Zurich American Insurance Co. v. Gill
Zurich American Insurance Co. v. Gill
Opinion of the Court
OPINION
I. Introduction
In a single point, Appellant Zurich American Insurance Company appeals the trial court’s summary judgment in favor of Appellee Lauren Gill, affirming that Zurich owes medical benefits to Gill under a workers’ compensation claim. The issue before this court is the interpretation of Texas Labor Code section 409.021(c) regarding the effect of the failure to contest the compensability of an injury. Zurich’s position is that (1) its failure to dispute that Gill had a compensable injury does not mean that it cannot dispute whether she had an injury at all, and (2) this court should render judgment in its favor because it proved to the trial court that no injury occurred as a matter of law. Gill’s position is that (1) by failing to timely dispute compensability, Zurich has waived its ability to contest the occurrence of this injury, and (2) she established that an injury occurred as a matter of law. Because we hold that Gill had an injury and that Zurich could not contest the compens-ability of the injury, we affirm the trial court’s judgment.
II. Background
Gill was an employee of Professional Employer Services from April 2000 until May 2001. Although she suffered from
A contested case hearing was held October 31, 2002. The hearing officer found that Gill sustained injuries that were ordinary diseases of life — specifically, chronic allergic rhinitis and maxillary sinusitis. The hearing officer further found that Gill’s allergic rhinitis and maxillary sinusitis were not injuries in the form of an occupational disease. She further found that although Zurich failed to timely contest compensability, and therefore could not challenge whether the injury was com-pensable, Gill did not timely notify her employer of her injury. Therefore, Zurich was relieved of any liability for the workers’ compensation claim.
Both Zurich and Gill appealed the hearing officer’s decision to the Workers’ Compensation Commission Appeals Panel. The Appeals Panel affirmed the hearing officer’s decision and order in part, holding that because the hearing officer is the sole judge of the weight and credibility of the evidence and, as the finder of fact, resolves the conflicts in the evidence and determines what facts have been established, the hearing officer’s determination that Gill did not sustain an injury in the form of an occupational disease was supported by sufficient evidence and was not so against the great weight and preponderance of the evidence as to be clearly wrong and unjust. Additionally, the Appeals Panel held that the hearing officer’s determination that the date of injury was June 1, 2000 was supported by sufficient evidence and was not so against the great weight and preponderance of the evidence as to be clearly wrong and unjust; thus, the hearing officer’s determination that Gill failed to timely notify her employer of her injury was supported by sufficient evidence and was not so against the great weight and preponderance of the evidence as to be clearly wrong and unjust. The Appeals Panel also held that the hearing officer did not err as a matter of law by determining that Zurich waived its right to contest the compensability of the injury by not timely contesting the injury in accordance with the version of section 409.021 of the Labor Code effective at that time. The Appeals Panel also held that the hearing officer did not err as a matter of law by determining that Continental Casualty Company v. Williamson
The Appeals Panel, however, reversed the hearing officer’s decision that Zurich was relieved of liability under section 409.002 because of Gill’s failure to timely notify her employer of her injury pursuant to section 409.001. The Appeals Panel explained that when a carrier loses its right to contest compensability, that loss includes its right to assert a defense under section 409.002 based upon the claimant’s failure to give timely notice of her injury to her employer. Consequently, Zurich was not relieved of liability. Finally, the Appeals Panel rendered the decision that because Zurich waived its right to contest compensability, Gill had a compensable injury as a matter of law.
Zurich then filed suit in district court, appealing the panel’s determinations that, among other things, it had waived the right to contest compensability of the claimed injury by not timely contesting the injury, and thus it was obligated to pay medical benefits for Gill’s medical care. Gill answered and counter-claimed, complaining that the Appeals Panel erred in finding that (1) she did not sustain an injury in the form of an occupational disease and (2) her medical problems were not caused, enhanced, or aggravated by her working conditions. Each party subsequently filed a motion for summary judgment.
The question presented to the trial court, according to Zurich’s motion, was “whether or not Ms. Gill sustained an injury as outlined in the Texas Labor Code.” In her motion for summary judgment, Gill posited the issue as whether Zurich “waived the right to contest compensability of the claimed injury by not timely contesting the injury.” After a hearing and considering the motions, the trial court denied Zurich’s motion and granted summary judgment in favor of Gill, finding that “(1) Zurich has waived the right to contest compensability; (2) thus judgment affirming the decision of the TWCC’s Appeals Panel decision number 023017 is appropriate; [and] (3) Zurich owes medical benefits to Lauren Gill.” This appeal resulted.
III. Analysis
A. Statutes
The goal of statutory construction is to give effect to legislative intent.
In this case, our analysis begins with an examination of the pertinent statutory definitions contained in section 401.011 of the Texas Labor Code:
(26) “Injury” means damage or harm to the physical structure of the body and a disease or infection naturally resulting from the damage or harm. The term includes an occupational disease.
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(34) “Occupational disease” means a disease arising out of and in the course of employment that causes damage or harm to the physical structure of the body, including a repetitive trauma injury. The term includes a disease or infection that naturally results from the work-related disease. The term does not include an ordinary disease of life to which the general public is exposed outside of employment, unless that disease is an incident to a compensable injury or occupational injury.8
To be “compensable,” the injury must arise out of and in the scope and course of employment for which compensation is payable.
At issue in this appeal is the meaning of a particular statutory section containing these defined phrases. Section 409.021(c) of the Texas Labor Code states: “If an insurance carrier does not contest the compensability of an injury on or before the 60th day after the date on which the insurance carrier is notified of the injury, the insurance carrier waives its right to contest compensability.”
Gill points the court to an additional deadline missed by Zurich contained in former section 409.021(a), applicable to this case, which reads:
An insurance carrier shall initiate compensation under this subtitle promptly. Not later than the seventh day after the date on which an insurance carrier receives notice of an injury, the insurance carrier shall (1) begin the payment of benefits as required by this subtitle or (2) notify the commission and the employee in writing of its refusal to pay and advise the employee of (A) the right to request a benefit review conference and (B) the means to obtain additional information from the commission.13
Gill argues that if Zurich’s construction of the statute is correct regarding its being
B. Case Law
Two cases touching on the issue before this court are discussed by the parties. In Williamson, claimant Claude Williamson alleged that on August 10, 1993, he fell down a staircase at work, which replicated a March 1993 injury.
The Appeals Panel affirmed the hearing officer’s findings of fact and conclusions of law, but disagreed with the conclusion that because there was a finding of no injury, Williamson was not entitled to benefits.
Continental then appealed the Appeals Panel decision to the trial court. The trial court affirmed the decision, which was again appealed to our sister court in Tyler.
Williamson has been held by the Texas Workers’ Compensation Commission Appeals Panel to be limited to situations where there is a determination by the hearing officer that the claimant did not have an injury, that is, no damage or harm to the physical structure of the body, as opposed to cases where there is an injury or disease determined by the hearing offi
The second case discussed by the parties is Continental Casualty Company v. Downs.
On appeal, the trial court affirmed the Appeals Panel’s decision, but the San Antonio Court of Appeals reversed the trial court and rendered judgment in favor of Downs because Continental had not, within seven days of notice of the claim, notified Downs of its refusal to pay benefits and therefore Continental could not contest compensability.
The Texas Supreme Court agreed with this analysis, holding that “[tjherefore, a carrier that has neither initiated benefits nor filed a notice of refusal, has not complied with the [seven-day] statutory requisite, and has failed to trigger the sixty-day period to investigate or deny compensability.”
[although the parties and the court of appeals label the consequence for failure to meet the seven-day pay-or-dispute deadline a “waiver,” that is not precisely what happens under the statutory scheme. We are presented not with a question of waiver, but of a deadline (seven days to pay or dispute), and a consequence for failing to meet that deadline (a carrier that does nothing fails to avail itself of the sixty-day period to investigate or deny compensability).33
C. Application
Applying the foregoing case law and statutory analysis to this case, we hold that Gill has an injury that is compensable by Zurich. When notified of a claim under the worker’s compensation statute, an insurer operating under the law effective in this case had seven days to either begin paying benefits or notify the commission and the employee of its refusal to pay.
But again, the Workers’ Compensation Commission Appeals Panel has repeatedly and consistently held that Williamson applies to situations where there is a determination that the claimant did not have an injury, as opposed to cases where there is an injury or disease which was determined by the hearing officer not to be causally related to the claimant’s employment.
Similarly, in appeal 981640, supra, where the appeal panel applied the Williamson decision, the hearing officer determined that there was no injury (reflex sympathetic dystrophy) and that determination was supported by the evidence. In the case under review, that was not the situation. Not only did the evidence support the hearing officer’s determination that the claimant sustained an occupational disease, but the fact that the claimant had a dystopia condition was not in dispute; rather, whether it related to her employment, a compensability issue, was the essence of the issue. In other words, the question was not that the claimant did not have an injury or condition at all but whether it was connected to her employment, a compensa-bility matter. We do not read the Williamson case to extend to situations where there is some injury or condition supported by the evidence and the pertinent issue is whether it relates to the employment, a compensability matter. To so extend Williamson would effectively read section 4-09.021(c) out of existence. (Emphasis added).38
We agree. Therefore, because the hearing officer found that Gill had an injury, Williamson does not apply to this case. Consequently, Zurich’s sole issue is whether Gill had an “injury.”
Because we are dealing with statutory construction, we must examine the Texas Labor Code’s definition of “injury.”
The statute specifies that the term “occupational disease” does not include “an ordinary disease of life to which the general public is exposed outside of employment, unless that disease is an incident to a compensable injury or occupational disease.”
Therefore, to be an “injury,” Gill’s condition must qualify as damage or harm to the physical structure of the body
The record shows, and Zurich does not contest, that Gill has chronic allergic rhinitis and maxillary sinusitis, which manifested in the form of sneezing, headaches, congestion, a sore throat, and a runny nose. The Appeals Panel recognized and agreed with the hearing officer’s determination that Gill had physical harm or damage to her body due to the chronic allergic rhinitis and maxillary sinusitis. Because Gill’s chronic allergic rhinitis and maxillary sinusitis resulted in the malfunctioning of the physical structure of the body,
Consequently, we hold that, under the facts of this case, although Gill’s condition was an ordinary disease of life, not incident to a compensable injury or occupational disease, her condition was an “injury” for purposes of section 401.011(26) of the Texas Labor Code. Thus, because Zurich cannot contest the compensability of the injury, it owes medical benefits to Gill. We overrule Zurich’s sole point.
IV. Conclusion
Having held that (1) Gill had an injury, (2) Zurich may not contest the compensa-bility of the injury, and thus (3) Zurich owes medical benefits to Gill, we affirm the trial court’s judgment.
McCOY, J. filed a dissenting opinion.
. 971 S.W.2d 108 (Tex.App.-Tyler 1998, no pet.).
. See, e.g., Appeals Panel No. 022274, 2002 WL 31474068, at *2 (Tex. Workers' Comp. Comm'n Oct. 17, 2002); Appeals Panel No. 022027-s, 2002 WL 31474007, at *2 (Tex. Workers’ Comp. Comm’n Sept. 30, 2002); Appeals Panel No. 990223, 1999 WL 202028, at *3 (Tex. Workers’ Comp. Comm’n Mar. 22, 1999); Appeals Panel No. 990135, 1999 WL 163482, at *4 (Tex. Workers' Comp. Comm’n Mar. 10, 1999); Appeals Panel No. 981847, 1998 WL 1012977, at *2 (Tex. Workers’ Comp. Comm’n Sept. 25, 1998).
. Cont’l Cas. Co. v. Downs, 81 S.W.3d 803, 805 (Tex. 2002).
. Id.
. Id.
. Broadhurst v. Employees Ret. Sys. of Tex., 83 S.W.3d 320, 323 (Tex.App.-Austin 2002, pet. denied).
. Tex. Lab.Code § 401.011(26), (34) (Vernon Supp.2004-05).
. Id. § 401.011(10).
. Id. § 409.021(c) (Vernon Supp.2004-05).
. See id.
. See TIG Premier Ins. Co. v. Pemberton, 127 S.W.3d 270, 272 n. 1 (Tex.App.-Waco 2003, pet. denied).
. Act of May 12, 1993, 73rd Leg., R.S., ch. 269, § 1, 1993 Tex. Gen. Laws 1195 (amended 2003) (current version at Tex Lab.Code Ann. § 409.021(a) (Vernon Supp.2004-05)).
. Williamson, 971 S.W.2d at 109.
. Id-
. Id.
. Id. at 110.
. Id.
. Id.
. Id. at 110.
. Mat 110-11.
. Id.
. Id. at 111.
. See, e.g., Appeals Panel No. 022274, 2002 WL 31474068, at *2; Appeals Panel No. 022027-s, 2002 WL 31474007, at *2; Appeals Panel No. 990223, 1999 WL 202028, at *3; Appeals Panel No. 990135, 1999 WL 163482, at *4; Appeals Panel No. 981847, 1998 WL 1012977, at *2.
. 81 S.W.3d at 804-07.
. Id. at 804.
. Id.
.Id.
. Id.
. Id. at 806.
. Id. at 807.
. Act of May 12, 1993, 73rd Leg. R.S., ch. 269, § 1, 1993 Tex. Gen. Laws 1195 (amended 2003).
. Tex. Lab.Code Ann. § 409.021(c).
. See Williamson, 971 S.W.2d at 110.
. See, e.g., Appeals Panel No. 022274, 2002 WL 31474068, at *2; Appeals Panel No. 022027-s, 2002 WL 31474007, at *2; Appeals Panel No. 990223, 1999 WL 202028, at *3; Appeals Panel No. 990135, 1999 WL 163482, at *4; Appeals Panel No. 981847, 1998 WL 1012977, at *2.
. Appeals Panel No. 981847, 1998 WL 1012977, at *2.
. See Tex. Lab.Code Ann. § 401.011(26).
. Id.
. Id. § 401.011(34).
. Id. § 401.011(26).
. Williamson, 971 S.W.2d at 110.
. Tex. Lab.Code Ann. § 410.165(a) (Vernon 1996); Williamson, 971 S.W.2d at 110.
. Williamson, 971 S.W.2d at 110.
. Id.
. Id.
. Id.
. See id.
. See GTE Southwest, Inc. v. Bruce, 998 S.W.2d 605, 610 (Tex. 1999) (holding, with regard to the injury of emotional distress, that "[t]he phrase 'physical structure of the body’ refers to the entire body, and emotional distress may constitute an ‘injury’ when it results in malfunctioning of the physical structure of the body”).
. See Williamson, 971 S.W.2d at 110; see also Broadhurst, 83 S.W.3d at 322.
Dissenting Opinion
dissenting.
I respectfully dissent. I do not believe that the Legislature intended that an “injury” encompass the symptoms of an “ordinary disease of life,” as has been found present here, any more than those from a
Reference
- Full Case Name
- ZURICH AMERICAN INSURANCE COMPANY, Appellant v. Lauren GILL, Appellee
- Cited By
- 15 cases
- Status
- Published