the claimant's knowledge of his dental condition, that the industrial injury created the necessity for the dental treatment. Electric Mutual Liability Co. v. Industrial Commission, 154 Colo. 491, 391 P.2d 677 (1964) (in reaching a conclusion concerning causation, the ALJ may make reasonable inferences from the evidence presented): see also Helvey v. Bison Propane Bottle Exchange, W. C. No. 4-608-265 (July 15, 2005). Therefore, the ALJ did not err in finding that the claimant sustained his burden of proof for entitlement to reimbursement for the dental treatment.
IT IS THEREFORE ORDERED that the ALJ's order dated September 17, 2009 is affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
____________________________________ Curt Kriksciun
____________________________________ Thomas Schrant
SHERWIN M GREEN, GREENVILLE, AL, (Claimant).
FARA, Attn: KIMBRA ALLEN, HOUSTON, TX, (Insurer).
CLIFTON, MUELLER BOVARNICK, PC, Attn: DIANE MURLEY, ESQ., GRAND JUNCTION, CO, (For Respondents).