AI Generated Opinion Summaries

This summary was computer-generated without any editorial revision. It is not official, has not been checked for accuracy, and is NOT citable.

Facts

A worker sustained a back injury on March 23, 2009, while working at a gas well. He was airlifted to a hospital, where he received emergency care and was instructed to follow up with his primary care physician (PCP). The worker sought treatment from his PCP the next day. Subsequently, the employer/insurer sent a letter stating that the worker had made the initial selection of his treating physician, which became a point of contention regarding the right to select the initial health care provider (HCP).

Procedural History

• Workers’ Compensation Administration, August 2009: The Workers’ Compensation Judge (WCJ) sustained the employer/insurer’s objection to the worker’s notice of change of HCP, concluding that reasonable notice was provided to the worker regarding his right to select the initial HCP.

Parties' Submissions

• Appellant (Worker): Argued that the employer/insurer failed to provide written notice of his right to select the initial HCP as required by law. He contended that he did not make a choice of HCP and that the care he received from his PCP should either be considered authorized or deemed the employer/insurer’s initial selection of HCP.
• Appellees (Employer/Insurer): Asserted that the March 31, 2009, letter provided adequate notice to the worker of his right to select the initial HCP. They argued that the worker’s follow-up with his PCP constituted his selection of the initial HCP and that the presumption under the applicable regulation could be rebutted with evidence.

Legal Issues

• Did the employer/insurer provide reasonable written notice to the worker regarding his right to select the initial HCP?
• Can the presumption under 11.4.4.11(C)(2)(b) NMAC, triggered by the employer’s failure to provide written notice, be rebutted with other evidence?

Disposition

• The Court of Appeals reversed the WCJ’s decision and remanded the case for further proceedings consistent with its opinion.

Reasons

Per Robles J. (Castillo and Vigil JJ. concurring):

The Court held that the employer/insurer failed to provide the worker with reasonable written notice of his right to select the initial HCP as required by 11.4.4.11(C)(2)(a) NMAC. The March 31 letter, which stated that the worker had already made a selection, did not constitute proper notice because it did not inform the worker of his right to choose.

The Court rejected the employer/insurer’s argument that the presumption under 11.4.4.11(C)(2)(b) NMAC could be rebutted with evidence. Citing precedent, the Court emphasized that allowing rebuttal would undermine the legislative intent behind the presumption, which is to ensure compliance with the statutory requirement for written notice.

The Court concluded that the care provided by the worker’s PCP must be considered the employer/insurer’s initial selection of HCP due to their failure to provide timely written notice. The WCJ’s interpretation of the March 31 letter as reasonable notice was found to be erroneous as a matter of law.