Knowlton v. WOOD RIVER MEDICAL CENTER

                IN THE SUPREME COURT OF THE STATE OF IDAHO

                                      Docket No. 37360

                                         )
LESIA KNOWLTON,                          )
                                         )
    Claimant/Appellant/Cross-Respondent, )
                                         )
                                                           Boise, May 2011 Term
v.                                       )
                                         )
                                                           2011 Opinion No. 62
WOOD RIVER MEDICAL CENTER,               )
Employer; FREMONT COMPENSATION           )
                                                           Filed: May 26, 2011
INSURANCE COMPANY, Surety; and           )
IDAHO INSURANCE GUARANTY                 )
                                                           Stephen W. Kenyon, Clerk
ASSOCIATION, Party of Interest,          )
                                         )
    Defendants/Respondents/Cross-        )
   Appellants.                           )
_______________________________________ )

       Appeal from the Industrial Commission of the State of Idaho.

       The decision of the Industrial Commission is affirmed.

       Troupis Law Office, P.A., Eagle, and R. Brad Masingill, Weiser, for appellant.
       Christ T. Troupis argued.

       Anderson Julian & Hull, LLP, Boise, for respondents. Matthew O. Pappas argued.
                                 _____________________


J. JONES, Justice.
       Lesia Knowlton appeals the Industrial Commission’s determination that she is not
entitled to workers’ compensation benefits because she failed to demonstrate that her medical
symptoms were causally related to an accident that occurred during the course of her
employment. We affirm.
                                            I.
                            Factual and Procedural Background
       During all times relevant to this appeal, Lesia Knowlton was employed as a unit secretary
at Wood River Medical Center. On September 12, 2000, Knowlton was working at her assigned
station when a toilet or bathroom floor drain in a patient’s room became clogged. The patient’s

                                               1
room was located near the area where Knowlton was working. One of the maintenance workers at
the hospital used a chemical to remedy the problem. The chemical produced a foul odor, which
Knowlton described as an “orange citrusy” smell. In an effort to ventilate 1 the patient’s room, the
hospital staff placed a fan in the doorway of the room, which blew air past Knowlton’s station until
her shift ended at approximately 4:00 p.m. 2 After several people complained about the odor, the
director of nurses and the infection control nurse decided to move the patient from the room where
the chemical was used to a different room in the hospital. According to Knowlton, the odor got
stronger as the day went on, and she began smelling an odor resembling “rotten eggs” coming from
the kitchen. Kitchen personnel informed her that the smell was coming from the drains. Knowlton
developed a headache as a result of breathing the odor.
        After returning home after her shift ended, Knowlton developed a cough and body aches.
The following day, Knowlton had to leave work around lunchtime because her symptoms had
worsened. Knowlton was only able to work a partial shift on September 14. On September 15,
three days after the incident, Knowlton sought medical treatment from Laria Thomas, a nurse
practitioner. During this visit, Knowlton reported that she was experiencing a cough, a sore throat,
and burning when she would breathe. Knowlton was prescribed antibiotics, cough syrup, and an
inhaler. A chest x-ray taken on a follow-up visit with Thomas was normal.
        Knowlton returned to work on September 18, and was told that the chemical used on the
day of the incident contained sulfuric acid. 3 The following day, Knowlton filled out and signed a
Form 1 Report of Injury or Illness.
         Knowlton visited Dr. Thomas Pryor on September 25. Dr. Pryor’s notes from the visit
indicate that Knowlton had a cough and bronchitis-like sounds in her lungs. During a follow-up
visit on September 28, Knowlton complained of a sore throat and a sore chest from coughing. Dr.
Pryor also noted that her sinuses were inflamed, and provided her with a release from work. By
October 4, Dr. Pryor noted that the sinus inflammation had “improved profoundly.” On the same

1
  Knowlton testified that there was no central air conditioning in the area in which she was working, and the area
was not well-ventilated.
2
  Knowlton initially testified during her deposition that she worked from 8:00 a.m. until 11:30 p.m. However, after
reviewing documents prior to the hearing, she determined that she had worked from 8:00 a.m. until approximately
4:00 p.m.
3
  Knowlton testified that she learned this information from Jody Alverson, the infection control nurse. Knowlton
also testified that her former attorney was given a Material Safety Data Sheet for a drain cleaner called Biatron
United 77. Although it was never conclusively determined precisely to what chemical Knowlton was exposed, the
parties proceeded under the assumption that Knowlton was likely exposed to sulfuric acid.

                                                        2
day, nurse practitioner Thomas also provided Knowlton with a release from work retroactive to the
day of the incident. The next day, Knowlton phoned Thomas and reported that she had another
negative reaction after being exposed to other cleaners at work.
        On October 13, on the advice of Dr. Pryor, Knowlton visited Dr. Ronald Fullmer, a
pulmonologist. During this visit, Knowlton complained of shortness of breath and hoarseness.
Knowlton also complained that her symptoms increased when exposed to animals, cold air, smoke,
and perfume. Dr. Fullmer recognized some vocal distortion, but mentioned that it became more
normal when she was not speaking about her initial exposure to the chemical. Dr. Fullmer’s
examination indicated that Knowlton’s head, eyes, ears, nose, and throat were normal. A medical
history taken during that visit indicated that Knowlton had been smoking cigarettes for “less than
one year.” According to Knowlton, she smoked prior to the chemical exposure but quit after the
incident.
        On October 25, nurse practitioner Thomas prescribed Wellbutrin at Knowlton’s request to
help her quit smoking. On December 11, Knowlton reported to nurse practitioner Thomas that she
had experienced a negative reaction to food on two occasions during which her eyes became itchy
and her throat and chest became red. Thomas’ notes indicate that Knowlton wondered if she was
reacting to some sulfa-containing component in the food. On December 20, Knowlton visited Dr.
Fullmer complaining that her symptoms had increased after being exposed to odors from the new
carpet and furnishings at her place of employment. Knowlton also mentioned having negative
reaction to foods.
        On the advice of Dr. Fullmer, Knowlton went to see Dr. Richard Henry, an allergist. While
visiting Dr. Henry, Knowlton complained of episodic hoarseness, chest tightness, shortness of
breath, and nasal congestion following exposure to strong odors, aerosol sprays, perfumes, and
scented soaps. She also mentioned that any products containing sulfur especially aggravated her
symptoms. Dr. Henry recommended that Knowlton undergo allergy skin testing.
        In January of 2001, Knowlton began to see another pulmonologist, Dr. Holly Carveth. Dr.
Carveth determined that Knowlton was suffering from reactive airway disease (RADS), 4 as well as




4
  RADS is the development of an asthma-like condition resulting from exposure to a respiratory irritant. RADS is
also commonly referred to as irritant-induced asthma.

                                                       3
gastroesophageal reflux disease (GERD). 5 Dr. Carveth referred Knowlton to a speech and language
pathologist to treat her vocal distortion. Dr. Carveth also noted that Knowlton had to be careful
about what she ate due to the onset of new food allergies. Knowlton was prescribed Prilosec to
treat the GERD symptoms.
        In June of 2001, Fremont Compensation Insurance Company (Fremont), Wood River
Medical Center’s insurance company, requested Dr. Fullmer’s opinion regarding Knowlton’s
exposure to sulfuric acid. Dr. Fullmer subsequently wrote a letter to Fremont explaining that
Knowlton’s initial diagnosis was an inhalation injury secondary to sulfuric acid exposure, but that
the injury was mild or minor and would only be expected to last four to six weeks. He also
explained that Knowlton likely reached maximum medical stability approximately six weeks after
the exposure, and it was unlikely that her continued symptoms were directly related to the
exposure. Rather, he believed her continued symptoms seemed more related to anxiety or a desire
for a secondary gain related to the accident. Finally, he stated that he did not believe Knowlton had
any significant physical impairment that was related to the industrial exposure.
        Knowlton subsequently filed a complaint with the Industrial Commission, seeking
reimbursement for her medical expenses and temporary total disability benefits. In the complaint,
Knowlton named Wood River Medical Center 6 and Fremont as defendants, and alleged that her
exposure to toxic sulfuric acid fumes on September 12, 2000, caused her to suffer a chronic cough,
dyspnea, laryngitis, RADS, and laryngospasm. Knowlton filed an amended complaint on May 12,
2003, this time seeking additional workers’ compensation benefits in the form of permanent partial
impairment benefits and permanent partial disability benefits. In the amended complaint, Knowlton
also added dysfunctional larynx and epigastric reflux to the list of medical problems allegedly
caused by the chemical exposure.
        Defense counsel subsequently filed an answer on behalf of Wood River, as well as
Cambridge Integrated Services, the successor in interest to Fremont, which had gone bankrupt at
some point after Knowlton’s complaint was filed. As a result of Fremont’s bankruptcy, the Idaho



5
  GERD is a condition that causes acid from the stomach to leak backwards to the esophagus, the larynx, and even
the respiratory tract.
6
  At the time Knowlton filed her complaint, St. Luke’s Regional Medical Center was in the process of purchasing
Wood River Medical Center. Believing that the purchase had been completed, Knowlton originally named St.
Luke’s as the defendant. However, Knowlton filed an amended complaint on May 12, 2003, naming Wood River as
the defendant.

                                                       4
Life and Health Insurance Guaranty Association (the Association) 7 was added as an interested
party in the litigation. 8
         At some point in 2002, Knowlton was awarded social security disability benefits as a result
of her continued symptoms. The Social Security Administration determined that Knowlton’s
allegations with regard to her medical symptoms were credible based on objective medical
findings.
         For the next several years, Knowlton continued to see Dr. Carveth. Dr. Carveth maintained
her diagnosis of RADS and noted that Knowlton was expressing significant anxiety and depression
related to her illness, as well as her sister’s unexpected death in a car accident. Knowlton continued
to develop additional symptoms related to an expanding list of triggers, including dust, pollen,
animal dander, industrial chemicals used in farm machinery maintenance, marking pens, smoke,
grooming products, and consumption of alcohol and many foods. Knowlton also underwent an
esophagogastroduodenoscopy (EGD). The test results showed inflammation at Knowlton’s
gastroesphageal junction, which is consistent with GERD.
         In September of 2005, Knowlton was examined by several of Respondents’ experts,
including toxicologist Dr. Stephen Munday, allergist Dr. William Wallace, and psychologist Dr.
Craig Beaver. Dr. Munday concluded that Knowlton did not meet the criteria for a RADS
diagnosis, and her symptoms were more likely the result of a GERD condition. Dr. Wallace
conducted a skin panel, testing for approximately 80 to 90 of the most common allergens and 6
of the major foods for which Knowlton had reported experiencing a reaction. All of the tests
came back negative. Dr. Beaver concluded that there was a correlation between stressful events
in Knowlton’s life and the development of her physical symptoms.
         For reasons not relevant to this appeal, a hearing on the merits of Knowlton’s claim did not
occur until June of 2008. At the hearing, the Referee heard live testimony from Knowlton, as well
as the Respondents’ toxicology expert, Dr. Munday. In addition to this testimony, the depositions


7
   The Association is a non-profit association whose members are insurance companies licensed to write life,
accident, and health/disability insurance policies in the State of Idaho. The Association was created after the
Legislature passed the Idaho Life and Health Insurance Guaranty Association Act (the Act). In the event that a
member insurer is determined to be insolvent and is ordered to be liquidated by a court, the Association provides
protection (subject to the limits set forth in the Act) to residents of the state who have a covered insurance policy
issued by the insolvent insurer. See title 41, chapter 36, Idaho Code.
8
  Wood River Medical Center, Fremont Compensation Insurance Company, and the Idaho Insurance Guaranty
Association will collectively be referred to as Respondents.

                                                         5
of other witnesses, including several of Knowlton’s family members, co-workers, and treating
physicians, taken both before and after the hearing, were entered into the record. Each party
submitted briefing on the matter at the close of the proceedings. Knowlton filed an opening brief
and a reply brief, each totaling thirty pages. Respondents filed a motion to strike Knowlton’s reply
brief, arguing that Knowlton had failed to adhere to the page limitation set forth in the
Commission’s Judicial Rules of Practice and Procedure. The Referee denied the motion without
commenting on the merits of Respondents’ argument.
          The Referee ultimately concluded that Knowlton had failed to demonstrate her medical
symptoms were causally related to the chemical exposure she experienced on September 12, 2000,
and that her symptoms were more consistent with GERD. Although the Referee determined
Knowlton was not entitled to time loss benefits, or any form of disability benefits, the Referee did
find that, because the medical treatment Knowlton received during the six weeks following the
incident was a reasonable precautionary step taken in response to her exposure to an unknown
chemical, she was entitled to compensation for those expenses.
          The Commission adopted the Referee’s findings of fact and conclusions of law. After the
Commission denied Knowlton’s motion for reconsideration, she timely appealed to this Court.
                                                     II.
                                             Issues on Appeal
   I.          Whether the Commission’s conclusion that Knowlton failed to demonstrate her
               medical symptoms were causally related to the chemical exposure at her
               workplace is supported by substantial and competent evidence?
   II.         Whether the Commission has jurisdiction to order the Idaho Insurance Guaranty
               Association to pay Knowlton workers’ compensation benefits or attorney fees?
   III.        Whether the Referee erred by denying Respondents’ motion to strike
               Knowlton’s reply brief?
   IV.         Whether the Commission abused its discretion by failing to award Knowlton
               attorney fees?
   V.          Whether either party is entitled to attorney fees on appeal?
                                                   III.
                                                Discussion
          A.      Standard of Review
          When reviewing a decision by the Industrial Commission, this Court exercises free review
over the Commission’s conclusions of law, but will not disturb the Commission’s factual
findings if they are supported by substantial and competent evidence. I.C. § 72-732; Stewart v.

                                                     6
Sun Valley Co., 140 Idaho 381, 384, 94 P.3d 686, 689 (2004). Substantial and competent
evidence is “relevant evidence which a reasonable mind might accept to support a conclusion.”
Boise Orthopedic Clinic v. Idaho State Ins. Fund, 128 Idaho 161, 164, 911 P.2d 754, 757 (1996).
The Commission’s conclusions regarding the credibility and weight of evidence will not be
disturbed unless they are clearly erroneous. Excell Constr., Inc. v. State, Dep’t of Labor, 141
Idaho 688, 692, 116 P.3d 18, 22 (2005). This Court will not re-weigh the evidence or consider
whether it would have drawn a different conclusion from the evidence presented. Id.
         B.       Causation
         On appeal, Knowlton argues that there is no evidence in the record to support the
Commission’s determination that her symptoms were likely caused by GERD. Rather, Knowlton
asserts that the testimony of her treating physicians, the testimony of her family members,
friends, and co-workers, and the medical records, including the results of her methacholine
challenge tests, 9 all demonstrate that she contracted RADS as a result of the chemical exposure.
Respondents, on the other hand, argue that the testimony of Dr. Munday, an expert in toxicology,
and the testimony of Knowlton’s treating physicians establish that Knowlton’s symptoms were
more consistent with GERD and could not have reasonably been caused by the chemical
exposure.
         A workers’ compensation claimant has the burden of proving “to a reasonable degree of
medical probability [that] the injury for which benefits are claimed is causally related to an
accident occurring in the course of employment.” Wichterman v. J.H. Kelly, Inc., 144 Idaho 138,
141, 158 P.3d 301, 304 (2007). “The issue of causation must be proved by expert medical
testimony, although the Industrial Commission as the finder of fact may consider other evidence
as well, including evidence regarding credibility.” Id.
         Although both parties presented testimony from numerous witnesses, the arguments in
this case are largely based on the conflicting testimony of Knowlton’s witness, Dr. Carveth, and
Respondents’ witness, Dr. Munday. Dr. Carveth testified that Knowlton developed RADS as a
result of the chemical exposure, while Dr. Munday testified that Knowlton did not meet the
criteria for a RADS diagnosis, and her symptoms were more likely the result of a GERD


9
 Methacholine challenge testing is one method of assessing airway responsiveness. Airway hyperresponsiveness is
one of the features that may contribute to a diagnosis of asthma. During the test, the patient breaths in methacholine,
which cause the airways to narrow. The degree of narrowing is then quantified.

                                                          7
condition. In concluding that Knowlton had failed to prove her medical symptoms were causally
related to the chemical exposure, the Commission gave greater weight to Dr. Munday’s opinion,
and agreed that Knowlton’s symptoms were more consistent with GERD than RADS. The
Commission also found that this conclusion was supported by the testimony and reports of Dr.
Fullmer and Dr. Beaver. Because this Court gives great deference to the Commission’s
conclusions regarding the credibility and weight of evidence, the only issue before this Court is
whether the evidence relied on by the Commission constitutes substantial and competent
evidence.
       The testimony and reports of Dr. Munday, Dr. Beaver, and Dr. Fullmer constitute
substantial and competent evidence supporting the Commission’s conclusion that Knowlton did
not meet her burden of proving her symptoms were casually related to the chemical exposure.
First and foremost, the Commission’s conclusion is supported by the testimony of Dr. Munday,
who specializes in treating patients who have been exposed to toxic chemicals, including sulfuric
acid. Dr. Munday, after reviewing Knowlton’s medical records, reviewing the hearing exhibits,
and personally examining Knowlton, specifically concluded that Knowlton’s symptoms were not
likely caused by chemical exposure but, rather, were likely a result of a GERD condition.
       Dr. Munday’s first basis for reaching this conclusion was that the symptoms Knowlton
first reported having on the day of the exposure were not consistent with someone who had been
exposed to sulfuric acid. According to Dr. Munday, sulfuric acid is a highly water soluble
chemical that is going to first affect the nose, throat, eyes, and upper airway upon exposure. Dr.
Munday also mentioned that sulfuric acid would cause a “high degree of irritation” to these
areas. For this reason, Dr. Munday was concerned about the symptoms Knowlton described on
the day of the exposure.
       There is not a description of eye burning and significant nasal burning which would
       be the first set of symptoms that would be anticipated and they would be so
       significant that you would expect somebody to actually leave the exposure if they
       were able to do so. So, I certainly agree that sulfuric acid is a respiratory irritant and
       under the right circumstances can cause respiratory damage or irritation. But it
       would be expected that the upper airways and mucous membranes would be
       affected first. That doesn’t appear to the description of the events that occurred.
Therefore, because Knowlton reported developing a headache and a sore throat on the day of the
exposure and did not similarly report any irritation in her eyes or any significant irritation with
her nose, Dr. Munday concluded her initial symptoms were not consistent with exposure to


                                                  8
sulfuric acid. 10
        The Commission found Dr. Munday’s report and testimony to be persuasive in this
regard, pointing out that
        [t]he medical records nearest the exposure noted that [Knowlton’s] most significant
        complaint was a cough. Referring to the day of the exposure, there is a passing
        reference to a burning sensation in [Knowlton’s] nose but no mention of eye
        irritation. By context, if either her eyes or nasal passages had been significantly
        burned, there would likely be more prominent mention of it, and the examination
        would likely have revealed injury to those organs.
        The second basis for Dr. Munday’s conclusion was that Knowlton is the only employee
or person who was present at the hospital on the day of the incident who claims to have suffered
any sort of residual symptoms or effects from the chemical exposure. According to Dr. Munday,
this further supports the conclusion that Knowlton’s symptoms were not a result of exposure to
sulfuric acid.
        The final basis for Dr. Munday’s conclusion was that Knowlton’s medical symptoms
were more consistent with GERD rather than exposure to a chemical such as sulfuric acid. Dr.
Munday explained that GERD can cause asthma-like symptoms similar to those Knowlton
suffers from. Specifically, Dr. Munday’s report indicates that,
        [Knowlton] has multiple findings that support [a GERD] diagnosis in that: 1) she
        has symptoms consistent with gastroesphageal and laryngopharyngeal reflux
        disease in terms of her hoarseness, pain and respiratory complaints; 2) secondly, she
        notes that her dentist has noted that she appears to have some abnormalities
        secondary to acid etching of her teeth, which certainly can occur with reflux
        disease; 3) she had an upper gastrointenstinal endoscopy, which confirmed she had
        substantial evidence of inflammation at her gastroesophageal junction, once again
        consistent with gastroesphageal reflux disease.
Importantly, Knowlton was also diagnosed with severe GERD by Dr. Carveth.
        Knowlton does not dispute the fact that she suffers from GERD. However, she argues the
medical evidence demonstrates that she developed GERD after the chemical exposure, and as a
result of suffering from RADS. In support of this argument, she cites to Dr. Carveth’s testimony
indicating that severe coughing episodes caused by RADS can lead to GERD. However, Dr.
Munday specifically opined that Knowlton’s GERD condition was not caused by the chemical
exposure.

10
   Dr. Carveth also testified that the medical records did not indicate Knowlton had complained of any nose or eye
irritation as a result of the exposure.

                                                        9
         I find it incredible that her treating pulmonologist, Dr. Carveth, at the University of
         Utah, notes in one place of her record that the patient never complained of reflux
         prior to the date of injury, at least, in my opinion, insinuating that the reflux would
         have been caused by this supposed exposure in the workplace. This is completely
         and patently scientifically unsupportable, and, in my opinion, the opposite is much
         more likely to be true; that since the patient has reflux and developed a sore throat,
         reflux would explain the acid taste, burning of her throat and subsequent
         development of her pulmonary symptoms.
In other words, Dr. Munday specifically reported that there is no medical evidence indicating
that GERD is somehow caused by RADS.
         Dr. Munday also thoroughly explained in his testimony and his report why he had
concluded that Knowlton did not meet the criteria for a RADS diagnosis. The eight clinical
criteria for diagnosing RADS include: (1) a documented absence of preceding respiratory
complaints; 11 (2) the onset of symptoms occurred after a single specific exposure incident or
accident; (3) the exposure to a gas, smoke, fume, or vapor which was present in very high
concentration and had irritant qualities to its nature; (4) the onset of symptoms occurred within
24 hours after the exposure and persisted for three months; (5) symptoms simulated asthma with
cough, wheezing and dyspenea; (6) pulmonary function tests may show airflow obstructions; (7)
methacholine challenge test was positive; and (8) other types of pulmonary diseases were ruled
out. Dr. Munday conceded that Knowlton developed symptoms immediately following the
chemical exposure and that her symptoms persisted for more than three months, but disputed that
the overall medical evidence, Knowlton’s medical history, and Knowlton’s symptoms indicated
she was suffering from RADS.
         First, Dr. Munday explained that patients generally do not develop RADS unless they
have suffered “extensive high-dose exposure to highly irritating agents.” He did mention that
there has been some discussion in the medical community regarding whether low or intermediate
doses could cause the syndrome, but explained that such a conclusion is controversial and not
widely supported. For this reason, Dr. Munday found that the fact that Knowlton had not been


11
   Dr. Munday testified that this criterion has largely been abandoned and it is possible for a patient to develop
RADS even if he or she has a preexisting respiratory condition. Although there is evidence in the record indicating
that Knowlton was diagnosed with mild dyspnea by Dr. Fullmer in 1988, Knowlton, both at oral argument and in
briefing, asserted that she was never treated for any respiratory condition prior to the incident. When addressing Dr.
Fullmer’s diagnosis of dyspnea in briefing, Knowlton explained that Dr. Fullmer’s assessment “did not include any
finding of asthma, and Dr. Fullmer ultimately concluded that Lesia Knowlton’s physical condition was entirely
normal.”

                                                         10
exposed to a high dose of chemical, 12 militated against a RADS diagnosis.
         Next, Dr. Munday also concluded that Knowlton was not suffering from RADS because
she continued to have normal, or near-normal, pulmonary functioning tests. Dr. Munday testified
that nearly all of the spirometry tests 13 produced normal results, and those that produced
abnormal results were so near normal that they were unimportant. In fact, Dr. Munday explained
that the normal breath ranges have recently been broadened and Knowlton’s abnormal tests
would now likely be classified as normal. Knowlton relies heavily on the results of the
methacholine tests conducted by Dr. Fullmer and Dr. Carveth to support her argument that the
Commission erred in concluding she had not demonstrated she was suffering from RADS as a
result of the chemical exposure. The results of the methacholine tests showed a moderate degree
of airway hyperresponsiveness. However, Dr. Munday testified that although this type of testing
is an effective way to rule out asthma in a patient, positive results must be interpreted in the
appropriate setting because false positives frequently occur. 14 He mentioned that ten to twenty
percent of people have a positive result, even if they do not suffer from asthma. Dr. Munday also
explained that the results of the methacholine tests were not helpful in determining causation
because whether a person is experiencing respiratory problems as a result of allergies, RADS, or
GERD, the tests do nothing to demonstrate which one is the cause.
         Finally, Dr. Munday determined that many of Knowlton’s symptoms were not
attributable to RADS. Specifically, Dr. Munday explained that the vocal cord dysfunction, the
odor-induced symptoms, and the subsequent development of allergic reactions to various foods
were not characteristic of someone suffering from RADS. He opined that Knowlton’s negative
reaction to odors may be a result of psychosomatic odor intolerance. In reaching this conclusion,
Dr. Munday found it important that all of Knowlton’s allergy tests were negative. Dr. Munday
also pointed out that there is no valid scientific evidence that would support an association
between exposure to sulfuric acid and the subsequent development of an allergy to other sulfa-
containing products. In other words, Knowlton’s concern that she was developing an allergy to


12
   Dr. Fullmer agreed with Dr. Munday that Knowlton was likely only exposed to a low dose of chemical. “Patient
describes an inhalation exposure with sulfuric acid at her workplace. I suspect it was a low concentration exposure,
as sulfuric acid is quite irritating and if the concentration had been high then she would have been motivated to leave
the area.”
13
   Spirometry tests measure the amount and/or speed of air that can be inhaled and exhaled by a patient.
14
   Dr. Munday cited to the American Thoracic Society’s “Guidelines for Methacholine and Exercise Challenge
Testing,” which explains the likelihood of false positive testing results.

                                                         11
foods containing sulfa as a result of the exposure to sulfuric acid is not medically supportable. As
mentioned above, Dr. Munday testified that Knowlton’s symptoms, especially the vocal cord
dysfunction, were more consistent with GERD, and there is no medical evidence that GERD is
somehow caused by RADS. 15
        The Commission’s conclusion is also supported by the testimony of Dr. Fullmer and Dr.
Beaver. Both Dr. Fullmer and Dr. Beaver testified that Knowlton’s symptoms were likely
attributable to her emotional distress rather than to the chemical exposure. Dr. Fullmer explained
that, while Knowlton’s initial diagnosis was an inhalation injury secondary to sulfuric acid
exposure, the injury was mild or minor and would only be expected to last four to six weeks. He
explained that he did not believe Knowlton suffered any significant physical impairment related to
the exposure after the six-week mark, and that it was more likely that her symptoms were related to
anxiety or a desire for secondary gain. Finally, he stated that he did not believe Knowlton had any
significant physical impairment that was related to the industrial exposure. Similarly, Dr. Beaver
concluded that there was a strong correlation between stressful events in Knowlton’s life and the
development of her physical symptoms. Although Dr. Beaver testified that he could not say that
Knowlton did not have any respiratory difficulties, he did testify that there was a “conditioned
relationship” between her emotional distress and her respiratory difficulties.
        The testimony and reports of these medical professionals constitute substantial and
competent evidence supporting the Commission’s decision. In support of her argument that the
Commission erred, Knowlton points to conflicting evidence and testimony in the record.
However, this Court is not in the position to re-weigh evidence or determine whether it would
have reached a different conclusion. Knowlton’s main focus on appeal appears to be the
temporal link between the chemical exposure and her medical symptoms. While the temporal
connection certainly supports Knowlton’s position, such a connection alone does not establish
that her symptoms were caused by the chemical exposure. The medical evidence relied on by the
Commission indicates that many of Knowlton’s continued symptoms are inconsistent with a
RADS diagnosis. Therefore, the Commission’s determination that Knowlton did not meet her
burden of proving her symptoms were related to the chemical exposure is supported by
substantial and competent evidence.

15
 Dr. Munday mentioned an article in the Journal of the American Medical Association indicating that reflux is a
major cause of laryngeal pathology.

                                                      12
       Although the Commission’s ultimate conclusion is supported by substantial and
competent evidence in the record, its discussion regarding Knowlton’s credibility is of some
concern. The Referee made the following findings of fact with regard to Knowlton’s credibility:
       31. Claimant’s testimony demonstrates she casually shifted from recalled fact to
           speculation without being aware she had done so. In her attempts to answer questions,
           it is impossible to separate actual memory from her supposed guesses at what might
           have happened.
       32. Materially significant portions of her testimony were internally inconsistent among
           her 2003 deposition, her 2004 deposition, and her 2008 hearing testimony. This is not
           to say that Claimant deliberately lied. On the contrary, she appeared to attempt
           honesty at all times. However, over time, her memory has become so confabulated
           with the story of her illness that no part of her memory of these events or her
           symptoms can be accepted at face value.
These credibility findings were adopted by the Commission.
       Determining the credibility of witnesses and evidence is a matter within the province of
the Commission. Stevens-McAtee v. Potlatch Corp., 145 Idaho 325, 331, 179 P.3d 288, 294
(2008). However, such findings are still subject to review by this Court. When analyzing the
Commission’s findings regarding credibility, this Court has bifurcated the issue into two
categories, “observational credibility” and “substantive credibility.” Painter v. Potlatch Corp.,
138 Idaho 309, 313, 63 P.3d 435, 439 (2003). Observational credibility “goes to the demeanor
of the appellant on the witness stand and it requires that the Commission actually be present for
the hearing in order to judge it.” Id. In contrast, substantive credibility “may be judged on the
grounds of numerous inaccuracies or conflicting facts and does not require the presence of the
Commission at the hearing.” Id. The Court will not disturb the Commission’s findings regarding
credibility if the findings are supported by substantial and competent evidence. Id.
       In this case, it does not appear from the record that the Referee had any reason to doubt
Knowlton’s credibility. Knowlton’s explanation of the events leading up to, and following, the
incident on September 12, 2000, has been consistent. Although the Referee is correct that some
details have been forgotten over the eight years leading up to the hearing, such is to be expected.
However, the fact that Knowlton at times had difficulty remembering certain details does not
support the Commission’s conclusion that Knowlton’s testimony could “not be accepted at face
value.” Interestingly, the Referee in this case is the same Referee that presided over the hearing
in Stevens-McAtee v. Potlatch Corp. In that case, the Referee held that the claimant’s testimony
was not credible because the claimant “improved” or “enhanced” his testimony by adding


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specific details at the hearing. Stevens-McAtee, 145 Idaho at 329, 179 P.3d at 292. On appeal,
this Court found that the Referee’s findings with regard to the claimant’s credibility were not
supported by substantial and competent evidence because, although there may have been slight
differences or additions at the hearing, the claimant’s testimony regarding how he was injured
had remained consistent, and any differences in his testimony did not support the Referee’s
conclusion that he was not credible. Id. at 331, 179 P.3d at 294. Similarly in this case, the
differences or additions in Knowlton’s testimony over the eight years preceding the hearing
does not support the Referee’s conclusion that Knowlton was not credible. Therefore, the
Commission’s conclusions with regard to Knowlton’s credibility are not supported by
substantial and competent evidence, and this Court is not required to accept them on appeal.
Nonetheless, because the issue of causation is dispositive on appeal and does not take into
account the Referee’s unsupported determination that Knowlton was not credible, this Court
affirms the Commission’s decision to deny Knowlton workers’ compensation benefits, other
than to cover the medical expenses incurred during the six weeks following the incident.
Because we affirm the Commission’s determination that Knowlton failed to meet her burden of
proving her symptoms are causally related to the chemical exposure, it is unnecessary for us to
consider the other issues raised by the Respondents on appeal, including whether the
Commission has jurisdiction to order the Association to pay Knowlton workers’ compensation
benefits and whether the Commission erred in denying the Respondents’ motion to strike.
       C.     Attorney Fees for the Proceedings Before the Commission
       Knowlton argues that if this Court finds that the Commission erred in denying her claim,
the Commission abused its discretion by failing to award her attorney fees incurred during the
proceedings before the Commission pursuant to I.C. § 72-804. I.C. § 72-804 authorizes attorney
fees to be paid to a claimant, where the employer or surety contests a claim for compensation
without reasonable grounds to do so. I.C. § 72-804. Because there is substantial and competent
evidence to support the Commission’s decision, the Commission did not abuse its discretion in
failing to award Knowlton attorney fees.
       D.     Attorney Fees on Appeal
       Knowlton also contends that she is entitled to an award of attorney fees on appeal
pursuant to I.C. § 72-804 and I.A.R. 41 because Respondents denied her claim and refused to
pay benefits without reasonable grounds. Because we affirm the Commission’s decision to deny

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Knowlton’s claim for additional workers’ compensation benefits, Knowlton is not entitled to
attorney fees on appeal.
        Respondents request attorney fees on appeal pursuant to I.A.R. 41 and 11.2 16 on the
ground that Knowlton frivolously pursued this appeal. I.A.R. 11.2 allows the Court to order a
party, or a party’s attorney, to pay attorney fees as a sanction for pursuing an appeal that is (1)
not well grounded in fact; (2) not warranted by existing law or a good faith argument for the
extension, modification, or reversal of existing law; or (3) was pursued for an improper purpose.
Respondents argue that attorney fees are warranted because, on appeal, Knowlton has
unreasonably sought to dispute the Commission’s factual findings by pointing to irrelevant
conflicts in the evidence. Although we affirm the Commission’s ultimate conclusion,
Knowlton’s appeal was not frivolously pursued such that sanctions are warranted against either
Knowlton or her counsel.
                                                      IV.
                                                   Conclusion
         There is substantial and competent evidence in the record to support the Commission’s
conclusion that Knowlton failed to demonstrate her medical problems were causally related to
the chemical exposure at Wood River Medical Center. Thus, this Court affirms the
Commission’s determination that Claimant is only entitled to workers’ compensation benefits for
the medical expenses incurred during the six weeks following the exposure. Costs, but no
attorney fees, are awarded to Respondents.


        Chief Justice EISMANN, and Justices BURDICK, W. JONES and HORTON CONCUR.




16
   In briefing, Respondents incorrectly cite I.A.R. 11.1 instead of 11.2 as a basis for attorney fees. This mistake
seems to be a result of the fact that I.A.R. 11.2 was previously numbered as I.A.R. 11.1, and has just recently been
renumbered. Respondents also cite Keller v. Rogstad, 112 Idaho 484, 733 P.2d 705 (1987), a case dealing with
sanctions under this rule before the renumbering went into effect. Therefore, despite the citation error, it is clear
what authority Respondents intended to provide in support of the request for attorney fees.


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