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2000 MT WCC 51
WCC No. 2000-0057
LINDA YOUNG, a/k/a LINDA PLUM YOUNG
LIBERTY NORTHWEST INSURANCE CORPORATION
WENDY'S OF MONTANA
FINDINGS OF FACT, CONCLUSIONS OF LAW AND JUDGMENT
Summary of Case: Claimant, an employee of Wendy's, was injured at work when a case of french fries fell on the back of her leg. Two days after the incident she reported leg pain to a physician's assistant. Two weeks after the incident she told a physician she also had low-back pain, which she traced to the accident. She claims her back pain increased and is disabling. She has not returned to work and seeks additional and ongoing temporary total disability benefits, medical benefits relating to her alleged back condition, coverage of an examination by an orthopedic surgeon, and designation of the surgeon as her treating physician.
Held: Claimant did not injure her back at work and has not persuaded the Court she suffers from disabling back pain. Three physicians and one physician's assistant found claimant's symptoms exaggerated and inconsistent with any objective medical condition. Based on claimant's testimony at trial and her videotaped deposition, an evaluation of her statements to various medical providers, and video surveillance, the Court finds claimant's reports of back pain are grossly exaggerated. She is not temporary totally disabled and is not entitled to further medical treatment for her back condition. Under section 39-71-1101, MCA, et seq., claimant is not entitled to demand treatment by an orthopedic surgeon who is not a member of the insurer's designated preferred provider organization (PPO).
¶1 The trial in this matter was held on July 5, 2000, in Billings, Montana. Petitioner, Linda Young (claimant), was represented by Mr. Paul E. Toennis. Respondent, Liberty Northwest Insurance Corporation (Liberty), was represented by Mr. Larry W. Jones. A trial transcript has not been prepared.
¶2 Exhibits: Exhibits 1 through 11, and 14 through 27, were admitted without objection. Exhibits 12 and 13 were admitted over claimant's relevance objections.
¶3 Witnesses and Depositions: The Court received depositions of Scott K. Ross, M.D., Steven J. Rizzolo, M.D., Richard P. Lewallen, M.D., Jane Kukes-Penney, Ron Maki, Cheryl Maki, Rhonda Wakai, and two videotaped depositions of claimant (May 4, 2000 and June 14, 2000.) Claimant, Dr. Scott K. Ross, Jane Kukes-Penney, and Glen Wheeler were sworn and testified at trial.
¶4 Outstanding motions: At the time of trial, claimant's Motion for Partial Summary Judgment Pursuant to A.r.m. 24.5.316 or in the Alternative Declaratory Ruling Pursuant to A.r.m. 24.5.351 was pending. The motions are considered in the present decision.
¶5 Issues presented: The issues as restated by the Court are as follows:
¶6 Having considered the Pretrial Order, the testimony presented at trial, the demeanor and credibility of the witnesses, the depositions, the exhibits, and the arguments of the parties, the Court makes the following:
FINDINGS OF FACT
¶7 Claimant is 47 years old. She is a high school graduate.
¶8 For many years prior to her husband's death in July 1998, claimant worked at "a little bit of everything" in the Mexican Star Café, a restaurant owned by her husband. She also worked over five years for the Montana Nugget Casino.
¶9 Claimant began working for Wendy's in Billings on April 1, 1999. During her employment at Wendy's, she worked at two Wendy's restaurant locations, the first located on Grand Avenue, the second on Central Avenue.
¶10 On July 16, 1999, while working at the Central Avenue Wendy's, a case of french fries fell and hit claimant on the back of her left leg behind her knee cap. (Young Dep. I at 9.) The accident occurred at 8:40 a.m. Claimant's work shift ended at 2:00 p.m. At that time, she was experiencing burning and sharp pain in the calf of her leg. (Id. at 13-14, Dep. Ex. 3, and Trial Test.) She did not work the next day. (Id. at 12-13.)
¶11 On July 20, 1999, claimant was evaluated by physician assistant Dave Johnson (Johnson) at the Deaconess Billings Clinic. (Ex. 2 at 80.) He took the following history from claimant:
¶12 The July 20th record does not mention back pain. On examination, Johnson noted "a small area of hematoma in the posterior left leg, proximal calf." (Id.) His impression was "[c]ontusion, left leg." (Id.) Johnson recommended claimant take the analgesic Aleve as needed and restricted her from frequent sitting, extensive walking, and kneeling or squatting. (Id. at 82.)
¶13 Claimant returned to work thereafter but only for a short period of time.
¶14 On July 23rd, she returned to Johnson, who recorded:
(Id. at 83.) Johnson found tenderness in the area of the bruise and noted his impression of "[c]ontusion left knee and proximal posterior calf." (Id.) He restricted claimant's work duties to sitting and limiting walking. He wrote that "she can certainly sit at a cash register utilizing a stool if they will accommodate that. If not, she will have to be off work for a few days." (Id. at 83-84.)
¶15 As on July 20th, Johnson's office note for July 23rd does not record any complaints of back pain. (Id.)
¶16 On July 28, 1999, a Wendy's manager talked to claimant about "coming in and working while sitting on a stool." (Ex. 5 at 3.) He told her that Wendy's would try to accommodate her restrictions. (Id.) On July 29th, claimant called the manager and told him her leg was swollen and she would not be going into work. (Id.)
¶17 Claimant returned to Johnson on July 30, 1999. In his office note, he wrote:
(Ex. 2 at 87.) He recorded her complaints as "numbness through the entire lower extremity, and some pain in her gluteal region on the left" (id.), commenting that the complaints were "a bit difficult to evaluate . . . because of recurrent pain about the knee." (Id.) His office note does not record any complaints of back pain.
¶18 Given claimant's continued pain, Johnson sent claimant to his supervising doctor, Dr. Scott Ross, Director of Occupational Health Services. (Id.) For the first time, fourteen days after the accident, claimant complained of back pain. Dr. Ross recorded: "In addition, she describes an aching discomfort in the central low back region. This is relatively new but is attributed by the patient to her work injury." (Id.)
¶19 At deposition, Dr. Ross testified he would expect claimant to have reported back pain within a day or two of the July 16th incident if claimant had injured her back. (Ross Dep. at 14.) He questioned "whether the complaints of back pain could be associated with the reported work injury." (Id. at 13.)
¶20 Dr. Ross found no objective evidence of significant back injury. He found no blanching of the skin, spasm, swelling, or bruising. (Id. at 24.) He did find several reasons to question claimant's pain complaints. He wrote:
(Ex. 27 at 2-3.)
¶21 Dr. Ross used various tests to help evaluate "whether someone's being forthright with you during the evaluation and to reproduce findings by testing with different methods the same anatomic structure." (Ross Dep. at 22.) He explained the tests as follows:
¶22 Based upon his July 30th examination, Dr. Ross concluded claimant would reach maximum medical improvement within 7-10 days with no permanent impairment. (Ex. 27 at 3.) He released her to modified work duties with restrictions on lifting, twisting, bending, climbing, crouching, and recommendation of frequent changes of position. The restrictions were effective until claimant returned for follow-up on August 5th. (Id.)
¶23 Claimant did not return to work. Dennis Stern, an assistant manager at Wendy's, made the following notes of conversations with claimant:
(Ex. 5 at 4.)
¶24 Claimant returned to Dr. Ross on August 3, 1999. Dr. Ross reported she was "in distress, complaining of low back and left leg pain. . . not[ing] 10/10 intensity pain with minimal palpation in the left popliteal space." (Ex. 27 at 4.) At trial, claimant testified she did not understand her statement of 10/10 pain to mean she had the most pain humanly possible, but only that she was having her maximal pain. She testified Dr. Ross did not explain the 0-10 properly. Dr. Ross, however, testified that he explained to claimant, as he explains to all patients asked to rate their pain, that 10 equals "pass out pain" or "call 911 pain." I credit Dr. Ross on this point.
¶25 Dr. Ross characterized claimant's pain responses during his August 3rd examination of her as "exaggerated." He contrasted her responses during examination to what he observed before and after the actual examination:
(Ex. 27. at 5.)
¶26 At the conclusion of his August 3rd examination, Dr. Ross referred claimant to Dr. Gregg L. Singer "for consultation regarding continued musculoskeletal low back pain complaints and pain complaints in the left leg." (Id.) Although claimant was initially pleased with the referral, Dr. Ross noted she later became "quite indignant and angry and stated that I was referring her to Dr. Singer who was in the same specialty as me." (Ex. 2 at 92.)
¶27 Claimant decided she needed treatment by an orthopedic surgeon. Sometime before the evening of August 3rd, she called Orthopedic Associates for an appointment but was told she needed a referral. (Trial Test.)
¶28 On the evening of August 3rd, claimant went to the emergency room at St. Vincent's Hospital, looking for a referral to an orthopedic surgeon. She was seen by Dr. Kathi Theade. (Ex. 2 at 110.) Dr. Theade recorded that claimant came "in complaining of three weeks worth of back pain," which she reported as unchanged "virtually since the day it started." (Id.) The history of back pain claimant gave Dr. Theade is inconsistent with the medical history disclosed in Dave Johnson's and Dr. Ross' records.
¶29 Dr. Theade examined claimant. She found it difficult to test claimant's range of motion, "but flexion was approximately 45 to 50 degrees, extension 10 degrees, abduction normal." (Id.) She found no tenderness in the sciatic notch and noted that reflexes and motor strength were all well preserved. She looked for Waddell's signs, but noted they "were negative for me." (Id.)
¶30 Regarding a referral to an orthopedic surgeon, Dr. Theade wrote,
(Id., emphasis added.)
¶31 Claimant testified Dr. Theade actually referred her to Orthopedic Associates during the emergency room visit. I am unpersuaded.
¶32 On the morning of August 4th, Dr. Ross spoke with claimant and "recommended she continue as planned with her appointment with Dr. Singer, and should she have any other requests or requirements, she could contact the insurance company directly (Liberty Northwest - Jim Belknap, claims adjuster)." (Ex. 2 at 92.)
¶33 On August 4th, claimant spoke with Glen Wheeler (Wheeler), the insurer's claims manager in Montana. Claimant asked Wheeler for authorization to treat with either Dr. Greg McDowell or Dr. Rizzolo, who are orthopedic surgeons. Wheeler then talked with Dr. Ross, who agreed to refer claimant for an orthopedic physician though continuing to question the objective basis of claimant's reports of back pain. Wheeler authorized claimant to see Dr. Greg McDowell. (Trial Test. and Ex. A to Motion for Partial Summary Judgment and Ex. B., Affidavit of O. Glen Wheeler, to Brief in Opposition to Motion for Partial Summary Judgment And/or Declaratory Ruling.)
¶34 On August 11, 1999, claimant was examined by Dr. Singer, who specializes in physical and rehabilitation medicine, not, as claimant believed, occupational medicine. Dr. Singer found claimant's history "a bit difficult to sort through" and noted "inconsistencies in examination." (Ex. 27 at 8-9.) He explained:
(Id. at 9.)
¶35 Dr. Singer diagnosed "leg contusion and lumbar strain with some numbness in the foot." He doubted the presence of "true radiculopathy." (Id.) He commented: "I suspect that there are some other issues that area [sic] impacting Ms. Young's behavior, and I suspect that these will impact upon her recovery." (Id.) He referred claimant back to Dr. Ross, recommending physical therapy which "should be short, exercise-directed, and [should] not involve any modalities as there are no findings on exam, and in fact her examination predicts a poor outcome." (Id. at 9-10.)
¶36 On August 18, 1999, claimant saw Dr. Richard P. Lewallen, an orthopedic surgeon. (Ex. 2 at 1.) One-third of his practice is devoted to children and, although he diagnoses spine problems in his patients, he does not perform back surgery. (Id. at 7.)
¶37 At the time of Dr. Lewallen's examination, claimant reported that since the accident she suffered low-back pain radiating down into her leg. X-rays of her spine were normal but based on claimant's pain reports Dr. Lewallen suspected a disk herniation. (Id. at 10.) He ordered an MRI.
¶38 On August 23, 1999, claimant returned to Dr. Ross, who had a copy of Dr. Lewallen's initial report. Claimant described low-back pain, ranging in intensity from 8/10 to 9/10, which was "deep, burning, and aching which is constant." (Ex. 2 at 95.) Dr. Ross again found no organic signs. He opined claimant had reached MMI with respect to her leg injury with no permanent impairment. With regard to her back, he stated:
(Id. at 96, emphasis in original.)
¶39 An MRI was conducted August 24, 1999. (Ex. 2 at 9.) Slight bulging of the annulus was noted at L3-4. At the L4-5 level, the MRI showed "mild central protrusion of the disk with slight indentation of the subarachnoid space and mild prominence of the dorsal ligaments and facet joints creating mild central stenosis." (Id.) The radiologist's conclusion stated:
¶40 Dr. Lewallen believed there was correlation between claimant's pain reports and the MRI findings. He testified: "she had facet arthritis changes which were greater on the left at L4-5, which correlated with her left leg - left back pain and left leg pain." (Lewallen Dep. at 12.) He ordered epidural steroid injections. (Ex. 2 at 2; Lewallen Dep. at 12.)
¶41 On August 30th, claimant returned to Dr. Ross, who found "[t]he patient continues to be noncompliant." (Ex. 2 at 100; emphasis in original.) He noted claimant had not filled recommended prescriptions and had not reported for physical therapy. With regard to the MRI, he noted:
(Ex. 2 at 100.)
¶42 At deposition, Dr. Ross opined that the "MRI findings are within normal limits for a woman her age and do not correlate with her examinations that I had or Dave Johnson or Rick Singer." (Ross Dep. at 90.) He emphasized the mild nature of the disk protrusion noted in the MRI, and described studies indicating that a significant percentage of the population have bulges, protrusions, or frank herniations without symptoms. (Id. at 44-46.) Lacking correlation of the MRI to specific symptoms consistently presented by claimant, Dr. Ross believed the MRI did not corroborate claimant's pain reports. (Id.)
¶43 Dr. Ross's assessment on August 30th was as follows:
(Ex. 2 at 102.) He concluded claimant was not yet at MMI, but released her to modified work duties. (Id.)
¶44 Claimant's final visit to Dr. Ross was on September 7, 1999. He noted she was complaining of some leg and knee pain, and sharp low-back pain with radiation. (Id. at 105.) She reported the sharp pain as "8/10 intensity" and a constant ache of "7/10 intensity." (Id.) He found her at MMI with no permanent impairment and released her to regular work duties without restriction.
¶45 On September 21, 1999, claimant returned to Dr. Lewallen. She reported that her pain limited her to walking only "approximately ¼ mile" and that steroid injections prescribed by the doctor had provided only 30 to 40 percent relief. (Ex. 2 at 4.) Dr. Lewallen testified that the treatment for claimant "wasn't terribly effective." (Lewallen Dep. at 12.) He testified it was "difficult to tell whether she's got - whether that's more from the arthritis in the facet joints, you know, versus nerve root irritation. Usually if it's a nerve root that's swollen and inflamed, then the epidural steroid injection may work better." (Id. at 12-13.)
¶46 Believing claimant had an element of spinal stenosis on the left at L-4, 5, he referred her for evaluation by Dr. Rizzolo. (Id.) Dr. Rizzolo examined claimant on October 18, 1999. (Ex. 2 at 16.) In his office note he recorded her chief complaint as "[l]ow back pain that radiates down her left leg." (Id.) Claimant told the doctor her back pain was "always present" and that she had intermittent leg pain, worse if she stood more than ten minutes. (Id.) Based on his physical examination of claimant, Dr. Rizzolo recorded:
¶47 Dr. Rizzolo read the x-rays as showing "minimal degenerative changes" with no instability or bony lesions. (Id.) The MRI "showed mild widespread degenerative changes with desiccation of the bottom three discs with no nerve root compression." (Id., bold in original.) The x-rays and MRI did not explain her symptoms or behavior. Dr. Rizzolo observed:
(Id. at 18.) He suggested "rapid aggressive work-up and non-confrontational approach [would be] most likely to return this patient to gainful employment without litigation and prolonged loss of function." (Id.) He also recommended certain tests to rule out other problems, along with four to six weeks of aggressive physical therapy. (Id.) Then, "[i]f, in fact, she claims she cannot return to work I would recommend a Functional Capacity Evaluation." (Id.)
¶48 At deposition, Dr. Rizzolo was asked whether he found any objective medical evidence supporting claimant's reports of back pain. He testified that
(Rizzolo Dep. at 6, emphasis added.)
¶49 Dr. Rizzolo testified he could not state whether imaging studies reflected pathology or normal aging. (Id. at 7.) He also testified that drawing the connection between claimant's symptoms and the alleged accident depended on her credibility. (Id. at 6.)
¶50 Claimant's workers' compensation benefits were terminated on October 28, 1999. (Young Dep. II at 69.)
¶51 Claimant returned to Dr. Lewallen in November. He ordered a bone scan, which he read as showing "some slight increased uptake at the left L4, 5 region," along with "some sclerosis and arthritic changes at the L4, 5 facet level." (Ex. 2 at 22.) Dr. Lewallen believed activity shown on the bone scan "was correlated with the plain films, which suggested sclerosis at L4-5." (Lewallen Dep. at 15.) He prescribed physical therapy. (Id.)
¶52 At deposition, Dr. Ross reviewed the bone scan report and testified it did not change his opinion regarding claimant's condition. (Ross Dep. at 124.) He disagreed with Dr. Lewallen's correlation of the bone scan with results of claimant's injury. (Id. at 143.)
¶53 Dr. Rizzolo testified that "uptake" indicated by the bone scan could be consistent with claimant's pain reports (Rizzolo Dep. at 10), but he did not believe he could "make the clinical correlation well enough between her complaints and presentation and physical examination and the bone scan result." (Id. at 11.)
¶54 On November 17, 1999, claimant was evaluated by physical therapist Kim Larson (Larson). She reported pain of 7 on a scale of 10, primarily located in the left low back, buttock, and hip. She reported the pain as "constant and it increases and decreases with different activities and throughout the day." (Ex. 2 at 47.) Larson assessed "decreased functional mobility secondary to pain, decreased in ROM and decreased strength in the left lower extremity and lumbar region." (Id. at 49.) He believed claimant's symptoms would benefit from therapy, as well as education in posture and body mechanics. (Id.) Larson planned four weeks of biweekly therapy (id. at 50) but claimant attended only two sessions. (Id. at 51).
¶55 On February 16, 2000, Dr. Lewallen wrote to claimant's counsel, opining that claimant's injury "did aggravate the condition of facet arthrosis." (Id. at 32.) He stated:
¶56 At deposition, Dr. Lewallen testified that claimant's main difficulty is facet arthritis, which contributed to her spinal stenosis. (Lewallen Dep. at 20.) These are long term degenerative changes but he opined that the accident at Wendy's aggravated her preexisting condition. (Id. at 20.)
¶57 Dr. Lewallen conceded that the MRI and bone scan do not in themselves indicate conditions causing pain. (Id. at 21-22, 25.) He agreed that claimant's reports of pain, hence her credibility, were "absolutely central" to his diagnosis. (Id. at 25.) He believed claimant's pain reports. His philosophy is, "You know, when you practice medicine, if you don't put any weight to what the patient tells you, you - you know, you really shouldn't be practicing medicine." (Id. at 25-26.)
¶58 Dr. Lewallen did not perform Waddell's or Kummel's tests on claimant, nor did he perform straight leg raising in more than one position or use any distraction techniques. (Id. at 26-27, 30.) When asked whether he formed any opinion whether claimant was exaggerating her reports of pain, Dr. Lewallen responded, "Well, I think I tried to take that [her reports of pain] at face value." (Id. at 29.)
¶59 On February 21, 2000, physical therapist Scott Welles (Welles) prepared another "initial" evaluation of claimant. (Ex. 2 at 53.) Claimant described her leg pain as a dull aching and her back pain as sharp. She rated her current pain level "as a 10/10 and at best in the last 30 days as a 9/10." (Id., emphasis added.) Welles commented:
(Id. at 54.)
¶60 A Functional Capacity Evaluation (FCE) was performed on May 30, 2000, by physical therapist Rhonda Wakai (Wakai). (Id. at 56-70.) Wakai concluded claimant was only able to work four hours a day at the sedentary-light level. (Id. at 56.) Her conclusion was grounded in claimant's subjective report. Wakai wrote in her report:
(Id., emphasis added.)
¶61 Wakai did not find evidence of claimant exaggerating her pain or limitations. However, a review of Wakai's report suggests she ignored signs of exaggeration. For instance, the report shows that the validity criteria she used indicated claimant used only "fair effort." In addition Wakai did not use all validity criteria in considering claimant's effort (Wakai Dep. at 15-16) and acknowledged errors in testing procedures (Id. at 42-43, 48).
¶62 In her deposition, Wakai testified she took claimant's reports at face value. She based some of her findings regarding claimant's limitations upon claimant's statements that "it hurts" or "that's as far as I can go." (Id. at 10.) Wakai acknowledged she did not use distraction techniques to assess symptom amplification. (Id. at 42-43, 48). Before writing her report, Wakai did not view a videotape of claimant's activities on September 7, 1999. (The video will be discussed later in these findings.) (Id. at 8.)
¶63 Claimant was deposed on May 4, 2000, and again on June 14, 2000. Her depositions were videotaped.
¶64 During her first deposition, she testified her leg pain has not gone away since the time of the accident, stating, "I constantly have a burning pain every day." (Young Dep. I at 15.) She testified the pain in her low back and buttocks increased with time. (Id. at 15-16.) With regard to her ability to engage in daily activities:
She testified she is able to shop for groceries only by leaning over her grocery cart and using it as support, "[l]ike a little walker." (Id. at 20.) She testified she could not carry groceries to her car, but had a friend carry them for her. (Id. at 20-21.) She testified: "I cannot stand for any more than ten or 15 minutes, so when I do my dishes, and the back starts to cramp up and spasm, it hurts my back and my leg, and then I sit down." (Id.) She testified she can sit in a chair for only 20 or 25 minutes before feeling the need to change positions. (Id. at 22.) At the 20 minute mark into her deposition she indicated she was already uncomfortable sitting and "that's why I'm swiveling in my chair. I'm about ready to get up." (Id., Videotape of Dep. at 2:26 p.m.) She testified that walking on cement has been a problem for her. (Id. at 23.)
¶65 She further testified that her limitations, as described by her, have persisted since two days after the accident:
(Id. at 16.)
¶66 Claimant's testimony was contradicted by her activities on September 7, 1999, which were surreptitiously videotaped by private investigators Cheryl and Ron Maki. The Court viewed the video prior to trial in connection with pretrial motions, and also viewed parts of it at trial and after trial. I also reviewed the surveillance log prepared by the Makis (Ex. 13) in correlation with the videotape itself. Both investigators testified the log accurately reflects their activities in taping claimant. (Cheryl Maki Dep. at 3-4; Ron Maki Dep. at 4-5.)
¶67 The video shows claimant shopping in Dillard's department store from 1:07 p.m. to approximately 1:30 p.m., which is approximately 20 minutes. She and a friend then drove to ShopKo, where she shopped for approximately another 40 minutes. The videotape shows claimant standing and walking in both stores. In ShopKo, it shows her friend, but not her, pushing a grocery cart. The total time of her walking and standing, without the aid of a cart and without apparent difficulty, is an hour. After shopping at ShopKo, claimant drove back to her friend's residence, where she removed bags of items from the trunk of the car, bending slightly at times at her waist, and carried them into the residence. She then returned home and is shown at 4:08 p.m. returning from a walk to her mailbox, a walk which she testified took her approximately 10 minutes (Young Dep. I at 24). At 4:20 p.m. she drove to Albertson's grocery store, entering the store at 4:22 p.m. and returning to her car at 4:51 p.m., a period of 29 minutes. She then drove to the Prairie Star Casino on 4th Avenue in Billings, which she entered just after 5:00 p.m. She remained at the casino until 10:10 p.m., a period of 5 hours. While her activities in the casino were not continuously filmed, the video which was taken shows her sitting, nearly immobile, at a video gambling machine, visiting at times with a friend, sometimes playing the machines.
¶68 On the video claimant walked slowly, but she is significantly overweight. Dr. Ross testified at trial that her gait appeared appropriate for a woman of her age and weight. I did not observe any obvious expressions of pain.
¶69 Based on his examinations and treatment of claimant, and his viewing of the video surveillance of claimant, Dr. Ross testified that claimant has no physical impairment or restrictions resulting from her industrial accident.
¶70 I am unpersuaded that claimant injured her back on July 16, 1999, as she claims or that she is unable to work. I further find that she reached maximum medical improvement at least by September 7, 1999.
¶71 In reaching my decision, I find that clamant's reports of pain and physical limitations are grossly exaggerated. She was not a credible witness. The medical evidence she tendered in support of her case depended on her veracity, and is therefore unreliable. I have considered not only my own evaluation of claimant's credibility when testifying at trial, but the following facts:
¶72 Liberty has utilizes a Preferred Provider Organization to treat injured workers. While Glen Wheeler authorized an orthopedic examination by Dr. Gregory McDowell, a PPO physician, he did not authorize claimant to see Dr. Lewallen or any other non PPO physician.
¶73 Claimant has produced no evidence to support her contention that she is entitled to designation of Dr. Lewallen as her treating physician. She began treatment with the Occupational Health Services Unit of the Deaconess Billings Clinic. Dr. Ross thus became her treating physician, as recognized by the insurer. Claimant has presented no circumstances requiring the insurer to change that recognition to Dr. Lewallen.
CONCLUSIONS OF LAW
¶74 Since claimant alleges an injury on July 16, 1999, the statutes in effect on that date apply in this case. Buckman v. Deaconess Hospital, 224 Mont. 318, 321, 730 P.2d 380, 382 (1986).
¶75 Claimant bears the burden of persuading the Court that she is entitled to benefits. See Ricks v. Teslow Consolidated, 162 Mont. 469, 512 P.2d 1304 (1973); Dumont v. Wicken Bros. Construction Co., 183 Mont. 190, 598 P.2d 1099 (1979).
¶76 Claims for temporary total disability benefits are governed by section 39-71-701, MCA (1999), which has stated as follows since 1995:
¶77 Claimant testified she received benefits through October 28, 1999. (Young Dep. II at 69.) She was not entitled to benefits after that date because her back condition was not caused by her work-related accident and in any event was exaggerated. By October 28th she had reached maximum medical improvement.
¶78 Medical benefits are governed by section 39-71-704, MCA (1999),(2) which provides in relevant part:
¶79 Claimant's choice of physicians is governed by managed care provisions of the Workers' Compensation Act. Section 39-71-1101, MCA (1997)(3), provides in pertinent part as follows:
Section 39-71-1104, MCA (1999), provides, and has provided since 1993:
¶80 Claimant was notified by the insurer that it contracted with a PPO. (Ex. 10.) She does not contend Dr. Lewallen was a member of a PPO, or that he otherwise meets requirements of the managed care statutes. Since claimant suffered a total wage loss for some period, under section 39-71-1101(3), MCA, the insurer was liable for treatment by Dr. Lewallen only if it specifically authorized the treatment. After claimant commenced treatment with Dr. Ross at the Billings Clinic, authorization for a change in treating physician was required. § 39-71-1101(2), MCA (1999). The insurer did not authorize claimant to change to Dr. Lewallen as her treating physician. The circumstances of claimant's injuries and medical care did not render the insurer's denial of care from a non-PPO physician unreasonable.
¶81 Claimant's argument that the insurer is estopped from denying that it authorized Dr. Lewallen as claimant's treating physician is unsupported by the evidence. No such authorization was given. Claimant was not credible. Even under her version of her conversation with Wheeler, at most she was authorized to treat with Dr. Lewallen for one visit.
¶82 1. Claimant did not injure her back at work on July 16, 1999, and is not entitled to additional compensation or medical benefits with respect to her back complaints.
¶83 2. Claimant is not entitled to additional temporary total disability benefits.
¶84 3. The insurer was not obligated to recognize Dr. Lewallen as claimant's treating physician and is not liable for charges by Dr. Lewallen.
¶85 4. Pursuant to ARM 24.5.348, this JUDGMENT is certified as final for purposes of appeal.
¶86 5. Any party to this dispute may have 20 days in which to request a rehearing from these Findings of Fact, Conclusions of Law and Judgment.
Dated in Helena, Montana, this 25th day of August, 2000.
c: Mr. Paul E.
1. This issue was initially presented through claimant's Motion for Partial Summary Judgment. Because the matter involved a disputed factual issue, decision was deferred to trial.
2. The statute was amended effective April 23, 1999, but not in any fashion relevant to this proceeding. See Ch. 442, L. 1999.
3. The 1999 legislature amended this section effective October 1, 1999, making the 1997 version applicable in this case. See Ch. 468, L. 1999.
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