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 in October 1992 while employed by the employer. The worker sought treatment from a physician, who later determined the worker had reached maximum medical improvement (MMI) in October 1993. In 1994, the parties entered into a partial lump-sum settlement agreement, which stipulated that medical treatment would remain open for life with the worker's chosen physician or their referral. Despite ongoing treatment, the employer later sought to change the worker's primary health care provider, leading to a dispute over the employer's liability for a back surgery performed in 1996 (paras 2-5).
Procedural History
- Workers' Compensation Judge: Found in favor of the employer, ruling that the employer was not liable for the costs of the worker's back surgery and follow-up treatment (para 5).
Parties' Submissions
- Worker-Appellant: Argued that the settlement agreement waived the employer's statutory right to change the worker's primary health care provider and that the employer was obligated to pay for the surgery performed by the designated physician (paras 7, 13).
- Employer/Insurer-Appellee: Contended that the settlement agreement was ambiguous, that the worker waived their right to object by failing to file a formal objection to the change of health care provider, and that the worker provided insufficient consideration for the agreement (paras 8, 11-12).
Legal Issues
- Did the employer waive its statutory right to redesignate the worker's primary health care provider by entering into the partial lump-sum settlement agreement? (para 1)
- Did the worker waive their right to challenge the change of health care provider by failing to file an objection? (para 1)
- Was the worker's back surgery reasonable and medically necessary, obligating the employer to pay for it? (para 1)
Disposition
- The court reversed the Workers' Compensation Judge's decision, holding that the employer waived its statutory right to change the worker's primary health care provider (para 15).
- The case was remanded to determine whether the back surgery was reasonable and medically necessary (para 15).
Reasons
Per M. Christina Armijo J. (Donnelly and Pickard JJ. concurring):
- The court found that the settlement agreement was unambiguous and clearly stipulated that the worker's medical treatment would remain open for life with the designated physician or their referral. This constituted a waiver of the employer's statutory right to change the worker's primary health care provider (paras 7-10).
- The employer's argument that the worker provided insufficient consideration for the agreement was rejected, as the worker's release of the employer from biweekly payment obligations constituted valid consideration (para 11).
- The court held that the worker was not required to file an objection to the change of health care provider because the employer had already waived its statutory right to make such a change through the settlement agreement (para 13).
- The court emphasized that the employer's obligation to provide medical treatment was limited to care that was reasonable and medically necessary. Since the Workers' Compensation Judge did not address this issue, the case was remanded for further proceedings on this point (para 14).