Johnson v. Darchuks Fabrication, Inc.
Johnson v. Darchuks Fabrication, Inc.
Opinion of the Court
This case considers whether the medical treatment parameters established under the workers' compensation act apply to an employee's claim for reimbursement of medical expenses that the employer contends are not reasonably necessary. Minnesota Rule 5221.6020, subpart 2 (2017), states that the treatment parameters "do not apply to treatment of an injury after an insurer has denied liability for the injury." Relying on this rule, the Workers' Compensation Court of Appeals concluded that the treatment parameters do not apply when an employer contests its obligation under the workers' compensation act to pay for an employee's particular medical treatment. We disagree. Accordingly, we reverse the Workers' Compensation Court of Appeals and remand the case to the workers' compensation judge for further proceedings consistent with this opinion.
FACTS
In September 2002, employee William Johnson suffered a right ankle injury when he stepped on a piece of scrap metal while working for Darchuks Fabrication, Inc. Within a short period, Johnson developed sharp pain and burning sensations that progressed up his right leg. These symptoms persisted and, eventually, Johnson was diagnosed with a condition known as "complex regional pain syndrome," which is recognized and governed by the workers' compensation treatment parameters. See
Since his injury, Johnson has consulted with numerous physicians and medical specialists. Early on, he was prescribed physical therapy and sympathetic blocks,
After his injury, Johnson sought workers' compensation benefits. In 2004, the parties reached an agreement and entered into a stipulation to settle Johnson's claim for benefits. Under the agreement, Darchuks accepted workers' compensation liability for the ankle injury and, in addition to making a lump-sum payment, agreed to pay ongoing medical expenses that were reasonably required to cure and relieve Johnson's symptoms.
Since 2005, Johnson has received treatment from his current physician, a general practitioner. He has not consulted with a pain specialist, as was previously recommended by a former treating physician. Over the years, Johnson's physician has prescribed a combination of medications that include muscle relaxers, calcium channel blockers, nerve medications, sleep medications, opioid analgesics, and anti-anxiety medications. With these medications, Johnson appears to have achieved some measure of control over his symptoms-but has never been able to eliminate the symptoms altogether.
*417Despite the stability of Johnson's symptoms, his ability to manage daily life has slowly declined. According to his medical records, for example, Johnson's capacity to do household chores and outside housework diminished between 2013 and 2015. During this period he also reported increased difficulty with daily exercise because of the pain. In October 2016, Johnson told his physician that his pain completely interferes with his general activity and sleep on a regular basis.
Presently, Johnson's treatment regime consists of five medications: Endocet (an opioid for pain), lorazepam (an anti-anxiety medication), nifedipine (to reduce contractions in his blood vessels in his leg), Neurontin (a brand-name medication for nerve pain), and cyclobenzaprine (to treat muscle spasms). Aside from changes in dosage prescribed by Johnson's physician, this treatment regime has remained unchanged for more than ten years. Johnson has a check-up with his physician every three months. As required by the treatment parameters, Johnson has signed and complied with a narcotic medication contract for his opioid prescription.
In May 2016, Darchuks requested that Johnson undergo an independent medical examination. It was the fourth independent medical examination conducted since Johnson's initial injury in 2002. Until then, every physician who had examined Johnson agreed with his complex regional pain syndrome diagnosis and agreed that the condition is causally related to Johnson's workplace ankle injury. The May 2016 report, however, cast doubt on the source of Johnson's symptoms and the complex regional pain syndrome diagnosis.
Based on the May 2016 report, Darchuks advised Johnson's physician in a letter denial
Darchuks' letter denial suspended its payment of medication expenses. Thus, in November 2016, Johnson filed a workers' compensation medical request seeking payment to cover the cost of his medications. Darchuks denied the request for payment. Relying on the findings of the May 2016 independent medical examination, Darchuks contended that Johnson's complex regional pain syndrome had resolved. Darchuks asserted, moreover, that it was not obligated to pay for Johnson's treatment because it was not reasonable or necessary and his continuing medication treatment was not compliant with the workers' compensation treatment parameters for long-term treatment with opioid analgesic medication. See *418
A formal hearing was held before a workers' compensation judge on July 21, 2017. After reviewing the reports submitted by Johnson's physician, the judge found Johnson's testimony to be credible, concluded that Johnson's diagnosis was correct, implicitly concluded that it was causally connected to Johnson's workplace injury, and found that his condition had not resolved. The judge also concluded that, by asserting that Johnson's complex regional pain syndrome had resolved, Darchuks had in effect "denied liability" for Johnson's injury. Consequently, the judge held that the treatment parameters did not apply to Johnson's claim. See
On appeal to the Workers' Compensation Court of Appeals, Darchuks argued that the compensation judge misunderstood its position. According to Darchuks, it continues to accept responsibility for the reasonable and necessary treatment for Johnson's injury; therefore, it has not triggered the bar under Rule 5221.6020, subpart 2, preventing application of the treatment parameters. The Workers' Compensation Court of Appeals rejected Darchuks' argument and affirmed the compensation judge's decision.
Before this court, Darchuks does not challenge the compensation judge's finding that Johnson suffers from complex regional pain syndrome that is causally related to his work-related ankle injury. Nor does Darchuks challenge the finding that Johnson's condition has not resolved. Darchuks' only contention on appeal is that the workers' compensation tribunals erred in concluding that the treatment parameters do not apply to Johnson's course of treatment. Accordingly, our review is limited to that question alone.
ANALYSIS
The workers' compensation act requires an employer to furnish medical treatment that is "reasonably ... required ... to cure and relieve from the effects" of a workplace injury.
*419The treatment parameters function as a "yardstick by which the treatment offered by the health care provider is measured." Jacka ,
The rules provide that the treatment parameters do not apply to treatment if the employer "denied liability for the injury."
Here, we are asked to determine whether Darchuks "denied liability" when, after the fourth independent medical examination questioned the reasonableness of the ongoing medication regime, it denied payment of Johnson's medical request. Stated differently, the question here is whether Darchuks lost the right to invoke the treatment parameters to challenge coverage for the treatment regime prescribed by Johnson's physician when it objected to the latest medical payment request. To resolve this question, we must first interpret the phrase "denied liability" in Minnesota Rule 5221.6020, subpart 2. We then apply our interpretation to the circumstances here.
I.
The meaning of an administrative rule is a question of law that we review de novo. J.D. Donovan, Inc. v. Minn. Dep't of Transp. ,
Rule 5221.6020, subpart 2, which governs the application of the treatment parameters generally, provides that the treatment parameters "do not apply to treatment of an injury after an employer has denied liability for the injury ."
From this language, we come to the straightforward conclusion that the phrase "liability for the injury" in Rule 5221.6020, subpart 2, refers to the employer's obligation to pay statutory benefits for personal injuries that are covered by the workers' compensation act. Consequently, under Rule 5221.6020, subpart 2, an employer may not invoke the treatment parameters when it denies liability, that is, when the employer claims that it is not obligated to pay compensation for an injury. An employer's denial might occur, for example, when a dispute arises between the parties concerning whether an injury is covered under the act. Under these circumstances, the employer's position disclaims responsibility for any compensation or benefits, as opposed to objecting to a particular treatment recommendation or regime. When an employer takes this position, there is no reason for the treatment parameters to apply unless and until the employer's liability is established.
This interpretation makes sense in light of other language in Rule 5221.6020, subpart 2. The rule provides that, in cases where an employer has denied liability for the employee's injury, the treatment parameters nevertheless "apply to treatment initiated after liability has been established ."
II.
With this understanding of the rule in mind, we assess whether Darchuks has denied liability for Johnson's injury here. When a question arises about the application of law to undisputed facts, we review it de novo. Gilbertson v. Williams Dingmann, LLC ,
We disagree. It is true that Darchuks contested the validity of Johnson's diagnosis and argued that his medical prescriptions were improper under the treatment parameters. But the bar against applying the treatment parameters is triggered only when an employer denies liability for an injury .
Johnson responds that, because complex regional pain syndrome is the only remaining diagnosis related to his workplace injury, when Darchuks asserted that the condition had resolved, it was a denial of liability for the injury. On this record, however, Johnson's argument is moot. The compensation judge expressly found that Johnson was correctly diagnosed with complex regional pain syndrome, the syndrome was causally related to his workplace ankle injury, and the condition has not resolved. Those factual findings were upheld on appeal, and, critically, Darchuks has not challenged them in this court.
*422Here, Darchuks asserts only that it is not obligated to pay for the treatment prescribed by Johnson's physician. This assertion follows from its position that Johnson's treatment does not comply with the treatment parameters because it is not reasonable and necessary. Darchuks is entitled to make that argument to the workers' compensation judge, as it did here. Cf. Jacka ,
Because Darchuks does not contest its liability to pay for treatment that is reasonably required to cure and relieve the effects of Johnson's workplace ankle injury, it has not "denied liability for the injury" under Rule 5221.6020, subpart 2. Rather, the treatment parameters apply to Johnson's medical request because the workers' compensation tribunals have established that Johnson suffers from complex regional pain syndrome, his condition is causally related to his workplace ankle injury, and his condition has not resolved. See
CONCLUSION
For the foregoing reasons, we reverse the decision of the Workers' Compensation Court of Appeals and remand the case to the workers' compensation judge for further proceedings consistent with this opinion.
Reversed and remanded.
Complex regional pain syndrome is related to, and sometimes referenced interchangeably with, reflex sympathetic dystrophy syndrome. See Complex Regional Pain Syndrome-Symptoms & Causes , Mayo Clinic Patient Care & Health Information, https://www.mayoclinic.org/diseases-conditions (last visited Apr. 19, 2019) [opinion attachment]. According to the Mayo Clinic, these conditions are not well understood, and "[s]ymptoms may change over time and vary from person to person." See
Sympathetic blocks are injections of anesthetics intended to relieve pain. Complex Regional Pain Syndrome , supra n.1.
Each of the parties quotes language from the 2004 settlement agreement, but the agreement was not entered in the record below and was not submitted in the briefing to our court. At oral argument, however, Darchuks' counsel represented that Darchuks "accepted liability" for Johnson's injury. Accordingly, the precise terms of the settlement are not material to our analysis.
The workers' compensation judge noted "one isolated exception" to Johnson's record of compliance, but did not describe the incident in his findings. Nothing in the record suggests that Johnson is abusing any of his medications.
When an employer has accepted primary liability but denies liability for a portion of benefits, it must do so in a "letter denial" that satisfies the requirements of the workers' compensation rules of practice. See
The workers' compensation tribunals never addressed whether Johnson's treatment plan complied with the treatment parameters because they concluded that the parameters did not apply to Johnson's request for reimbursement.
We have also held that the treatment parameters do not bind the compensation judge's inherent discretion to "depart from the rules in those rare cases in which departure is necessary to obtain proper treatment." Jacka ,
As the Workers' Compensation Court of Appeals has aptly explained, " '[w]hen an employer and insurer deny liability for a work injury ... [they] have no real interest in information about the course of the employee's care and no legitimate expectation of influencing or limiting the employee's treatment options.' " Schulenburg v. Corn Plus , 65 W.C.D. 237, 248-49 (Minn. WCCA 2005) (quoting Mattson v. Nw. Airlines ,
Although not necessary for our decision, we note that this interpretation is consistent with the workers' compensation tribunals' own rules of practice. See
The Workers' Compensation Court of Appeals has held that a denial of medical causation is a denial of liability for an injury. See Schulenburg , 65 W.C.D. at 247-49.
At oral argument, in fact, Darchuks expressly stated that it accepts the compensation judge's finding that Johnson suffers from complex regional pain syndrome.
It might be a different case if Darchuks had asserted that Johnson no longer suffered from any symptoms causally connected to his work-related ankle injury. Compare Mattson ,
Reference
- Full Case Name
- William H. JOHNSON v. DARCHUKS FABRICATION, INC. and Harleysville Insurance Company, Relators, and Injured Workers Pharmacy, Intervenor.
- Cited By
- 8 cases
- Status
- Published