April 14 2009
DA 08-0311
IN THE SUPREME COURT OF THE STATE OF MONTANA
2009 MT 127
JERRY NARUM,
Petitioner and Appellee,
v.
LIBERTY NORTHWEST INSURANCE CORP.,
Respondent/Insurer and Appellant.
APPEAL FROM: Montana Workers’ Compensation Court, WCC No. 2007-1987
Honorable James Jeremiah Shea, Presiding Judge
COUNSEL OF RECORD:
For Appellant:
Larry W. Jones, Law Offices of Larry W. Jones, Missoula, Montana
For Appellee:
Patrick R. Sheehy, Halverson, Sheehy & Plath, Billings, Montana
Submitted on Briefs: March 4, 2009
Decided: April 14, 2009
Filed:
__________________________________________
Clerk
Justice Patricia O. Cotter delivered the Opinion of the Court.
¶1 Liberty Northwest Insurance Corporation (Liberty) appeals from a decision of the
Workers’ Compensation Court (WCC) holding that Liberty is liable to claimant Jerry
Narum (Narum) for medical and hospital benefits related to the treatment of his left hip,
and granting him an award of attorney fees and costs as well as a statutory penalty of
20% pursuant to § 39-71-2907, MCA. We affirm.
FACTUAL AND PROCEDURAL BACKGROUND
¶2 Narum worked in the beer and wine business for 37 years. For the last 17 years of
his employment, he drove a small semi-truck delivering beer. Narum’s job duties
including heavy lifting and loading. On March 6, 2003, Narum was stepping out of his
truck when he either slipped or missed the last step and fell to the pavement, landing on
his left side. Narum experienced slight pain at the time but ignored it and continued to
work. Several weeks later, when the pain had not subsided, he filed a workers’
compensation claim, claiming injury to his left hip. Narum filed a report of the
occupational injury on April 4, 2003, in which he described the circumstances of the
injury.
¶3 Prior to this accident, Narum had never received any treatment for either hip. The
first time he experienced pain in his hip was subsequent to the fall. Liberty accepted
liability for the claim and paid benefits through December 3, 2003. After he filed his
claim, Narum sought medical treatment with Rebecca Rinehart (Rinehart), a physician’s
assistant. Rinehart referred Narum to Dr. Michael C. Willis (Dr. Willis), an orthopedic
surgeon who specializes in sports medicine.
2
¶4 Dr. Willis first saw Narum on April 9, 2003. In his examination, Dr. Willis noted
that Narum had been complaining of a progressive onset of pain in his left hip. Because
Dr. Willis’ examination occurred days after Rinehart’s examination of Narum, Dr. Willis
had not reviewed her notes and was not aware of the slip and fall injury when he
examined Narum. X-rays taken of Narum’s hip in conjunction with the examination
indicated to Dr. Willis that Narum was suffering from a degenerative joint disease in his
left hip. Dr. Willis recommended medical treatment for the pain. Dr. Willis also
suggested Narum might be a candidate for hip replacement surgery at a later date, but did
not favor surgery at that point because he was “very active” and the surgery would limit
his activities. Narum had a follow-up visit with Dr. Willis approximately six weeks later.
During that visit, Narum continued to complain about pain in his left hip.
¶5 Narum continued to work for his employer until June 2003, when the business was
sold and he was not rehired by the new owner. Since that time, Narum has not worked
and considers himself retired.
¶6 On July 18, 2003, Narum saw Dr. Scott K. Ross (Dr. Ross) for a medical
consultation regarding his ongoing hip pain. Dr. Ross reviewed the records of Narum’s
visit with Rinehart and Dr. Willis, and conducted his own examination. Dr. Ross
concluded that Narum’s hip pain had improved approximately 20% since the accident,
but that he continued to experience sharp pain in his left hip, which bothered him more
when he was at rest. Narum reported that he was sometimes pain-free, but used pain
medication on a daily basis. Dr. Ross noted that Narum had subjective complaints of
pain and that the x-rays indicated significant degenerative osteoarthritis. Dr. Ross opined
3
that Narum was not at maximum medical improvement (MMI) at that time. Dr. Ross
recommended physical therapy and continued use of pain medication to treat Narum’s
symptoms.
¶7 Dr. Ross re-evaluated Narum on September 9, 2003. Dr. Ross noted that Narum
continued to experience pain when sitting, had developed a limp, and reported an almost
constant pain in his left hip. Dr. Ross noted that while Narum’s degenerative condition
had been present for some time, Narum was asymptomatic before the March 2003 work
injury, and had not yet recovered to his pre-injury status. Dr. Ross recommended a
follow-up visit with Dr. Willis and a consideration of more aggressive therapy
alternatives, including cortisteroid injections and possible hip replacement. Dr. Ross
gave Narum an 8% whole person impairment rating. Narum continued to receive
treatment for the pain resulting from his hip condition.
¶8 On October 17, 2003, Dr. Michael H. Schabacker (Dr. Schabacker) performed an
independent medical examination (IME) on Narum. Dr. Schabacker’s report summarizes
Narum’s medical records and his own recorded notes of Narum’s examination, and
contains responses to questions submitted by a representative of Liberty. Dr. Schabacker
noted that Narum was asymptomatic prior to the March 2003 injury, but had continued to
experience ongoing hip pain after the accident, which varied from no pain to moderate
pain in relation to his activity level. Dr. Schabacker’s impression was that Narum had
persistent left hip pain following his fall at work which was exacerbated by his left hip
degenerative condition. Dr. Schabacker opined that Narum’s degenerative joint disease
predated the work injury in March 2003, and that it was more probable than not that the
4
work injury led to left hip pain due to the preexisting problem. Dr. Schabacker
concluded it was unlikely that Narum would have experienced a prolonged recovery from
the industrial injury if he had not suffered the degenerative condition in the first place,
and that the injury itself did not lead to the development of the degenerative condition.
Dr. Schabacker also concluded that only 25% of Narum’s condition was attributable to
his work-related injury and that he should have received only a 2% impairment rating.
¶9 On November 18, 2003, Dr. Willis wrote a letter explaining his treatment and
examinations of Narum. In the letter, Dr. Willis stated that his degenerative condition
had been exacerbated by the work injury. Dr. Willis also stated that Narum’s “injury has
been disconnected from his Workers’ Compensation Claim, as it was more than likely a
pre-existing condition, exacerbated by work. Mr. Narum has significant hip pain, which
has since the time of this injury, limited his ability to return to work, and he really feels
that he is unable to return to the form of work which he was doing prior to this
exacerbation.” Dr. Willis further concluded in the letter that Narum’s degenerative hip
condition made it unlikely that he could return to the type of employment he engaged in
at the time of the injury.
¶10 Liberty continued to pay Narum medical benefits until December 2003, when it
informed him that it would no longer pay benefits because he had reached MMI and had
been given an 8% impairment. Narum then obtained counsel in order to reach a
settlement. Narum later testified that his primary concern was to ensure that his medical
benefits remained open, since his medical examinations indicated that he would
eventually need a hip replacement.
5
¶11 In early 2004, Narum’s attorney began negotiating a settlement with Liberty. On
February 23, 2004, the terms of this settlement were memorialized in a letter. The letter
stated that the parties had agreed Liberty would pay Narum $25,000 in new money and
would allow Narum to reserve his medical benefits. The settlement was approved by the
Department of Labor and Industry on March 11, 2004. The terms of the agreement,
drafted pursuant to the Department’s standard Petition for Settlement form, stated in
pertinent part as follows:
The claimant and the insurer petition the Department of Labor & Industry
for approval of this settlement allowing the claim to be fully and finally
closed. Further medical and hospital benefits are reserved by the claimant,
excepting those conditions stated specifically in the Special Provisions
below.1 The claimant understands that by entering into a settlement, both
the insurer and the claimant agree to assume the risk that the condition of
the claimant, as indicated by reasonable investigation to date, may be
other than it appears or may change in the future. Specifically, the parties
acknowledge that the claimant may require a total hip replacement in the
future . . . .
¶12 On May 11, 2004, Narum was seen again by Dr. Willis. Dr. Willis noted that
Narum had not been back to work as a driver and determined that Narum’s symptoms of
hip degeneration were exacerbated by his previous work position. Dr. Willis concluded
that Narum would not be able to return to his previous position as a driver.
¶13 For some time after the settlement, Liberty continued to pay Narum medical
benefits related to his left hip. On January 12, 2006, Liberty sent Dr. Willis a letter
asking him two true/false questions about the causation of Narum’s hip condition. One
of the questions asked whether “Mr. Narum’s present condition is related to his preinjury
1
These exceptions are not relevant to Liberty’s appeal.
6
degenerative hip joint disease and not his work injury of 03-06-2003.” Dr. Willis circled
“true” after this statement. The second question asked whether “Mr. Narum’s present
condition is related to his ongoing physical activities and is not related to his work injury
of 03-06-2003.” Dr. Willis circled “false” after this question, and wrote “His condition is
related to [degenerative joint disease] of his hip. His ‘activities’ are not causative.”
Based on Dr. Willis’ response to the letter, Liberty refused to make further payments of
medical benefits related to the treatment of his left hip.
¶14 In January 2007, Narum realized he was going to need hip replacement surgery.
During this time, Narum was receiving cortisone shots for his hip pain, which Liberty
refused to pay for. Narum later testified that Liberty did not inform him that it would no
longer pay for the cortisone shots, but that he received word of Liberty’s refusal to pay
from his medical provider after Liberty had informed the provider that it would not pay
for the shots. On September 7, 2007, Narum had hip replacement surgery which was
performed by Dr. Willis. Liberty refused to pay for the surgery and related treatment
based on Dr. Willis’ responses to the January 2006 letter.
¶15 Narum subsequently filed a claim before the WCC, seeking medical and hospital
benefits related to treatment for his left hip condition, an award of reasonable attorney
fees and costs, and a statutory penalty of 20% based on Liberty’s refusal to pay benefits.
The WCC considered all of Narum’s medical records, as well a deposition from Dr.
Willis. In addition, Narum testified before the WCC and the court found him to be a
credible witness. In a written order dated June 4, 2008, the WCC found that Liberty was
7
liable for medical and hospital benefits related to treatment of Narum’s hip, and awarded
Narum a 20% statutory penalty and reasonable attorney fees and costs.
¶16 In its factual findings, the WCC considered whether Dr. Willis’ evaluations of
Narum indicated that his work accident had caused his pain, or whether the pain and
resulting hip surgery was attributable solely to his degenerative condition. In his
deposition, when asked if the March 2003 injury was “the cause or the aggravant” to
Narum’s degenerative joint disease which caused the hip pain, Dr. Willis responded as
follows: “If he had had continued pain related to that fall, then it would be my opinion
that that injury exacerbated his pain. He certainly had interims of very little, if no pain.”
The WCC noted that Dr. Ross’ evaluations of Narum seemed to contrast with the
opinions of Dr. Willis, as Dr. Ross had noted that Narum was in ongoing and continuous
pain from the left hip, and had been asymptomatic prior to the March 2003 injury.
Furthermore, Dr. Ross had specifically indicated that Narum should receive more
aggressive therapy for his treatment, including injections and possible hip replacement.
The WCC reconciled this dissonance in the evidence as follows:
Dr. Ross’ history contrasts noticeably with that of Dr. Willis’. Dr.
Willis was unaware of Petitioner’s industrial accident, and based his
opinion that it did not exacerbate Petitioner’s degenerative hip condition
on his understanding that Petitioner experienced periods of little to no pain
subsequent to the industrial accident. Dr. Ross’ history, however, reflects
that Petitioner had ongoing and continuous pain which worsened over time
and was relieved only through use of medication.
Petitioner testified that since the day of his industrial accident, he
has had constant pain, but it has waxed and waned depending on his
activity level. He also received several cortisone shots which almost
completely alleviated his pain for three or four months after each shot.
However, the shots eventually ceased working. Petitioner described his
hip pain as a “steady, slow-moving increase” from the day of the industrial
8
accident forward, and asserted that the pain has never entirely gone away
since the accident. Petitioner may have experienced low-pain or pain-free
periods subsequent to his industrial accident, but these periods were due to
pain management of one type or another. I find that Dr. Wills
misapprehended Petitioner’s alleged “interims of very little, if no pain.” I
find that the evidence demonstrates Petitioner had ongoing pain from the
time of his industrial accident.
¶17 Additionally, the WCC addressed Dr. Willis’ responses in the January 2006 letter
with regard to the causation of Narum’s hip condition. In his deposition, Dr. Willis
explained that he read the second question (see ¶ 13) to be an either/or proposition,
seeking to ascertain whether Narum’s condition was due to his work, or other activities.
Dr. Willis explained that the degenerative condition itself was caused by neither, and thus
responded “false” to the question, clarifying his response with an additional sentence.
¶18 In its conclusions of law, the WCC determined that the underlying causation of
Narum’s hip condition (i.e., whether it was related to the industrial accident or solely to
the pre-existing degenerative condition) was no longer at issue with respect to Liberty’s
liability for Narum’s medical and hospital benefits, because of the terms of the settlement
agreement. The WCC noted that all the doctors who examined Narum offered their
opinions as to whether he would need hip surgery, and the extent to which Narum’s hip
condition was caused by the industrial accident. Liberty knew these facts going into the
settlement discussions, and made a decision to settle Narum’s claim knowing that hip
replacement surgery might be required at some point in the future. In fact, the language
of the settlement itself explicitly contemplated such a possibility. See ¶ 11. The WCC
concluded that Liberty was bound by the terms of this agreement under basic principles
of contract law, and further, that Liberty was not in a position to accept liability for the
9
claim, settle it, and then “un-accept” the claim at a later date because it changed its mind.
Accordingly, the WCC found that Liberty was responsible for medical and hospital
benefits related to Narum’s hip surgery and treatment based on the settlement agreement.
¶19 Additionally, the WCC concluded that Narum was entitled to reasonable attorney
fees and costs pursuant to § 39-71-611, MCA, because Liberty denied the claim, the
WCC later determined it was compensable, and because its actions in denying the claim
were unreasonable. With respect to the unreasonableness of Liberty’s actions in denying
the claim, the WCC noted that Liberty had been paying benefits for years, then suddenly
stopped paying them without notifying Narum, and denied payment for the hip surgery in
spite of the fact that it was specifically contemplated by the settlement. The WCC
concluded that Liberty had failed to provide a persuasive explanation for how it could
justify the cessation of payments under these circumstances. Finally, the WCC
determined that Narum was entitled to a 20% statutory penalty under § 39-71-2907,
MCA, based on Liberty’s unreasonable refusal to pay medical benefits.
¶20 Liberty now appeals from the WCC’s decision, presenting four issues on appeal.
First, Liberty maintains that the WCC erred in holding that the causation of the hip
condition was not at issue based on the terms of the settlement agreement, and asserts that
under the Workers’ Compensation Act Narum must still prove causality before it can be
found liable for benefits, irrespective of the language in the settlement. Second, Liberty
argues that Narum failed to introduce substantial evidence proving that his injury caused
him to require hip surgery. Third, Liberty argues that it did not unreasonably deny
liability and that the statutory penalty should be reversed. Fourth, Liberty maintains that
10
the WCC erred in awarding attorney fees because it did not unreasonably deny liability
for his hip replacement surgery.
¶21 We conclude that Narum met his burden of proof in this case and showed that his
industrial accident caused the need for his hip replacement surgery and other treatment
for the hip condition both before and after the surgery. Accordingly, we decline to
address Liberty’s first issue. Thus, we restate the issues on appeal as follows:
¶22 Issue One: Did Narum satisfy his burden of proof and demonstrate that his
industrial accident caused him to require hip replacement surgery and other related
treatment for his hip condition?
¶23 Issue Two: Did the WCC err in awarding attorney fees and costs in this case?
¶24 Issue Three: Did the WCC err in awarding a statutory penalty based on Liberty’s
denial of Narum’s claims?
STANDARD OF REVIEW
¶25 We review the WCC’s findings of fact to determine whether they are supported by
substantial credible evidence. Kratovil v. Liberty Northwest Ins. Corp., 2008 MT 443,
¶ 13, 347 Mont. 521, 200 P.3d 71. Substantial credible evidence is such evidence which
a reasonable mind could accept as adequate to support a conclusion. Evidence is
considered substantial even if it is contradicted by other evidence, somewhat less than a
preponderance, or inherently weak. Kratovil, ¶ 13. We conduct a de novo review of the
WCC’s conclusions of law to determine if they are correct. Kratovil, ¶ 13.
¶26 Issue One: Did Narum satisfy his burden of proof and demonstrate that his
industrial accident caused him to require hip replacement surgery and other
related treatment for his hip condition?
11
¶27 Liberty argues that the WCC impermissibly ignored Narum’s statutory burden of
proof to show that his industrial accident caused him to require hip surgery, and instead
turned the resolution of this case into a credibility contest between Dr. Willis and Narum.
The point of dispute here for Liberty concerns the WCC’s finding that Dr. Willis
misapprehended whether or not Narum was pain-free after his accident, and whether the
industrial accident led to the hip replacement surgery. Liberty asserts that Dr. Willis’
deposition established that his degenerative joint disease had a natural progression which
led to the surgery and related treatment. As noted above at ¶ 16, however, the WCC
found that Dr. Willis had misapprehended Narum’s condition by concluding that Narum
experienced “interims of very little, if no pain.” Based on Narum’s testimony, as well as
the evidence in the medical records, the WCC concluded that Narum’s pain in his left his
hip was attributable to his industrial accident, as it led to the ongoing pain in his left hip.
Liberty asserts this was error and that if the WCC discounts Dr. Willis’ opinion, then
there is essentially no medical evidence demonstrating that Narum’s hip surgery and
related treatments were more probably than not due to his industrial accident.
¶28 Under § 39-71-407(2)(a)(ii), MCA, an insurer is liable for an injury “if the injury
is established by objective medical findings and if the claimant establishes that it is more
probable than not that . . . a claimed injury aggravated a preexisting condition.” The
claimant has the burden of proving by a preponderance of the evidence that he sustained
an injury on the job, and that there is a casual connection between his current condition
12
and his injury. Best v. State Compensation Ins. Fund, 276 Mont. 302, 305, 916 P.2d 108,
110 (1996).
¶29 The WCC came to the conclusion that Narum’s industrial accident aggravated his
preexisting degenerative condition based on Narum’s testimony and the medical records
of the other treating physicians, including Dr. Ross. A review of the record in this case
shows that the WCC’s conclusion was supported by substantial credible evidence. First,
Dr. Willis’ opinion itself is somewhat contradictory on the question of whether Narum’s
industrial accident led to surgery and treatment for the hip. As noted above at ¶ 9, in his
November 18, 2003 letter, Dr. Willis stated that Narum’s “injury has been disconnected
from his Workers Compensation Claim, as it was more than likely a pre-existing
condition, exacerbated by work. Mr. Narum has significant hip pain, which has since the
time of this injury, limited his ability to return to work, and he really feels that he is
unable to return to the form of work which he was doing prior to this exacerbation.”
Even though he states that Narum’s injury is “disconnected” from his claim, by implying
that Narum had experienced significant hip pain since the time of the accident, Dr. Willis
appears to verify that the liability criteria under § 39-71-407(2)(a)(ii), MCA, and
Narum’s burden of proof with respect to causality, have in fact been satisfied. Moreover,
all the other medical professionals—including Dr. Ross and Dr. Schabacker, who
performed an IME—as well as Narum, whom the WCC found credible, agreed that
Narum was asymptomatic before the industrial accident, and that, since the accident, he
has seen a steady degeneration of his condition and increasing pain. This provided
substantial evidence for the WCC to conclude that the industrial accident exacerbated his
13
degenerative condition leading to ongoing pain, thus requiring surgery and other
treatment.
¶30 Liberty implies that the WCC had no choice but to follow certain portions of Dr.
Willis’ opinion simply because he was the treating physician. However, “a treating
physician’s opinion is not conclusive. To presume otherwise would quash the role of the
fact finder in questions of an alleged injury. The Workers’ Compensation Court, as the
finder of fact, is in the best position to assess witnesses’ credibility and testimony. It is
the function of a finder of fact to weigh the credibility of both non-medical and medical
evidence.” EBI/Orion Group v. Blythe, 1998 MT 90, ¶ 13, 288 Mont. 356, 957 P.2d
1134 (quotation and citation omitted). Liability, of course, can only be established based
upon “objective medical findings” pursuant to § 39-71-407(2), MCA. The record
indicates that such objective medical findings were present in this case, and that the
WCC’s findings of fact were supported by substantial credible evidence.
¶31 Thus, we conclude that Narum met his statutory burden of proof and demonstrated
that his need for hip surgery and other treatments for his left hip were directly caused by
the industrial accident which aggravated his pre-existing degenerative condition. Thus,
Liberty is liable to Narum for the related medical and hospital costs, including treatments
before the surgery, the surgery itself, and any post-surgical care or treatment. While the
WCC based its determination of liability primarily upon the terms of the settlement, we
decline to resolve Liberty’s liability on that ground because the WCC provided ample
factual findings for us to conclude that Narum has demonstrated that his industrial
accident aggravated his pre-existing hip condition. Because the WCC reached the right
14
result, we affirm its decision even though we do not fully adopt its reasoning. See Wells
Fargo Bank v. Talmage, 2007 MT 45, ¶ 23, 336 Mont. 125, 152 P.3d 1275 (stating that
we will affirm a court’s decision even if it reaches the right result for the wrong reason).
¶32 Issue Two: Did the WCC err in awarding attorney fees and costs in this case?
¶33 Under § 39-71-611, MCA, an insurer can be held liable for reasonable attorney
fees if the insurer denies liability for a compensation claim, the claim is later judged
compensable, and the WCC determines that the insurer’s actions in denying liability were
unreasonable. Because Liberty denied liability and we conclude that it is liable, we now
turn to the question of whether the WCC erred in concluding that Liberty’s actions in
denying Narum’s claim were unreasonable.
¶34 The WCC’s finding with respect to the reasonableness of Liberty’s actions in
denying Narum’s claim is an issue of fact, subject to the substantial evidence standard of
review. Taylor v. State Compensation Ins. Fund, 275 Mont. 432, 441, 913 P.2d 1242,
1247 (1996). The WCC concluded that Liberty’s actions in denying Narum’s claim were
unreasonable for several reasons. First, it noted that Liberty stopped paying for ongoing
medical treatment after it had previously accepted liability and had already paid for
medical benefits related to Narum’s hip condition for years. Furthermore, Liberty never
informed Narum that it would stop paying for the injections he was receiving; Narum
only learned of Liberty’s refusal to pay when his medical provider contacted him. With
respect to the hip replacement surgery, the WCC found that Liberty denied payment for
this benefit even though the settlement agreement specifically identified hip replacement
surgery as a possibility acknowledged by the parties. Finally, the WCC found that
15
Liberty simply provided no persuasive explanation as to how it could justify stopping
payment for Narum’s ongoing treatment under these circumstances.
¶35 Liberty argues the WCC erred in finding that its actions in denying Narum’s
claims were unreasonable. We disagree. Liberty’s main argument against the WCC’s
finding of unreasonableness is that it had a genuine legal and medical doubt that it was
liable based Dr. Willis’s opinion. However, we agree with the WCC that this still does
not explain why it agreed originally to pay for Narum’s hip surgery in the settlement, or
why it suddenly stopped paying Narum benefits for injections for his hip after initially
accepting liability for Narum’s condition. These were key facts in support of the WCC’s
finding of unreasonableness, and they are supported by substantial credible evidence.
Thus, we conclude the WCC did not err in finding that Liberty’s actions in denying
Narum’s claims were unreasonable and awarding attorney fees and costs in his favor.
¶36 Issue Three: Did the WCC err in awarding a statutory penalty based on Liberty’s
denial of Narum’s claims?
¶37 Under § 39-71-2907, MCA, the WCC may increase by 20% the full amount of
benefits due to a claimant during the period of delay or refusal to pay if the insurer’s
delay or failure to pay is unreasonable. In awarding this penalty, the WCC incorporated
its finding of unreasonableness from its analysis under the attorney fees and costs issue
discussed above. Because we have affirmed the finding of unreasonableness as based on
substantial credible evidence under issue two, we affirm the award of the statutory
penalty as well.
16
¶38 The Dissent disagrees with our imposition of attorney fees and a statutory penalty,
asserting that Liberty had a legitimate legal right to contest causation for future medical
expenses. In this connection, the Dissent faults the Court for falling back upon the
settlement agreement to justify the fees and the penalty, after having declined to resolve
the case on the basis of that agreement. Dissent, ¶¶ 41, 42. Respectfully, the Court’s
rationale is not internally inconsistent. While we declined to resolve the case on the basis
that the settlement agreement was dispositive of liability for medical bills irrespective of
causation, we need not ignore the fact that the settlement agreement exists, that Liberty
did agree in that document to reserve further medical and hospital benefits, and that
Liberty specifically contemplated the prospect of total hip replacement in the future. This
is but one fact, together with Liberty’s cessation of payment for medical benefits without
notice to Narum premised upon a “true/false” questionnaire answer, of which the WCC
took account in assessing fees and the penalty. We in turn properly take account of this
fact, and others, in affirming the WCC’s decision to award fees and the penalty.
CONCLUSION
¶39 While we decline to adopt the exact reasoning of the WCC and decline to decide
this case solely on the terms of the settlement, we nonetheless affirm its decision. We
conclude that, based on the WCC’s findings of fact which are themselves based upon
substantial credible evidence, Narum has met his burden of proof and demonstrated that
the industrial accident aggravated his degenerative hip condition, and caused him to
require treatment and surgery for his left hip. Finally, we conclude that the WCC’s
finding that Liberty acted unreasonably in denying his claim was also based on
17
substantial credible evidence, and thus affirm the award of reasonable attorney fees and
costs, as well as the 20% statutory penalty.
/S/ PATRICIA COTTER
We concur:
/S/ MIKE McGRATH
/S/ JAMES C. NELSON
/S/ BRIAN MORRIS
Justice Jim Rice concurring in part and dissenting in part.
¶40 I concur with the result the Court reaches under denominated Issue One. Although
the evidence was contradictory, the conclusions entered by the WCC with regard to the
cause of Narum’s hip replacement were supported by substantial evidence. However, it
is noteworthy that the WCC, in reaching its conclusions, had to discount the opinion of
Dr. Willis, Narum’s treating physician, by determining that Dr. Willis had
“misapprehended” Narum’s condition. This, to say the least, is a rare conclusion within
worker’s compensation jurisprudence, which usually gives substantial weight to and
relies upon the treating physician’s opinions. See Nielson v. State Compen. Ins. Fund,
2003 MT 95, ¶ 39, 315 Mont. 194, 69 P.3d 1136 (“As a general rule, testimony of a
treating physician is entitled to greater evidentiary weight than that of other doctors.”).
18
Though I agree with the WCC’s conclusions with regard to causation of Narum’s hip
replacement, I believe that the WCC’s discounting of Dr. Willis’s opinion bears
consideration in the resolution of the attorney fee and penalty issues.
¶41 Concluding that Narum met his evidentiary burden of proof to establish causation,
the Court states it will not address Liberty’s first issue—whether the WCC erred by
concluding that causation for the hip replacement was “no longer an issue in this case”
under the parties’ settlement agreement. However, though this issue may not be
necessary to resolve Narum’s entitlement to reimbursement, the WCC’s determination
that causation was no longer an issue was also the reason it penalized Liberty for
contesting the expense. The WCC reasoned that “Respondent denied payment . . . even
though medical benefits were reserved and the possibility of hip replacement surgery was
specifically identified in the settlement agreement. Respondent has provided this Court
with no persuasive explanation as to how it could justify stopping payment for the
ongoing treatment of Petitioner’s hip condition for which it had accepted liability.”
(Emphasis in original.) The answer to this question would be that, though accepting
liability for the injury, Liberty believed it had a legitimate causation defense to future
medical claims and had not agreed to a blanket acceptance of all such costs. Thus, I
believe a review of the causation issue is likewise important to resolution of the attorney
fee and penalty matters.
¶42 As it turns out, so does this Court. In affirming the WCC’s imposition of attorney
fees and the 20% penalty, the Court turns back on its initial decision not to address the
causation issue, reasoning that Liberty’s reliance upon Dr. Willis’s opinion “does not
2
explain why it agreed originally to pay for Narum’s hip surgery in the settlement, or why
it suddenly stopped paying Narum benefits for injections for his hip after initially
accepting liability for Narum’s condition.” Opinion, ¶ 35. The Court here is actually
affirming the WCC’s determination that causation no longer remained an issue because
liability had been accepted.
¶43 I disagree with the WCC’s conclusion that causation for Narum’s hip replacement
was “no longer an issue” under the settlement agreement. Of course, if that were the
case, there would be no need to analyze the evidence to determine if Naurm’s work injury
had caused the surgery—the issue would be settled as a matter of law. The Petition for
Settlement, which constitutes the settlement agreement approved by the Department of
Labor and Industry, provided that Narum was reserving further medical and hospital
benefits, and then stated as follows:
The claimant understands that by entering into a settlement, both the
insurer and the claimant agree to assume the risk that the condition of the
claimant, as indicated by reasonable investigation to date, may be other
than it appears or may change in the future. Specifically, the parties
acknowledge that the claimant may require a total hip replacement in the
future. Additionally, the parties ackknowledge (sic) that based on
claimant’s age and physical restrictions, his return to work poetnetial (sic)
is and will continue to be limited. The claimant . . . further understands
that if this Petition is approved, this insurer is forever released from
payment of compensation under the Worker’s Compensation and
Occupational Disease acts for injuries or diseases specified above. The
claimant understands this Petition represents a settlement and, if
approved, may not be reopened by the Department. [Emphasis in original.]
As it states, this language is intended to make sure that the parties, in entering a final
settlement which the Department may not reopen, understood that Narum’s condition
may “change in the future.” That understanding holds a consequence for both sides: if
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Narum gets worse, Narum will have settled for too little; if Narum improves, Liberty will
have paid too much. Either way, the agreement explains that the party suffering the
financial loss would have no recourse. This language is directed toward disability
compensation issues, and is bolded in the original agreement to ensure the claimant
understands he will be ineligible for future disability compensation payments if he gets
worse, including, as it explains, suffering from a limited work potential or requiring a
total hip replacement. This language does not expand upon Liberty’s responsibility for
future medical costs—which Narum clearly reserved in the agreement—and does not
provide that Liberty is waiving the right to contest causation for those future costs.
Further, it does not say, as the Court offers, that Liberty “agreed originally to pay for
Narum’s hip surgery in the settlement.” Opinion, ¶ 35. As Liberty notes, the statutory
requirement that Narum demonstrate his entitlement to medical benefits by a
preponderance of the evidence remained applicable. Sections 39-71-407 and 704, MCA
(2001). The WCC reasoned that Liberty “cannot accept liability for a claim, settle the
claim, and then un-accept the claim at a later date because it has changed its mind about
whether it should have accepted liability in the first place.” I do not believe Liberty did
so.1
¶44 Liberty alternatively argues that if the agreement is deemed to be ambiguous, this
case should be remanded for further proceedings in which extrinsic evidence could be
considered. However, we need not reach a final conclusion about the agreement’s
1
The Department of Labor & Industry’s letter to Liberty notifying them that the Department had
approved the settlement agreement stated that “[t]he insurer will, where applicable, make
payment.”
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interpretation for purposes of the attorney fee and penalty issues. From the agreement’s
plain language, discussed above, I believe Liberty had a legitimate legal position that it
had not waived the right to contest causation for future medical costs, including the hip
replacement. Further, I believe that Liberty had a legitimate medical premise for
questioning whether Narum’s hip replacement was related to his work accident, by the
opinion of Narum’s treating physician, Dr. Willis.
¶45 We have explained that the statutory penalty “was never intended to eliminate the
assertion of a legitimate defense to liability” and that “the existence of a genuine doubt,
from a legal standpoint, that any liability exists constitutes a legitimate excuse for denial
of a claim or delay in making payments.” Marcott v. Louisiana Pacific Corp., 275 Mont.
197, 205, 911 P.2d 1129, 1134 (1996). I believe the WCC’s imposition of attorney fees
and 20% penalty was premised upon incorrect legal assumptions and was not reasonable.
I would reverse under Issues Two and Three.
/S/ JIM RICE
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