Mildred Deloach V Fara Insurance Services

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Automated Summary

Key Facts

Mildred Deloach sustained a work-related head injury on October 6, 2009 at LSU Agricultural Center. FARA Insurance Services accepted the claim and approved her choice of physician, Dr. Arsham Naalbandian. Dr. Naalbandian's November 22, 2010 report indicated her post-traumatic headaches appeared to have resolved. There was a two and one-half year gap in treatment before she saw Dr. Naalbandian again in March 2013. On October 14, 2013, Claimant requested evaluation with Dr. Gerald Leglue, a physiatrist. FARA disputed the claim for medical benefits and filed a 1002 Notice of Controversion. The WCJ denied the expedited motion to see Dr. Leglue due to lack of evidence supporting the request. The Court affirmed the WCJ's decision, finding FARA had evidence to reasonably controvert the claim for additional medical treatment and that the burden of proof should have rested with FARA rather than Claimant.

Issues

  • The case addresses whether FARA reasonably controverted the claimant's request for a change of physician from Dr. Naalbandian to Dr. Leglue. FARA argued the claimant's post-traumatic headaches from the October 2009 work injury had resolved, as evidenced by Dr. Naalbandian's November 2010 report and normal diagnostic tests conducted in March 2013. The court examined whether FARA met its burden to show the treatment was not medically necessary, finding that FARA provided sufficient evidence through the treating physician's reports and normal test results. The claimant submitted no evidence or testimony to rebut FARA's position that the requested medical treatment was not medically necessary.
  • The central legal issue concerns whether the workers' compensation judge correctly placed the burden of proof on the claimant (Mildred Deloach) to demonstrate her need for a new physician, or whether the burden should have rested with FARA Insurance Services to show the requested treatment was not medically necessary. Under Louisiana Revised Statutes 23:1121(B)(1), an injured employee has an absolute right to select one treating physician in any field without employer approval, but La.R.S. 23:1201(F)(2) provides that this right may not apply if the claim is reasonably controverted. The court analyzed whether FARA reasonably controverted the claim by presenting evidence that the claimant's post-traumatic headaches had resolved and that subsequent medical tests were normal, thereby determining who bore the burden of proof in the dispute over the claimant's request to see Dr. Leglue, a physiatrist.

Holdings

The court affirmed the workers' compensation judge's denial of the claimant's request to see Dr. Leglue, finding that FARA reasonably controverted the claim for medical benefits and the claimant failed to provide evidence to rebut FARA's position that the requested treatment was not medically necessary.

Remedies

The Court of Appeal affirmed the Workers' Compensation Judge's judgment denying the Claimant's expedited motion to see Dr. Gerald Leglue, a physiatrist. The Court held that the burden of proof should have rested with FARA to reasonably controvert the claimant's request for medical treatment, but FARA provided sufficient evidence that the treatment was not medically necessary. All costs of this appeal were assessed to the Claimant-Appellant, Mildred Deloach.

Legal Principles

  • The court held that under La.R.S. 23:1121 and 23:1201, the burden of proof should rest with the employer/insurer (FARA) to reasonably controvert a claimant's request for medical treatment, not on the claimant. The WCJ incorrectly placed the burden on Claimant. FARA met its burden by showing: (1) Dr. Naalbandian's November 2010 report indicated post-traumatic headaches had resolved; (2) there was a 2.5 year treatment gap; (3) March 2013 diagnostic tests (EEG, Brain Stem Auditory Evoked Response, Visual Evoked Response) were normal; (4) Claimant submitted no evidence or testimony to rebut FARA's position that the requested treatment was not medically necessary.
  • Under La.R.S. 23:1121(B)(1), an employee has an absolute right to select one physician in any field or specialty without employer approval. The selection of a new physician in a different specialty does not require approval. However, La.R.S. 23:1201(F)(2) provides that penalties and attorney fees are precluded if the claim is reasonably controverted. To determine if a claim has been reasonably controverted, a court must ascertain whether the employer/insurer engaged in a nonfrivolous legal dispute or possessed factual and/or medical information to reasonably counter the claimant's information.

Precedent Name

  • Brown v. Texas-LA Cartage, Inc.
  • Ewing v. Hilburn
  • Nelson v. Windmill Nursery of La., L.L.C.
  • Smith v. Southern Holding Inc.
  • Thompson v. The Animal Hosp.
  • Tulane Univ. Hosp. & Clinic v. Lockheed Martin Corp.
  • Davis v. Sheraton Operating Corp.
  • Krogh v. Tri-State Refrigeration

Cited Statute

  • Louisiana Revised Statutes 23:1121
  • Louisiana Revised Statutes 23:1201
  • Louisiana Revised Statutes 23:1203
  • Louisiana Revised Statutes 23:1201.1

Judge Name

  • Marc T. Amy
  • John E. Conery
  • Sylvia R. Cooks

Passage Text

  • However, we find FARA put forth evidence and testimony to reasonably controvert Claimant's continued need for any medical treatment. The evidence showed Claimant had been approved and was treated by Dr. Naalbandian, her choice of physician, since 2009. After Dr. Naalbandian's report of November 22, 2010, declaring that Claimant's post-traumatic headaches from the work accident appeared to have resolved, there was a two and one-half year gap in treatment before she saw Dr. Naalbandian again in March of 2013. FARA approved her continuing treatment with Dr. Naalbandian, as well as a recommended Electroencephalogram (EEG), a Brain Stem Auditory Evoked Response test and Visual Evoked Response test. All these tests came back normal. It was not until FARA received a request to see Dr. Leglue that it conducted an investigation which revealed Dr. Naalbandian believed her post-traumatic headaches were resolved back in November of 2010 and the March 2013 tests were normal. FARA then filed the appropriate 1002 Notice controverting the claim for medical benefits. Claimant submitted no evidence or testimony to rebut FARA's submissions supporting its position that the requested medical treatment was not medically necessary.
  • The WCJ denied the request to see Dr. Leglue, finding there was nothing in the record to support additional medical treatment pending the follow-up report from Dr. Naalbandian, who was the Claimant's treating physician. The recordsupports this finding, and the judgment appealed from is affirmed.
  • We find the WCJ applied the wrong legal standard in this case. Claimant was given the burden to produce evidence to support her claim to see Dr. Leglue. The burden of proof should have rested with FARA to reasonably controvert Claimant's request to see Dr. Leglue.