Supreme Court Reverses Court of Appeals, Concludes that Section 85.27(4) Does Not Automatically Require Continuation of Medical Benefits Before Notice from Employer
In Ramirez-Trujillo v. Quality Egg, No. 14-0640 (Iowa April 15, 2016), the Court wrestled with the meaning of section 85.27(4) of the Iowa Code. The sentence in issue in this case states that "If the employer chooses the care, the employer shall hold the employee harmless for the cost of care until the employer notifies the employee that the employer is no longer authorizing all or any part of the care and the reason for that change in authorization." The commissioner concluded that section 85.27(4) required a notice to the claimant in all circumstances if the employer was terminating previously authorized care. The district court reversed, finding that Quality Egg reasonably believed claimant had recovered from the work injury and did not need to provide notice. The Court of Appeals agreed with the commissioner and reversed the district court.
In a lengthy decision, the Supreme Court reverses the decision of the Court of Appeals and remands the claim to the commissioner for further determination as to whether a notice was required, given the evidence presented in the case. The Court first notes that although section 85.27(4) was a "bread and butter provision of the workers' compensation statute regularly administered by the commissioner." Nonetheless, the court was not "firmly convinced" that the legislature attempted to delegate authority to the commissioner and thus gave the commissioner no deference in interpreting the provision.
The court notes that the statute "plainly indicates an employer who authorizes care is responsible for the cost of the care up to the time when the employer notifies the employee it is no longer authorizing care." The Court also notes that the "employer's statutory burden to monitor an injured employee's care is not an onerous one." The Court, however, goes on to note that because the operative phrase is "choose the care" and not "has chosen the care at some time in the past," the responsibility to provide notice is limited. The Court concludes that section 85.27(4) "limits employer liability for authorized care to expenses incurred seeking care related to the medical condition or conditions for which the employee sought care in the aftermath of a workplace injury. . . ." The Court finds that an employer can establish it is not liable for the cost of care "if it proves by a preponderance of the evidence the employee knew or reasonably should have known either that the care was unrelated to the medical condition or conditions upon which the employee's claim for workers' compensation is based or that the employer no longer authorized the care the employee received at the time the employee received it."
The Court sets out a seven step test for determining whether the employer has proven that the employee knew or reasonably should have known that care was no longer authorized. These included the following:
1. The method in which the employer communicated that the care was authorized during the period it was authorized;
2. The actual communications between the employer and employee concerning care;
3. Any communications between the employer and medical providers;
4. The amount of time that passed between the date care was originally authorized and the date the employee sought the disputed care;
5. The nature of the injury for which the employer authorized care;
6. The nature of the care received by the employee, including the overall course of care;
7. Any other matters bearing on what the employee knew or did not know concerning the authorization of care.
In the context of the case, the Court concluded that the commissioner had made no findings of fact that would permit the Court to know whether claimant knew or reasonably should have known that the employer no longer authorized care by Wright Medical Center. A remand was therefore found to be appropriate.
Justice Hecht dissented, noting that although the standard authorized by the majority could have been adopted by the legislature, it was not. He believed that the words of section 85.27(4) were clear and unambiguous and required a notice by the employer when care had been authorized and was now being terminated. Justice Hecht noted that the bright line rule created by the language of 85.27(4) was being rewritten in a manner that would create confusion and spawn additional litigation.
In a lengthy decision, the Supreme Court reverses the decision of the Court of Appeals and remands the claim to the commissioner for further determination as to whether a notice was required, given the evidence presented in the case. The Court first notes that although section 85.27(4) was a "bread and butter provision of the workers' compensation statute regularly administered by the commissioner." Nonetheless, the court was not "firmly convinced" that the legislature attempted to delegate authority to the commissioner and thus gave the commissioner no deference in interpreting the provision.
The court notes that the statute "plainly indicates an employer who authorizes care is responsible for the cost of the care up to the time when the employer notifies the employee it is no longer authorizing care." The Court also notes that the "employer's statutory burden to monitor an injured employee's care is not an onerous one." The Court, however, goes on to note that because the operative phrase is "choose the care" and not "has chosen the care at some time in the past," the responsibility to provide notice is limited. The Court concludes that section 85.27(4) "limits employer liability for authorized care to expenses incurred seeking care related to the medical condition or conditions for which the employee sought care in the aftermath of a workplace injury. . . ." The Court finds that an employer can establish it is not liable for the cost of care "if it proves by a preponderance of the evidence the employee knew or reasonably should have known either that the care was unrelated to the medical condition or conditions upon which the employee's claim for workers' compensation is based or that the employer no longer authorized the care the employee received at the time the employee received it."
The Court sets out a seven step test for determining whether the employer has proven that the employee knew or reasonably should have known that care was no longer authorized. These included the following:
1. The method in which the employer communicated that the care was authorized during the period it was authorized;
2. The actual communications between the employer and employee concerning care;
3. Any communications between the employer and medical providers;
4. The amount of time that passed between the date care was originally authorized and the date the employee sought the disputed care;
5. The nature of the injury for which the employer authorized care;
6. The nature of the care received by the employee, including the overall course of care;
7. Any other matters bearing on what the employee knew or did not know concerning the authorization of care.
In the context of the case, the Court concluded that the commissioner had made no findings of fact that would permit the Court to know whether claimant knew or reasonably should have known that the employer no longer authorized care by Wright Medical Center. A remand was therefore found to be appropriate.
Justice Hecht dissented, noting that although the standard authorized by the majority could have been adopted by the legislature, it was not. He believed that the words of section 85.27(4) were clear and unambiguous and required a notice by the employer when care had been authorized and was now being terminated. Justice Hecht noted that the bright line rule created by the language of 85.27(4) was being rewritten in a manner that would create confusion and spawn additional litigation.
Comments
Post a Comment