IN THE SUPREME COURT OF IOWA
No. 14–0640
Filed April 15, 2016
DEANNA JO RAMIREZ-TRUJILLO,
Appellant,
vs.
QUALITY EGG, L.L.C., WRIGHT COUNTY EGG DIVISION, and
SELECTIVE INSURANCE COMPANY OF AMERICA,
Appellees.
On review from the Iowa Court of Appeals.
Appeal from the Iowa District Court for Polk County, Scott D.
Rosenberg, Judge.
Both parties seek further review of a court of appeals decision
upholding a ruling of the Workers’ Compensation Commission.
DECISION OF COURT OF APPEALS AFFIRMED IN PART AND
VACATED IN PART; DISTRICT COURT JUDGMENT AFFIRMED IN
PART AND REVERSED IN PART; CASE REMANDED WITH
INSTRUCTIONS.
Mark S. Soldat of Soldat, Parrish-Sams & Gustafson, PLC,
West Des Moines, for appellant.
Richard G. Book of Huber, Book, Cortese & Lanz P.L.L.C.,
West Des Moines, for appellees.
2
WIGGINS, Justice.
An employee injured her back at work. Her employer
acknowledged its liability for the injury and authorized care. The
employer paid for the cost of the care the employee received to treat the
back injury through September 30, 2009. The employee brought a
workers’ compensation claim seeking reimbursement of medical
expenses she incurred for additional back treatment between May 2010
and April 2011 and workers’ compensation benefits for the same period.
The employer argued it did not authorize the medical expenses the
employee incurred between May 2010 and April 2011. The employer also
maintained the expenses did not have a causal connection to her
compensable workplace injury. The workers’ compensation
commissioner concluded the treatment the employee received between
May 2010 and April 2011 was not causally related to her workplace
injury. However, the commissioner held the employer was liable for the
claimed medical expenses because the employer failed to notify the
employee it was no longer authorizing care as required by Iowa Code
section 85.27(4) (2009). Both parties sought judicial review.
The district court reversed the final agency decision in part,
concluding the agency misinterpreted section 85.27(4). Both parties
appealed, and we transferred the case to the court of appeals. The court
of appeals reversed the district court in part, concluding the district
court erroneously interpreted section 85.27(4).
Both parties sought further review, which we granted. On further
review, we will let the court of appeals decision stand as the final
decision of this court to the extent it affirmed the district court decision
affirming in part the final agency decision. However, we find the
commissioner erroneously interpreted Iowa Code section 85.27(4).
3
Accordingly, we affirm in part and vacate in part the decision of court of
appeals, affirm in part and reverse in part the district court judgment,
and remand the case to the district court with instructions to remand the
case to the commissioner for further proceedings consistent with this
opinion.
I. Background Facts and Proceedings.
On August 1, 2009, Deanna Ramirez-Trujillo slipped on an egg on
the floor at her workplace in Clarion, Iowa. Although Ramirez-Trujillo
managed to catch herself and did not fall to the floor, she injured her
back. Her employer, Quality Egg, L.L.C., Wright County Egg Division,
completed an incident report acknowledging her workplace injury.
Quality Egg authorized Wright Medical Center to evaluate and treat
Ramirez-Trujillo. Physician assistants at Wright Medical Center treated
Ramirez-Trujillo for acute low back strain and severe muscle spasms on
August 3, 7, 13, 21, and 31. At each visit, Ramirez-Trujillo signed the
bottom of the authorization form to release her medical records to
Quality Egg and its insurer, Selective Insurance Company of America.
After her August 3 visit, her health care provider released her to return to
work with restrictions.
Throughout the months of August and September, Ramirez-Trujillo
received prescription medications, transcutaneous electrical nerve
stimulation treatment, and physical therapy. Though she received an
authorization form from Quality Egg each time she saw a physician
assistant at Wright Medical Center, she did not receive any authorization
forms for her physical therapy appointments. On September 30,
Ramirez-Trujillo had a follow-up appointment with a physician assistant
at Wright Medical Center. Quality Egg once again authorized Wright
Medical Center to evaluate and treat Ramirez-Trujillo, and she once
4
again signed the authorization form to release her medical records to
Quality Egg and its insurer. The physician assistant released Ramirez-
Trujillo to full duty without any work restrictions. The physician
assistant’s notes indicated Ramirez-Trujillo’s back strain was resolving
and no follow-up care was required. The notes also indicated Ramirez-
Trujillo could return to the clinic should further problems arise.
On December 26, Ramirez-Trujillo sought treatment for low back
pain radiating up to her head and down to her toes at the emergency
room at Wright Medical Center. She received an injection, prescriptions
for several medications, and a temporary work release. The physician
assistant’s notes indicated Ramirez-Trujillo said the pain had begun after
she shoveled snow the previous day. She returned to work on
December 29.
On May 1, 2010, Ramirez-Trujillo again sought treatment for low
back pain at the emergency room at Wright Medical Center. She received
two injections, prescriptions for several medications, and a temporary
work release. The treating physician advised Ramirez-Trujillo to seek
follow-up care in one week. The physician’s notes acknowledged
Ramirez-Trujillo’s historical problems with back pain and indicated there
had been no clear triggers for her pain that day.
Over the next several weeks, Ramirez-Trujillo received follow-up
care from a physician assistant and a doctor at Wright Medical Center.
She began physical therapy and continued to take prescription
medication. On May 17, Ramirez-Trujillo reported her pain was gone
and she felt ready to return to work. The doctor released her to full duty
without work restrictions. During a follow-up appointment on June 9,
however, Ramirez-Trujillo reported she was still experiencing intermittent
low back pain and muscle spasms.
5
On June 13, Ramirez-Trujillo again sought treatment at the
emergency room at Wright Medical Center. An x-ray of her lumbar spine
showed disc space narrowing at L5-S1. Her treating physician
prescribed medication and instructed her to seek follow-up care. The
physician’s notes indicated Ramirez-Trujillo said she had been
experiencing intermittent back pain since she injured her back when she
slipped on an egg at work.
On June 14, Ramirez-Trujillo sought follow-up care at Wright
Medical Center. The doctor who treated Ramirez-Trujillo ordered an MRI,
which revealed a prominent disc extrusion with mild to moderate spinal
stenosis at L5-S1. The doctor’s notes indicated Ramirez-Trujillo said she
had previously injured her back at work but characterized her recent
pain as a separate episode. The notes also indicated Ramirez-Trujillo
expressly stated “this is not workman’s comp.” The doctor referred
Ramirez-Trujillo to orthopedic surgeon Mark Palit.
On June 28, Dr. Palit saw Ramirez-Trujillo at Wright Medical
Center and administered a steroid injection. On July 19, Dr. Palit saw
Ramirez-Trujillo at a follow-up appointment. Because Ramirez-Trujillo
reported she continued to experience severe pain, Dr. Palit offered to
perform decompression surgery. Dr. Palit’s notes indicated Ramirez-
Trujillo told him the August 2009 slip injury had resolved with
conservative care by October 2009 and said she did well until May 2010
when she was going up some stairs and her back locked up.
On August 4, Dr. Palit performed decompression surgery on
Ramirez-Trujillo. Dr. Palit discharged her from Wright Medical Center
the following day. Ten days later, she sought treatment at the emergency
room at Wright Medical Center due to drainage occurring at the surgical
site and received an antibiotic to treat cellulitis. Ramirez-Trujillo
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attended follow-up appointments with Dr. Palit at Wright Medical Center
in August, September, and October. Ramirez-Trujillo sought further
treatment in November and December for increased pain in her back
radiating to her right hip and foot. Dr. Palit prescribed medication and
physical therapy. Between the date of the surgery and the end of the
year, she received three temporary work releases from Dr. Palit.
However, each work release covered only a few days.
At a follow-up appointment on January 3, 2011, Dr. Palit imposed
work restrictions on Ramirez-Trujillo and ordered another MRI of her
lumbar spine due to her continuing pain. The MRI revealed a recurrent
disk protrusion at L5-S1. Ramirez-Trujillo attended several additional
follow-up appointments during January and February, during which she
received prescriptions and a steroid injection. On March 23, Dr. Palit
performed a revision of the decompression surgery. He discharged
Ramirez-Trujillo from Wright Medical Center the following day.
This appeal follows from a notice and petition Ramirez-Trujillo filed
with the workers’ compensation commissioner against her employer and
its insurer 1 on October 13, 2010. She sought workers’ compensation
benefits, penalty benefits, and medical expenses she incurred from May
2010 through April 2011. 2 Quality Egg stipulated Ramirez-Trujillo
sustained an injury in the course of her employment on August 1, 2009,
that caused her a temporary disability. Additionally, Quality Egg
stipulated the treatment Ramirez-Trujillo received was reasonable and
necessary and the fees charged by her care providers were fair and
1Throughout the remainder of this opinion, “Quality Egg” refers to Ramirez-
Trujillo’s employer and its insurer.
2Ramirez-Trujillo did not seek reimbursement of the medical expenses she
incurred during December 2009.
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reasonable. Quality Egg argued it did not authorize the medical
expenses Ramirez-Trujillo incurred between May 2010 and April 2011.
Quality Egg also argued those medical expenses did not have a causal
connection to her compensable workplace injury. However, Quality Egg
did not dispute the medical expenses Ramirez-Trujillo incurred were at
least causally connected to the medical condition upon which her claim
of injury was based.
The evidence presented at the arbitration hearing established
medical providers treated Ramirez-Trujillo for low back strains and
spasms on several occasions dating back to the time when she was
eleven years old, but that her prior back issues had resolved before her
August 2009 work injury. 3
Ramirez-Trujillo submitted a written evaluation and report
prepared by Dr. Robin Epp, a certified independent medical examiner.
Based on a physical examination of Ramirez-Trujillo and a review of her
medical records, Dr. Epp concluded Ramirez-Trujillo’s back condition
and the treatment she received after September 30, 2009, were directly
and causally related to her work injury and her subsequent work
activities. Ramirez-Trujillo’s testimony and other testimony by lay
witnesses supported Dr. Epp’s opinion.
Quality Egg submitted a written medical opinion prepared by
Dr. Donna Bahls. Based on her review of a portion of Ramirez-Trujillo’s
medical records, Dr. Bahls concluded neither the work injury nor
Ramirez-Trujillo’s subsequent work activities contributed to the periods
3Ramirez-Trujillo had previously visited Wright Medical Center for treatment of
back pain even before she began working for Quality Egg. In January 2006, Ramirez-
Trujillo went to the emergency room at Wright Medical Center, complaining of lower
back pain after slipping and falling on ice.
8
of disability she experienced after the December 2009 shoveling incident.
Dr. Bahls further concluded neither the work injury nor Ramirez-
Trujillo’s subsequent work activities prior to the shoveling incident
caused her disk to herniate. Rather, Dr. Bahls concluded the shoveling
incident or other events Ramirez-Trujillo mentioned to her doctors
caused the periods of disability she experienced and the medical care she
received on and after December 26, 2009.
Quality Egg also submitted an exhibit on which Dr. Palit indicated
his agreement with the following statement:
Dr. Palit do you agree that it is your opinion that you cannot
state with reasonable medical certainty that the central and
right paracentral prominent disc extrusion at L5-S1 with
mild to moderate stenosis shown on the MRI, the symptoms
reported by Ms. Ramirez-Trujillo in May-July 2010, the
herniated nucleus pulposus at L5-S1 that you diagnosed,
the surgery you performed on August 4, 2010 described as
an L5-S1 bilateral hemilaminotomy, foraminotomy and
discectomy and the revision of the L5-S1 surgery that you
performed were caused by or related to the injury of August
1, 2009?
Two employees testified and submitted written statements on
behalf of Quality Egg, including one employee who was Ramirez-Trujillo’s
supervisor and another who was her coworker. Both employees testified
to hearing Ramirez-Trujillo state she had slipped or fallen on some stairs
at home. 4 In addition, Ramirez-Trujillo’s supervisor testified regarding
various conversations he claimed to have had with her in which she
admitted the condition she was seeking treatment for at the time was not
work-related.
4Though Ramirez-Trujillo admitted her back once locked up as she walked up
the three stairs outside her home, she denied ever having fallen down them. Her
testimony suggested those were the only stairs at her home.
9
The deputy commissioner issued an arbitration decision
extensively summarizing the above facts and testimony. The arbitration
decision expressly addressed the credibility of the witnesses, including
both the lay witnesses who testified and the expert witnesses whose
reports the parties submitted as exhibits. The deputy commissioner also
made numerous legal conclusions, one of which is particularly relevant
to this appeal. Namely, the deputy commissioner concluded Ramirez-
Trujillo’s condition after September 30, 2009, was not the result of her
August 2009 work injury. The deputy commissioner thus denied
Ramirez-Trujillo’s claims for workers’ compensation benefits and medical
expenses incurred after September 30, 2009.
Ramirez-Trujillo appealed to the workers’ compensation
commissioner. The appeal decision affirmed and adopted the majority of
the arbitration decision, noting the hearing deputy’s findings of fact and
conclusions of law could be adequately separated for review on appeal
and giving deference to the hearing deputy’s credibility assessments.
The appeal decision thus affirmed the hearing deputy’s conclusion that
the medical expenses Ramirez-Trujillo incurred from May 2010 through
April 2011 were not causally related to the August 2009 work injury.
However, the appeal decision nonetheless awarded Ramirez-Trujillo the
medical expenses she incurred from May 2010 through April 2011 and
associated transportation expenses because she incurred them while
seeking care from providers Quality Egg authorized and because Quality
Egg conceded it failed to notify her it was not authorizing further
treatment. The commissioner interpreted Iowa Code section 85.27(4) to
require an employer to cover the cost of authorized care unless the
employer satisfies its duty to monitor the care it authorizes and its duty
10
to notify the employee when further care is no longer authorized, even if
the care provided is ultimately found to be unrelated to the work injury.
Quality Egg sought judicial review of the portion of the final agency
decision ordering it to reimburse and hold Ramirez-Trujillo harmless for
medical expenses she incurred after September 30, 2009. Ramirez-
Trujillo asserted the agency erred in failing to comply with Iowa Code
section 17A.16(1) and in applying legal standards on the issue of
causation.
The district court affirmed the final agency decision in part and
reversed in part. The court concluded the agency did not violate section
17A.16(1) and did not err in finding Ramirez-Trujillo’s condition after
September 30, 2009, was not causally related to her work injury.
However, the court also concluded the agency misinterpreted section
85.27(4). The court found Quality Egg reasonably believed Ramirez-
Trujillo had recovered from the work injury and would not seek further
care for that injury after September 30, 2009. It also found Quality Egg
did not receive notice Ramirez-Trujillo was seeking further care after that
date for conditions related to the work injury. The court therefore
concluded Quality Egg was not liable for the expenses Ramirez-Trujillo
incurred after September 30.
Ramirez-Trujillo appealed the district court judgment. We
transferred the case to the court of appeals. The court of appeals
affirmed the portion of the district court judgment affirming a portion of
the final agency decision. However, the court of appeals concluded the
district court erroneously interpreted section 85.27(4). Accordingly, the
court of appeals reversed the portion of the district court judgment
reversing the agency’s determination that Quality Egg was liable to
11
Ramirez-Trujillo for the expenses she incurred from May 2010 through
April 2011.
Both parties sought further review.
II. Scope of Review.
When this court grants an application for further review, we retain
discretion to review all the issues raised on appeal or in the application
for further review, or only a portion thereof. Gits Mfg. Co. v. Frank, 855
N.W.2d 195, 197 (Iowa 2014). In exercising this discretion, we choose to
review only the issue concerning the proper interpretation of Iowa Code
section 85.27(4). Accordingly, the court of appeals decision will stand as
the final decision to the extent it affirmed the district court judgment
affirming portions of the final decision of the workers’ compensation
commissioner.
The standards set forth in Iowa Code chapter 17A govern judicial
review of final decisions by the workers’ compensation commissioner.
Westling v. Hormel Foods Corp., 810 N.W.2d 247, 251 (Iowa 2012); see
Iowa Code § 17A.1(2). When the legislature has clearly vested authority
to interpret statutory language in an agency, we will defer to an agency
interpretation of that language. Renda v. Iowa Civil Rights Comm’n, 784
N.W.2d 8, 10–15 (Iowa 2010). Thus, when the legislature has clearly
vested the agency with interpretive authority, we will reverse an agency
decision only when its interpretation of statutory language is “irrational,
illogical, or wholly unjustifiable.” Coffey v. Mid Seven Transp. Co., 831
N.W.2d 81, 88 (Iowa 2013) (quoting NextEra Energy Res. LLC v. Iowa
Utils. Bd., 815 N.W.2d 30, 37 (Iowa 2012)); see Iowa Code § 17A.19(10)(l),
(11)(c). If the legislature did not clearly vest the agency with interpretive
authority, however, we review questions of statutory interpretation for
12
correction of errors at law. Westling, 810 N.W.2d at 251; see Iowa Code
§ 17A.19(10)(c), (11)(b).
In determining whether the legislature has clearly vested
interpretive authority in the workers’ compensation commissioner, we
consider the nature of the statutory language the agency has construed.
See Burton v. Hilltop Care Ctr., 813 N.W.2d 250, 256–57 (Iowa 2012).
When the legislature has not explicitly granted interpretive authority, we
must examine “the phrases or statutory provisions to be interpreted,
their context, the purpose of the statute, and other practical
considerations to determine whether the legislature intended to give
interpretive authority to an agency.” Clay County v. Pub. Emp’t Relations
Bd., 784 N.W.2d 1, 4 (Iowa 2010) (quoting Renda, 784 N.W.2d at 11–12).
We are more likely to conclude the legislature clearly vested
interpretive power in an agency when the agency necessarily must
interpret the statutory language at issue in carrying out its duties and no
relevant statutory definition applies. Renda, 784 N.W.2d at 12, 14. In
addition, when the statutory language at issue is a substantive term
within the special expertise of an agency, we generally conclude the
legislature has vested the agency with authority to interpret it. See
NextEra Energy, 815 N.W.2d at 37. Ultimately, however, we will defer to
an agency interpretation only when we are firmly convinced “the
legislature actually intended (or would have intended had it thought
about the question) to delegate to the agency interpretive power with the
binding force of law.” Renda, 784 N.W.2d at 14 (quoting Arthur E.
Bonfield, Amendments to Iowa Administrative Procedure Act, Report on
Selected Provisions to Iowa State Bar Association and Iowa State
Government 63 (1998)).
13
We have never before interpreted the statutory language at issue in
this appeal, though we have previously interpreted statutory language in
the same subsection of the Code. See, e.g., Bell Bros. Heating & Air
Conditioning v. Gwinn, 779 N.W.2d 193, 202–08 (Iowa 2010). Therefore,
we begin our analysis by determining whether the legislature clearly
vested the workers’ compensation commissioner with authority to
interpret the statutory language at issue. See, e.g., Gartner v. Iowa Dep't
of Pub. Health, 830 N.W.2d 335, 343 (Iowa 2013).
Iowa Code section 85.27(4) affords an employer who does not
contest the compensability of a workplace injury a qualified statutory
right to control the medical care provided to an injured employee. R.R.
Donnelly & Sons v. Barnett, 670 N.W.2d 190, 195, 197 (Iowa 2003). It
provides in relevant part,
For purposes of this section, the employer is obliged to
furnish reasonable services and supplies to treat an injured
employee, and has the right to choose the care. 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 the
change in authorization.
Iowa Code § 85.27(4) (emphasis added).
The legislature has not expressly vested the workers’ compensation
commissioner with authority to interpret the workers’ compensation
statutes in chapter 85. The fact the legislature has granted the
commissioner authority to adopt and enforce rules necessary to the
implementation of chapter 85 does not itself indicate the legislature has
clearly vested the commissioner with authority to interpret it. See
Roberts Dairy v. Billick, 861 N.W.2d 814, 817 (Iowa 2015).
Section 85.27(4) constitutes a bread-and-butter provision of the
workers’ compensation statute regularly administered by the
14
commissioner. The fact that an agency necessarily must interpret
statutory language in carrying out its duties provides a potential basis
for concluding the legislature clearly vested interpretive authority
therein. Renda, 784 N.W.2d at 12, 14. However, we have previously
declined to conclude the legislature clearly vested interpretive authority
in the workers’ compensation commissioner on this basis standing alone.
See Iowa Ins. Inst. v. Core Grp. of Iowa Ass’n for Justice, 867 N.W.2d 58,
65, 77 (Iowa 2015). In fact, we have declined to defer to the
commissioner’s interpretations of various provisions of chapter 85 in
recent years. Id. at 65. Moreover, section 85.27(4) contains no
substantive terms uniquely within the interpretive expertise of the
workers’ compensation commissioner.
On balance, we are not firmly convinced the legislature intended to
delegate authority to interpret section 85.27(4) to the workers’
compensation commissioner. See Renda, 784 N.W.2d at 14.
Accordingly, we will not defer to the commissioner’s interpretation of
section 85.27(4) and will substitute our own judgment for that of the
commissioner should we conclude the commissioner’s interpretation
rests on an error at law. See Iowa Code § 17A.19(11)(b); Renda, 784
N.W.2d at 14–15.
III. Analysis and Discussion.
When interpreting the statutory provisions contained in chapter 85
of the Iowa Code, our goal is to determine and effectuate the legislature’s
intent. United Fire & Cas. Co. v. St. Paul Fire & Marine Ins. Co., 677
N.W.2d 755, 759 (Iowa 2004). To determine legislative intent, we look to
the language chosen by the legislature and not what the legislature
might have said. Schadendorf v. Snap-On Tools Corp., 757 N.W.2d 330,
337 (Iowa 2008). Absent a statutory definition, we consider statutory
15
terms in the context in which they appear and give each its ordinary and
common meaning. Rojas v. Pine Ridge Farms, L.L.C., 779 N.W.2d 223,
235 (Iowa 2010). When reasonable persons could disagree as to what a
statute means, the meaning of the statute is ambiguous. Holstein Elec.
v. Breyfogle, 756 N.W.2d 812, 815 (Iowa 2008). Ambiguity may arise due
to uncertainty concerning the meaning of particular words or upon
examination of all the statute’s provisions together in context. Id.
When the meaning of the statute is ambiguous, we may consider
rules of statutory construction in our interpretive analysis. Id. We
assess the statute in its entirety rather than isolated words or phrases to
ensure our interpretation is harmonious with the statute as a whole.
Schadendorf, 757 N.W.2d at 337. Because we presume the legislature
included every part of the statute for a purpose, we avoid construing a
statutory provision in a manner that would make any portion thereof
redundant or irrelevant. Rojas, 779 N.W.2d at 231; see Iowa Code
§ 4.4(2). We also avoid construing statutory provisions in a manner that
will lead to absurd results. Iowa Ins. Inst., 867 N.W.2d at 75; see Iowa
Code §§ 4.4(3), .6(5).
The primary purpose of the workers’ compensation statute
contained in chapter 85 is to benefit the worker. Griffin Pipe Prods. Co. v.
Guarino, 663 N.W.2d 862, 865 (Iowa 2003). To this end, chapter 85
encourages employers to compensate employees who receive workplace
injuries promptly and provides a forum for efficient resolution of
workplace-injury claims with minimal litigation. See Des Moines Area
Reg’l Transit Auth. v. Young, 867 N.W.2d 839, 847 (Iowa 2015); Bell
Bros., 779 N.W.2d at 202; Flint v. City of Eldon, 191 Iowa 845, 847, 183
N.W. 344, 345 (1921).
16
In enacting the right-to-choose provision in section 85.27(4), our
legislature sought to balance the interests of injured employees against
the competing interests of their employers. Bell Bros., 779 N.W.2d at
202, 207; IBP, Inc. v. Harker, 633 N.W.2d 322, 326–27 (Iowa 2001). The
statute imposes an affirmative duty on employers who concede the
compensability of workplace injuries to furnish care to injured
employees. Bell Bros., 779 N.W.2d at 202. However, it also empowers
employers who fulfill this obligation “to substitute their judgment for that
of their injured employees on the important question of which medical
professionals are best suited to diagnose and treat work-related injuries.”
Baker v. Bridgestone, 872 N.W.2d 672, 678 (Iowa 2015); see R.R.
Donnelly, 670 N.W.2d at 195. In other words, the statute grants
employers a limited right to choose who provides the care to an injured
employee—a right that is modified by several statutory protections
afforded to employees. Bell Bros., 779 N.W.2d at 202–04.
Because our legislature sought to balance the interests of
employers and the interests of injured employees in enacting section
85.27(4), the right of employers to control care is not absolute. See
Baker, 872 N.W.2d at 678 n.3. Rather, an employer’s right to control
care is a limited or qualified right. R.R. Donnelly, 670 N.W.2d at 195,
197; W. Side Transp. v. Cordell, 601 N.W.2d 691, 693 (Iowa 1999); see
Bell Bros., 779 N.W.2d at 203–04. Thus, although the statute promotes
the prompt resolution of claims without litigation, it also anticipates that
workplace injuries can lead to disputes between employers and injured
employees. R.R. Donnelly, 670 N.W.2d at 195; see Bell Bros., 779 N.W.2d
at 204.
At issue in this appeal is the second sentence of section 85.27(4),
which provides,
17
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 the
change in authorization.
We must determine how the legislature intended this sentence to modify
the right of employers to choose care for injured employees.
The first half of the sentence provides an employer who chooses
the care an injured employee receives “shall hold the employee harmless
for the cost of care.” When the term “shall” appears in a statute, it
generally connotes the imposition of a mandatory duty. In re Marriage of
Thatcher, 864 N.W.2d 533, 539 (Iowa 2015); In re Det. of Fowler, 784
N.W.2d 184, 187 (Iowa 2010). Moreover, rules of statutory construction
set forth in the Iowa Code specify that in statutes enacted after July 1,
1971, the word “shall” imposes a duty unless otherwise specified by the
legislature. 5 Iowa Code § 4.1(30)(a). Absent any ambiguity in a statutory
definition, we are obligated to apply the statutory definition the
legislature adopted to explain a statutory term. Sherwin-Williams Co. v.
Iowa Dep’t of Revenue, 789 N.W.2d 417, 425 (Iowa 2010). Accordingly,
we interpret the plain language of section 85.27(4) to obligate employers
to hold employees harmless for authorized medical expenses.
The remainder of the sentence clarifies the scope of this obligation.
Namely, it provides an employer who chooses care for an injured
employee has a corresponding duty to “hold the employee harmless for
the cost of the care until the employer notifies the employee that the
5The legislature enacted the language in section 85.27(4) granting employers a
right to choose care in 1976. 1976 Iowa Acts ch. 1084, § 3 (codified in relevant part at
Iowa Code § 85.27 (1977)); Bell Bros., 779 N.W.2d at 202 n.1. The legislature enacted
the second sentence of section 85.27(4) in 2004. See 2004 Iowa Acts 1st Extraordinary
Sess. ch. 1001, § 9 (codified at Iowa Code § 85.27(4) (2005)).
18
employer is no longer authorizing all or any part of the care and the
reason for the change in authorization.” Iowa Code § 85.27(4). The
ordinary meaning of the word “until” is “up to the time that.” Webster’s
Third New International Dictionary 2513 (unabr. ed. 2002). Thus, section
85.27(4) 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.
Because section 85.27(4) obligates an employer to notify an
employee when it is no longer authorizing care, it also obligates an
employer to determine when it no longer wishes to authorize care. With
the power to choose the care comes the responsibility to monitor the care
for the purpose of determining when further care will no longer be
authorized. 6 An employer can easily reconsider whether it wishes to
authorize further care when an authorized medical provider indicates an
employee requires no further care for a workplace injury or when the
employer authorizes a new provider to take over an employee’s care.
Therefore, the employer’s statutory burden to monitor an injured
employee’s care is not an onerous one.
Section 85.27(4) balances this minimal burden with a significant
corresponding benefit—a means of extinguishing the employer’s ongoing
obligation to pay for medical expenses following its acknowledgment of
compensability and exercise of the right to choose care. Interpreting
6Though we conclude deference to the agency’s interpretation is not appropriate,
we note the commissioner previously reached the same conclusion in interpreting
section 85.27(4). See, e.g., Warner v. Alpha’s, Iowa Workers’ Comp. Comm’n No.
1269904, 2002 WL 32125384, at *6 (Sept. 9, 2002) (“An employer’s act of directing the
care and the claimant’s compliance with the employer’s directives binds defendants to
pay the cost of the care that it chose. Employers are under an obligation to monitor the
care they authorize and must pay for authorized care until the time they inform the
employee that they are withdrawing authorization.” (Citation omitted.)).
19
section 85.27(4) to reward an employer who monitors the care it
authorizes and communicates to the employee when it is no longer
authorizing care is consistent with our prior recognition that the
legislature sought to balance the interests of employees and employers in
enacting section 85.27(4). Bell Bros., 779 N.W.2d at 202, 207; IBP, 633
N.W.2d at 326–27.
On the one hand, section 85.27(4) protects the right of employers
to choose care in various ways. Once an employer’s right to control
medical care attaches under section 85.27(4), “it remains with the
employer under the statute until the employer denies the injury is work-
related, withdraws authorization of the care, or until the commissioner
orders alternative care.” Bell Bros., 779 N.W.2d at 207. An employer’s
denial of compensability leads to the loss of its right to choose care only
when it denies the claimed injury arose in the course and scope of
employment. Id. Thus, when an employer acknowledges the injury an
employee suffered is compensable, the employer does not forfeit its right
to choose care just because it disagrees with the employee as to the
nature or extent of the disability caused by the workplace injury. Id.
Even after a dispute arises concerning the compensability of a portion of
the injured employee’s ongoing care, the employer is entitled to control
ongoing care to treat injuries with respect to which it does not contest
compensability. See id. After an employer relieves an employee of the
burden of proving causation by acknowledging compensability and
authorizing care, the employer may reinstate that burden to the extent it
believes compensability is in doubt. See id. at 207–08.
On the other hand, section 85.27(4) safeguards the ability of
employees to make decisions regarding the course of the care they
receive. Nothing in the statute prevents an employee from obtaining
20
unauthorized care. See id. at 205; see also R.R. Donnelly, 670 N.W.2d at
197. In addition, nothing in the statute prevents an employee from
obtaining reimbursement for expenses incurred in seeking unauthorized
care upon an adjudication of compensability. 7 Bell Bros., 779 N.W.2d at
206. Rather, an employee generally may recover medical expenses
incurred in seeking unauthorized care upon proving by a preponderance
of the evidence the care was reasonable and beneficial under the totality
of the circumstances. Id. Moreover, when the employee believes the
employer has not offered care promptly or has offered care that is unduly
inconvenient or not reasonably suited to treat the injury sustained, the
employee may apply with the workers’ compensation commissioner for
approval to seek alternate care. 8 R.R. Donnelly, 670 N.W.2d at 196; W.
Side Transp., 601 N.W.2d at 693. Thus, the commissioner retains
authority to order the employer to pay for care chosen by the employee.
W. Side Transp., 601 N.W.2d at 693. Additionally, the statute instructs
7An employer may successfully assert a lack-of-authorization defense when an
employee seeks reimbursement for unauthorized care obtained after the workers’
compensation commissioner denies the employee’s application for alternate care on the
merits. Bell Bros., 779 N.W.2d at 205; R.R. Donnelly, 670 N.W.2d at 197–98.
8Notably, the commissioner has adopted two regulations that bolster our
conclusion an employee is entitled to be informed when an employer decides it will no
longer authorize care. First, the commissioner will not hear the parties on an
application for alternate care until the employee communicates the basis of his or her
dissatisfaction to the employer. See Iowa Admin. Code. r. 876—4.48(4), (8); see also
Iowa Code § 85.27(4) (stating an employee with reason to be dissatisfied with the care
offered “should communicate the basis of such dissatisfaction to the employer, in
writing if requested”). As a result, the employee cannot receive an order directing the
employer to pay for alternate care until he or she knows that care will be denied by the
employer. Second, the commissioner will dismiss an application for alternate care if the
employer denies the condition for which care is sought is compensable. R.R. Donnelly,
670 N.W.2d at 196, 197; see Iowa Admin. Code r. 876—4.48(7). Thus, an employee
needs to know whether to apply for alternate care or seek adjudication on
compensability in order to avoid delayed reimbursement for expenses incurred in
seeking care.
21
the commissioner to issue decisions on applications for alternate care
within ten to fourteen days of their receipt. Iowa Code § 85.27(4).
As the foregoing overview makes clear, section 85.27(4) does not
require employees to prove medical causation in order to establish
employer liability for authorized medical expenses. 9 Rather, under
section 85.27(4), an employer obtains the right to choose care only by
conceding the compensability of the claimed injury. Bell Bros., 779
N.W.2d at 207. That means before the employer chooses care and
authorizes it, the employer must concede the claimed injury arose in the
course and scope of employment. See Lakeside Casino v. Blue, 743
N.W.2d 169, 173 (Iowa 2007) (explaining that a compensable injury
requires a connection between the injury and employment, which “is
established by showing the injury arose out of and in the course of the
worker’s employment”). To interpret section 85.27(4) to require an
employee seeking payment of authorized medical expenses to prove
compensability after the employer has conceded compensibility would
upset the delicate balance of employer and employee protections the
legislature sought to achieve in enacting section 85.27(4). To do so
would undermine the concept of authorized care and subject employees
to retroactive liability for care they did not choose. 10 See Iowa Ins. Inst.,
9We note this conclusion is consistent with prior interpretations of section
85.27(4) by the commissioner. See Warner, 2002 WL 32125384, at *6 (“When an
employer chooses the care it must pay for the care it chose, even if it later learns that it
might not have been liable for that care if it had not directed the care.”).
10We have never considered the question of whether section 85.27(4) requires an
employee to prove compensability of the condition for which treatment was sought to
establish an entitlement to reimbursement of authorized medical expenses. We once
reinstated a ruling by the commissioner disallowing medical expenses because “the
claimant had failed to present sufficient evidence to prove a causal connection between
the conditions which were the subject of the treatment and the claimant’s work-related
injury.” Auxier v. Woodward State Hosp.-Sch., 266 N.W.2d 139, 144 (Iowa 1978).
However, we did so because the trial court erroneously determined the claimant had
22
867 N.W.2d at 75 (“We have long recognized that statutes should not be
interpreted in a manner that leads to absurd results.”); see also Iowa
Code § 4.4(3) (stating it is presumed the legislature intends statutes to
effect just and reasonable results); id. § 4.6(5) (indicating a court may
consider consequences in construing an ambiguous statute).
Conversely, it is apparent from the language of the statute the
employer generally must choose the care as a precondition to being
responsible for its costs. The operative phrase is “chooses the care,” not
“has chosen the same provider at some time in the past.” Furthermore,
the second sentence of subsection (4) must be read together with the first
sentence, which states, “For purposes of this section, the employer . . .
has the right to choose the care.” Iowa Code § 85.27(4). Thus, the
choice of care referenced in the second sentence of section 85.27(4) is a
choice for purposes of the entire section—namely, section 85.27. And
the overall purpose of the section is the treatment of “injuries
compensable under [chapter 85].” Id. § 85.27(1). This further highlights
that employer liability in section 85.27(4) is premised upon an employer’s
_____________________
established a causal connection between the conditions treated and the workplace
injury as a matter of law. See id. In that case, we did not consider whether section
85.27(4) requires reimbursement of authorized medical expenses not causally
connected to a workplace injury. See id. Because that question was not actually
presented and decided in Auxier, we do not treat that case as controlling.
The commissioner’s interpretation of the statute on this question is not entitled
to deference. See Iowa Code § 17A.19(11)(b). Nonetheless, we note the commissioner
no longer interprets section 85.27(4) to require an employee to demonstrate authorized
medical expenses were causally connected to the workplace injury to establish an
entitlement to reimbursement. See, e.g., Norton v. Leonard Express, Inc., Iowa Workers’
Comp. Comm’n No. 5027578, 2013 WL 482726, at *2 (Jan. 23, 2013) (“Employer[s]
must pay for the care they authorize, even if that care was later on determined
unrelated to the work injury.”); Lenzini v. Des Moines Area Cmty. Coll., Iowa Workers’
Comp. Comm’n No. 5002823, 2003 WL 22513678, at *5 (Oct. 29, 2003) (“When an
employer chooses the care it must pay for the care it chose, even if it later learns that it
might not have been liable for that care if it had not directed the care.”).
23
choice of care for a particular injury. Under the plain statutory language
of section 85.27(4), it is not enough that the employee happened to show
up for treatment at a health care provider to which the employer had
referred the employee in the past.
Similarly, interpreting section 85.27(4) to impose liability on
employers for any medical care an employee receives from an authorized
medical provider would lead to absurd results. As we recently stated:
We have long recognized that statutes should not be
interpreted in a manner that leads to absurd results. In
order to apply this well-established rule, we sometimes
consider fact patterns other than the one before the court to
determine if a particular statutory interpretation would have
untoward consequences. That is part of the judicial
function—to consider alternative statutory interpretations
and see where those alternatives logically lead.
Iowa Ins. Inst., 867 N.W.2d at 75–76 (citations omitted); see Iowa Code
§§ 4.4(3), .6(5). Undoubtedly, the legislature did not intend an employer
who acknowledged the compensability of a foot injury to be liable for
expenses the employee incurred after getting the flu merely because the
employee sought care at an authorized medical center.
Interpreting section 85.27(4) to require such a result would
discourage employers from authorizing care for fear of incurring liability
for conditions clearly unrelated to the workplace. For example,
employers would be discouraged from authorizing care to a medical
facility as opposed to an individual specialist in order to avoid liability for
treatment the employee receives for unrelated conditions. It is unlikely
the legislature intended that result, as employees retain the ability to
exercise some degree of choice concerning who will treat their injuries
when their employers authorize care from medical facilities rather than
individual medical providers.
24
To illustrate, we note the provider at issue here is the Wright
Medical Center located in Clarion, Iowa, the county seat of Wright
County. The record does not indicate whether there are any other health
care facilities or individual health care providers in Wright County, but
clearly Wright Medical Center offers a wide array of services. From
reviewing the medical records, we know it has an emergency room, a
rehabilitation department, a family practice clinic, a specialty clinic,
hospital beds, and facilities for surgeries and births. Undoubtedly,
Quality Egg did not intend to bind itself to pay for any care Ramirez-
Trujillo might receive at Wright Medical Center merely by authorizing her
to seek care for her work injury at that facility.
Consequently, we conclude 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 and upon which the employee’s
claim for workers’ compensation benefits is based. 11
Here, Quality Egg produced no evidence to suggest Ramirez-
Trujillo did not incur the expenses she claimed seeking treatment for a
back condition. In fact, Quality Egg conceded the medical expenses
Ramirez-Trujillo incurred were at least causally connected to the medical
condition upon which her claim of injury was based. Accordingly, under
the foregoing analysis, it remains unclear whether Quality Egg was
11We previously determined section 85.27(4) implicitly limits employer liability
for unauthorized care. See Bell Bros., 779 N.W.2d at 206 (indicating an employee may
generally recover medical expenses incurred in seeking unauthorized care upon proving
by a preponderance of the evidence that such care was reasonable and beneficial under
the totality of the circumstances). Because it would be unfair to impose the cost of care
the employer chose on the employee merely because it was not reasonable or turned out
not to be beneficial, we do not interpret section 85.27(4) to implicitly limit employer
liability for authorized care in precisely the same manner.
25
required to hold Ramirez-Trujillo harmless for care she received from
May 2010 through April 2011. This is because Quality Egg produced no
evidence to show it notified Ramirez-Trujillo that it was not authorizing
further care.
In essence, Quality Egg disputes the care Ramirez-Trujillo received
from May 2010 through April 2011 was authorized care, even though it
concedes it initially authorized her to seek care in the aftermath of her
workplace injury. 12 Thus, Quality Egg argues a second limiting principle
constrains employer liability for authorized care under section 85.27(4).
Specifically, Quality Egg suggests an employer need only notify the
employee it is no longer authorizing care to relieve itself of liability when
a reasonable employer would know the injured worker continues to seek
care. Quality Egg thus argues the statute imposes an obligation on
employees to make sure care authorizations are still in force before
seeking further care.
We disagree. Section 85.27(4) contains no language to suggest the
legislature intended to obligate employees to make sure care
authorizations remain in force before accepting care. Rather, the plain
language of the statute obligates employers who authorize care for
workplace injuries. Namely, an employer who authorizes care must pay
for the cost of care until the employer notifies the employee it is no longer
authorizing care. For purposes of determining whether an employer is
liable for the cost of care an employee received after the employer
authorized care for a workplace injury and failed to notify the employee it
12The statute requires an employer to hold an employee harmless for the cost of
authorized care until it notifies the employee it is no longer authorizing care, but it does
not indicate that care remains authorized until the employer notifies the employee it is
no longer authorizing care. See Iowa Code § 85.27(4).
26
was not authorizing further care, it is irrelevant that the employer did
not intend its authorization to remain in effect. 13
Importantly, nothing in the language of section 85.27(4) suggests
employees have a duty to investigate or a duty to inquire as to whether
an authorization remains in effect before seeking care. To conclude the
statute imposes such a duty on employees when the language of the
statute clearly imposes a duty on employers would be inconsistent with
our longstanding practice of construing chapter 85 liberally in favor of
employees. See Griffin Pipe Prods., 663 N.W.2d at 865. The legislature
did not intend employees to fear they might have to pay for care they did
not choose merely because they accept it. Interpreting section 85.27(4)
to impose a continuing obligation on employees to make sure the
employer still authorizes care before accepting it would turn the statute
on its head.
However, that does not mean the statute permits an employee to
take advantage of an employer by seeking compensation after the fact for
care the employee knew or should have known was not within the scope
of the employer’s prior authorization. Section 85.27(4) seeks to protect
the employer who acknowledges an injury arose in the course and scope
of employment and honors its obligation to “furnish reasonable services
and supplies to treat an injured employee.” Iowa Code § 85.27(4). We
simply do not believe section 85.27(4) requires an employer to notify an
employee it is no longer authorizing care when the employee knows or
reasonably should know the care sought is for a condition unrelated to a
compensable workplace injury or the prior authorization is no longer in
13We agree with the commissioner an employer “cannot revoke authorization
retroactively to avoid liability for expenses previously incurred.” Warner, 2002
WL 32125384, at *6.
27
effect. See Iowa Ins. Inst., 867 N.W.2d at 75–76; see also Iowa Code
§§ 4.4(3), .6(5).
Accordingly, we conclude an employer may establish it is not liable
for the cost of care an employee received from an authorized medical
provider 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 benefits is based or that the
employer no longer authorized the care the employee received at the time
the employee received it. With respect to the latter alternative, the
determinative question is whether the totality of the circumstances
indicates the employee knew or should have known the employer no
longer authorized the care the employee received, not whether the
employee believed the care was compensable when the employee received
it. An employer may avoid liability by showing the employer gave the
employee actual notice of a change in authorization as required by
section 85.27(4). 14 Alternatively, the employer may prove the employee
had knowledge of facts and circumstances that would have led a
reasonable employee to conclude the employer was no longer authorizing
care for the claimed injury. 15
14In
other words, the employer may disprove liability by showing it notified the
employee that the employer was “no longer authorizing all or any part of the care and
the reason for the change in authorization.” Iowa Code § 85.27(4).
15Of course, if it turns out the care was related to a workplace injury, the
employer must pay for care regardless of what the employee knew or should have
known at the time unless the employer proves it notified the employee of a change in
authorization. Employer liability for authorized care does not turn on the beliefs of the
employee. Warner, 2002 WL 32125384, at *6 (“It is unreasonable to expect a claimant
to have the medical expertise necessary to decide whether to accept the care directed by
the employer upon the chance the employer might later deny liability for the condition
being treated. Lay persons, such as claimant, are not competent to testify on the issue
28
We caution that the outcome under this test does not rely on the
concepts of constructive knowledge or constructive notice because
section 85.27(4) imposes no duty of knowledge on employees. See
Knowledge, Black’s Law Dictionary (10th ed. 2014) (defining
“constructive knowledge”); Notice, Black’s Law Dictionary (defining
“constructive notice”). Likewise, it does not rely on the concepts of
implied knowledge, implied notice, or inquiry notice because section
85.27(4) imposes no duty of inquiry on employees. See Knowledge,
Black’s Law Dictionary (defining “implied actual knowledge”); Notice,
Black’s Law Dictionary (defining “implied notice” and “inquiry notice”).
In addition, we caution that the test we now adopt to determine
employer liability for authorized medical expenses under section 85.27(4)
does not turn on the subjective beliefs an employee holds with respect to
compensability or medical causation. 16 Rather, it is an objective test.
This distinction is important because employees are ordinarily
laypersons without the expertise necessary to make accurate
determinations regarding medical causation. See Bradshaw v. Iowa
Methodist Hosp., 251 Iowa 375, 383, 101 N.W.2d 167, 171 (1960). We
long ago recognized that medical causation “is a question with respect to
which only a medical expert can express an intelligent opinion.” Id.
Thus, an employee’s subjective beliefs concerning the cause of a medical
condition or the compensability of expenses incurred are ordinarily
_____________________
of medical causation because they lack competency to do so. They are no more
competent when they are receiving the care than when testifying.”).
16This conclusion arguably follows from the fact that employer liability for
authorized care does not turn on the compensability of the injury. As the commissioner
has recognized, it would be unreasonable for employer liability to turn on the beliefs of
the employee. Warner, 2002 WL 32125384, at *6.
29
incompetent to prove or disprove compensability or medical causation.17
See Cedar Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa
2011); Bradshaw, 251 Iowa at 383, 101 N.W.2d at 171. Moreover, in the
context of determining whether an employer is liable for authorized care,
compensability and medical causation are not even at issue in a claim for
reimbursement. 18
We conclude an employer may prove it is not liable for the cost of
care an employee received from an authorized medical provider despite
the employer’s failure to give the notice section 85.27(4) requires under
limited circumstances. However, when an employer seeks to avoid
liability for care an employee received from an authorized provider and
cannot prove it notified an employee it was not authorizing further care
from that provider, the employer bears the burden of proving by a
preponderance of evidence the employee knew or reasonably should have
known either that the care the employee received was unrelated to the
medical condition or conditions upon which the employee’s claim for
17It is irrelevant whether the employee’s subjective belief was based on
statements made by a medical professional. As the evidence before the hearing deputy
in this case demonstrates and the commissioner surely knows, medical professionals
often arrive at conflicting conclusions regarding medical causation. See Warner, 2002
WL 32125384, at *6 (“Medical experts commonly disagree as to the cause of a condition
and an injured claimant cannot be held to know when to accept and when to reject the
care the employer’s physicians offer.”). Generally, an expert opinion regarding medical
causation is not determinative in a claim for workers’ compensation benefits. See
Cedar Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa 2011). Rather, it is
within the province of the commissioner to accept or reject an expert opinion. Id.
18Employee statements indicating an employee subjectively believed the
employer was no longer authorizing further care are relevant to determining whether
the employee knew the employer was no longer authorizing care he or she received.
However, because the overarching purpose of the workers’ compensation statute is to
protect workers, ambiguous statements should be construed as statements concerning
causation or compensability and not as statements concerning the effectiveness of a
prior authorization for care unless circumstances clearly suggest the latter
interpretation is more appropriate. Employees are generally lay persons not familiar
with the legal standards applied in assessing their workers’ compensation claims.
30
workers’ compensation benefits is based or that the employer no longer
authorized the care the employee received at the time the employee
received it.
In determining whether the employer has proven by a
preponderance of evidence the employee knew or reasonably should have
known it no longer authorized the care the employee received at the time
the employee received it, the commissioner shall consider the following
facts and circumstances: (1) the method in which the employer
communicated to the employee that care was authorized throughout the
period during which the employer concedes care was authorized; (2) the
actual communications between the employer and employee throughout
that period and thereafter concerning the injury, the care, and the costs
of the care; (3) any communications between the employee and medical
providers; (4) how much time passed between the date the employer
authorized care 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 the employee received, including the overall course of
the care and the frequency with which the employee sought or received
care throughout the period during which the employer concedes care was
authorized and thereafter; and (7) any other matters shown by the
evidence to bear on what the employee knew or did not know with
respect to the question of whether the employer authorized the care
sought when the employee received it. If the employer proves the
employee knew or reasonably should have known the employer did not
authorize further care when he or she received care from a previously
authorized provider, the employer is not liable for the cost of the
unauthorized care.
31
Our resolution of the statutory interpretation issue in this case
protects the interests of both employers and employees and honors the
legislature’s intent in enacting and amending section 85.27(4). By
construing section 85.27(4) to avoid potential due process problems that
could arise when an employee is denied reimbursement of medical
expenses without notice from the employer, our interpretation of section
85.27(4) is also consistent with the principle of constitutional avoidance.
See Auxier v. Woodward State Hosp.-Sch., 266 N.W.2d 139, 142 (Iowa
1978) (concluding a claimant’s interest in workers’ compensation
benefits constitutes a property right an employer cannot terminate
without prior notice).
The commissioner made no findings of fact that would permit us to
assess whether Ramirez-Trujillo knew or reasonably should have known
Quality Egg no longer authorized further care by Wright Medical Center
for her back injury when she sought and received care from May 2010
through April 2011. Therefore, remand is appropriate because we are
unable to determine from this record whether Quality Egg is liable for the
medical expenses Ramirez-Trujillo incurred during this period under our
interpretation of section 85.27(4). On remand, the commissioner should
find the facts necessary to determine whether Quality Egg proved by a
preponderance of the evidence that Ramirez-Trujillo knew or reasonably
should have known Quality Egg no longer authorized further care for her
back injury when she incurred the disputed medical expenses. If the
commissioner allows further testimony, the commissioner may properly
limit that testimony to matters as to which each witness has not
previously testified. Winnebago Indus. v. Smith, 548 N.W.2d 582, 584
(Iowa 1996).
32
IV. Disposition.
We affirm in part the decisions of the court of appeals and the
district court. The court of appeals decision stands as the final decision
of this court to the extent it affirmed the district court decision affirming
in part the final agency decision. We reverse in part the district court
judgment and remand the case to the district court with instructions to
remand the case to the commissioner for further proceedings consistent
with this opinion.
DECISION OF COURT OF APPEALS AFFIRMED IN PART AND
VACATED IN PART; DISTRICT COURT JUDGMENT AFFIRMED IN
PART AND REVERSED IN PART; CASE REMANDED WITH
INSTRUCTIONS.
All justices concur except Hecht, J., who dissents.
33
#14–0640, Ramirez-Trujillo v. Quality Egg
HECHT, Justice (dissenting).
Although the standard devised by the majority for determining
whether an employer authorized medical care could have been adopted
by the legislature, I do not believe it was. Accordingly, I respectfully
dissent.
In relevant part, section 85.27(4) provides:
For purposes of this section, the employer is obliged to
furnish reasonable services and supplies to treat an injured
employee, and has the right to choose the care. 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 the
change in authorization. An employer is not liable for the
cost of care that the employer arranges in response to a
sudden emergency if the employee’s condition, for which care
was arranged, is not related to the employment.
Iowa Code § 85.27(4) (2009) (emphasis added).
The majority concludes this statute is ambiguous. It is not. If the
“statutory language is plain and its meaning clear, ‘we do not search for
legislative intent beyond the express terms of the statute.’ ” Denison
Mun. Utils. v. Iowa Workers’ Comp. Comm’r, 857 N.W.2d 230, 235 (Iowa
2014) (quoting State Pub. Defender v. Iowa Dist. Ct., 663 N.W.2d 413,
415 (Iowa 2003)).
As the majority correctly observes, it is well established that an
employer “has the right to choose the care” for work-related injuries.
Iowa Code § 85.27(4). This right to choose the care refers to an
employer’s power to designate which provider(s) of medical care will be
authorized to treat the employee’s injury. See id. Such control comes at
a price. First, employers choosing providers of care generally concede
34
their employees’ injuries are compensable. 19 See Bell Bros. Heating & Air
Conditioning v. Gwinn, 779 N.W.2d 193, 202 (Iowa 2010) (noting
employers receive the right to choose care “[o]nce compensability is
acknowledged”); 15 James R. Lawyer, Iowa Practice Series: Workers’
Compensation § 15:2, at 199 (2015) [hereinafter Lawyer] (“If the employer
denies the compensability of an injury under the act, it cannot . . . seek
to guide the care.”). Second, employers hold their employees harmless
for the cost of the care provided by the chosen providers. Iowa Code
§ 85.27(4); 15 Lawyer § 15:2, at 198–99.
Employers have significant power in the process of furnishing
medical services as they select who shall be authorized providers.
Employers can confer authorization of care by a provider; they can also
reasonably terminate it. Authorization lasts “until the employer notifies
the employee that the employer is no longer authorizing all or any part of
the care and the reason for the change in authorization.” Iowa Code
§ 85.27(4). The notice of a change in authorization does not conclusively
cut off the employer’s obligation to furnish medical services under
section 85.27(1); it does, however, oblige the injured employee to prove
medical causation as to any services obtained from unauthorized
providers for treatment of a work-related injury. 15 Lawyer § 15:2, at
199 (noting the employer’s obligation to provide medical services under
section 85.27 extends to unauthorized medical care that “is beneficial in
improving the worker’s condition”). The commissioner applied the clear
language of section 85.27(4) and concluded Quality Egg is obligated to
pay for medical expenses Ramirez-Trujillo incurred for treatment by the
19Compensable injuries are those arising in the course and scope of
employment. Iowa Code § 85.3(1).
35
authorized provider after September 2009 because Quality Egg failed to
notify Ramirez-Trujillo that further treatment by that provider was not
authorized. In this instance, I believe the commissioner correctly applied
the statute.
The majority fashions a new standard for determining whether an
employer’s authorization of care can terminate notwithstanding the
employer’s failure to notify their injured employee of the termination.
The new standard is problematic because it is not found within section
85.27(4). The statute is not ambiguous, so we need not apply rules of
interpretation or develop new standards to divine its meaning. Section
85.27(4) expressly confers upon employers the right to “choose the care”
and prescribes the consequences of an employer’s choice of medical care
for the employee. Iowa Code § 85.27(4). Among the consequences is the
employer’s obligation to hold employees harmless for the cost of services
supplied by authorized providers. Id.
The legislature expressly prescribed only one safe harbor in which
the employer’s choice of care does not result in a concession of
compensability: “An employer is not liable for the cost of care that the
employer arranges in response to a sudden emergency if the employee’s
condition, for which care was arranged, is not related to the
employment.” Id. The unmistakable rationale for this safe harbor is that
in emergent scenarios, employers do not have time to assess whether the
injury or condition for which treatment is urgently needed arose out of
and in the course of employment. Notably, Quality Egg makes no claim
in this case that its authorization of the Wright Medical Center as a
provider was granted in a sudden emergency.
Section 85.27(4) expressly exempts employers from their statutory
duty to hold employees harmless from the cost of medical services
36
provided by authorized providers if employers give their employees notice
that the authorization is terminated or changed. Id. Under the clear
meaning of the statute, the employer’s authorization of care for treatment
of a compensable injury continues until the employer gives the employee
notice of a change. The majority’s new standard announces that an
employer’s notice terminating or changing authorization is not the only
means of terminating authorization and avoiding the duty to hold the
employee harmless. Under the new standard, employers can now avoid
the consequences of choosing care—even if they fail to give the statutory
notice—by proving the employee knew or should have known the care
was beyond the scope or duration of the employer’s authorization.
The majority’s new standard allowing employers to avoid the
consequences of choosing care without giving notice as contemplated in
section 85.27(4) is problematic for several reasons. First, it is
incompatible with the clear language of the statute indicating a provider
is authorized until notice to the contrary is given. Second, I think the
new standard will create confusion and uncertainty among parties in
workers’ compensation cases about whether medical care is authorized.
Confusion and uncertainty will spawn more litigation—an untoward
consequence for a workers’ compensation system intended to be simple,
quick, and inexpensive. See, e.g., Baker v. Bridgestone/Firestone, 872
N.W.2d 672, 677 (Iowa 2015); Morrison v. Century Eng’g, 434 N.W.2d
874, 877 (Iowa 1989); Flint v. City of Eldon, 191 Iowa 845, 847, 183 N.W.
344, 345 (1921). In place of the former predictable bright-line rule
allocating to employers liability for medical care provided by authorized
providers for work-related injuries until the authorization is withdrawn
by notice, the majority’s new standard encourages additional fact-based
inquiries about what the employee knew about the scope and duration of
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a provider’s authorization and when she knew it. Employers will be
motivated to litigate whether injured employees knew or should have
known the care provided was for a condition outside the scope of the
employer’s authorization, or whether employees knew or should have
known the authorization had expired under the circumstances even if
the employer gave no notice of expiration as contemplated in section
85.27(4). Litigating these questions will make workers’ compensation
proceedings slower and more expensive as lawyers and fact-finders
scrutinize the often complex factual circumstances addressed in the
standard’s numerous factors. As with any multi-factored standard, fact-
based outcomes will be more unpredictable than outcomes produced by
the commissioner’s bright-line rule. See United States v. Mead Corp., 533
U.S. 218, 241, 121 S. Ct. 2164, 2178, 150 L. Ed. 2d 292, 312 (2001)
(Scalia, J., dissenting) (criticizing “th’ol’ ‘totality of the circumstances’
test” because it thwarts predictability and hampers “litigants who want
to know what to expect”). With due respect, the clear language of the
statute and its bright-line allocation of responsibility for care provided by
authorized providers prior to notice of a change is far superior to (and far
simpler than) the majority’s new unwieldy standard.
I agree completely with the majority’s conclusion that employees
are not generally equipped to assess whether the condition for which
they consult an authorized provider is attributable to a work-related
injury. I am convinced this very understanding informed the legislature’s
choice of a bright-line rule allocating liability to employers the cost of
care provided by those they choose until employers give notice of the
withdrawal or change of the provider’s authorization. Iowa Code
§ 85.27(4) (“[T]he employer shall hold the employee harmless for the cost
of care until the employer notifies the employee that the employer is no
38
longer authorizing all or any part of the care and the reason for the
change in authorization.”).
The majority designs the new standard to remedy unfairness it
perceives in the risk that an employer might be required to pay for
medical services provided by an authorized provider for a condition
ultimately found not to have been causally connected to a compensable
injury. But this risk is one the legislature built into the system as part of
the delicate balance between the interests of injured employees and their
employers in workers’ compensation cases. Bell Bros., 779 N.W.2d at
207 (“[T]he overall approach of section 85.27(4) [is] to balance the control
given to the employer with safeguards for the employee.”); see also Baker,
872 N.W.2d at 676–77 (describing the “series of tradeoffs” inherent in the
workers’ compensation system). Employers receive the opportunity to
control the care under section 85.27(4). The price of this opportunity for
control, as I have suggested above, includes employers’ concessions of
(1) the causal connection between the employment and the injury, and
(2) medical causation—medical treatment reasonable in amount and
necessary to treat the compensable injury. See Bell Bros., 779 N.W.2d at
202.
I acknowledge the commissioner’s decision in this case presents an
instance in which an employer paid a price for its decision to control the
medical care. The commissioner’s decision held Quality Egg liable for
some medical expenses the commissioner ultimately found causally
unrelated to the compensable injury Ramirez-Trujillo sustained in
August 2009. 20 The rationale for the commissioner’s decision was based
20All of the disputed medical expenses were for treatment of Ramirez-Trujillo’s
back pain, not some part of the anatomy unaffected by the work-related injury. The
legislature’s bright-line hold harmless rule did not impose on Ramirez-Trujillo the
39
on Quality Egg’s failure to give notice under section 85.27(4) that it had
terminated the care provider’s authority to treat Ramirez-Trujillo’s back.
In my view, the majority’s newly-conceived multifactored standard for
limiting the scope and duration of Quality Egg’s authorization disrupts
the balance of interests set by the legislature. The balance prescribed by
the legislature afforded Quality Egg the opportunity to terminate its
provider’s authority to provide services by giving a simple notice to
Ramirez-Trujillo. By giving such a notice, Quality Egg could have shifted
the burden of proving medical causation back to Ramirez-Trujillo. But it
failed to give the notice, and the Commissioner therefore correctly
ordered that Ramirez-Trujillo be held harmless for the cost of the care.
Employers’ responsibility to hold injured employees harmless for
care provided by authorized providers absent a termination notice—a
feature of the delicate balance between the competing interests of
employers and employees—does not impose an onerous burden. After
choosing the care for injured employees, employers and their insurers
routinely and regularly monitor the care through full access to medical
records and information. 21 Armed with detailed information about their
authorized providers’ services and their employees’ responses to
treatment, employers are well-equipped to meet the responsibilities
assigned to them under section 85.27(1) and protect their interests
_____________________
burden of sorting out before seeking treatment from the authorized provider whether
the back pain she experienced after September 30, 2009, was causally related to the
2009 injury or some other unrelated activity such as scooping snow. The legislature
reasonably, in my view, concluded such complex determinations are typically beyond
the ken of lay people and are best left to medical experts. In short, the hold harmless
obligation worked quite sensibly under the circumstances presented in this case.
21The employee or claimant making a claim for benefits must release “all
information . . . concerning [their] physical or mental condition relative to the claim.”
Iowa Code § 85.27(2).
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under section 85.27(4). Because they control the care under the
statutory scheme, employers are readily able to give employees notice of
“change[s] in authorization” when the employer chooses. Iowa Code
§ 85.27(4). This means of changing employers’ authorizations of care
renders the majority’s multifactored standard completely unnecessary.
In this case, Quality Egg could easily have withdrawn Wright Medical
Center’s authority to treat Ramirez-Trujillo’s back at Quality Egg’s
expense in September 2009 when Ramirez-Trujillo was discharged from
care, or in December 2009 when she returned to the provider with
complaints arising after she shoveled snow—but it did not.
Because I believe the majority’s new standard is unsupported by
the clear language of section 85.27(4) and likely to create confusion and
spawn more litigation, I would affirm the court of appeals decision and
the commissioner’s application of the statute.