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are subject to modification and technical correction prior to official
publication in the North Carolina Reports and North Carolina Court of Appeals
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authoritative.
NO. COA07-190
NORTH CAROLINA COURT OF APPEALS
Filed: 18 December
2007
JUDY PERRY,
Employee-Plaintiff,
v. North
Carolina Industrial Commission
I.C.
File No. 042720
CKE RESTAURANTS, INC.,
Employer-Defendant,
and
TRAVELERS INSURANCE COMPANY,
Carrier-Defendant.
Appeal by Defendants from Opinion and Award entered 17
November 2006 by the North Carolina Industrial Commission. Heard in the Court of Appeals 19 September
2007.
Doran,
Shelby, Pethel and Hudson, P.A., by David A. Shelby, for Plaintiff-Appellee.
Morris
York Williams Surles & Barringer, LLP, by Stephen Kushner and Angela M. Easley,
for Defendants-Appellants.
STEPHENS, Judge.
I. FACTS AND PROCEDURE
Judy Perry (“Plaintiff”) slipped and fell at work on 6
October 1999, injuring her head and back. Plaintiff contended that as a result of the accident, she was
entitled to payment of compensation for missed work, payment of medical
expenses and treatment, payment for permanent partial disability, and payment
for permanent total disability.
Plaintiff’s employer, CKE Restaurants, Inc., commonly known as Hardee’s,
and Travelers Insurance Company (collectively “Defendants”), accepted
compensability for the claim as a “medicals only claim.”
The case was heard before Deputy Commissioner Amy L.
Pfeiffer on 28 November 2001. Deputy
Commissioner Pfeiffer filed an Opinion and Award on 7 August 2002, in which she
found that Plaintiff had sustained an injury which resulted in a concussion and
materially exacerbated Plaintiff’s preexisting back condition. Furthermore, Deputy Commissioner Pfeiffer
determined that Plaintiff was temporarily totally disabled and entitled to
temporary total disability benefits from 29 March 2000 through 17 July 2001;
Plaintiff reached maximum medical improvement on 17 July 2001; Plaintiff was
entitled to permanent partial disability benefits for a fifteen percent permanent
partial impairment to her back; and Defendants were responsible for all related
medical treatment received by Plaintiff due to her back condition. Neither party appealed the decision.
After that Opinion and Award was filed, Plaintiff sought and
received a significant amount of additional medical treatment, including three
back surgeries, without advising Defendants or seeking preauthorization for
such treatment from Defendants. On 5
August 2004, Plaintiff filed a “Request that Claim be Assigned for Hearing,”
asserting that she had sustained a change of condition within the meaning of
N.C. Gen. Stat. §97-47 and was entitled to further benefits and medical
treatment. Defendants filed a response,
contending Plaintiff had not sustained a change of condition within the meaning
of N.C. Gen. Stat. §97-47; Plaintiff had not contested Deputy Commissioner
Pfeiffer’s prior determination that Plaintiff had reached maximum medical
improvement in July 2001; Plaintiff had not sought any authorization for
medical treatment from Defendants for several years; any medical treatment
Plaintiff had received since 7 August 2002 had not been authorized by
Defendants; and all benefits owed to Plaintiff pursuant to Deputy Commissioner
Pfeiffer’s Opinion and Award had been paid by Defendants.
The case was heard before Deputy Commissioner John B. Deluca
on 28 June 2005. In an Opinion and
Award filed 30 March 2006, Deputy Commissioner Deluca determined that
Plaintiff’s back condition was causally related to her compensable injury of 6
October 1999; Plaintiff had sustained a change of condition on 8 November 2002
and had not yet reached maximum medical improvement; Plaintiff was entitled to
total disability benefits from 8 November 2002 until further order of the
Industrial Commission; and Plaintiff was entitled to payment of medical and
related expenses incurred or to be incurred as a result of Plaintiff’s
compensable injury.
From this Opinion and Award, Defendants appealed to the Full
Industrial Commission. The Full
Commission affirmed Deputy Commissioner Deluca’s decision with minor
modifications. Defendants appealed the
decision of the Full Commission to this Court. The sole issue on appeal is whether the Full Commission erred
in awarding additional medical compensation to Plaintiff where Plaintiff failed
to seek preauthorization for her medical treatment, thus excusing Defendants
from liability for such treatment pursuant to N.C. Gen. Stat. §97-25.3.
II. DISCUSSION
Appellate review of an Opinion and Award of the Full
Commission is limited to a determination of whether the Full Commission’s
findings of fact are supported by any competent evidence, and whether those
findings support the Full Commission’s legal conclusions. Adams v. AVX Corp., 349 N.C. 676, 509
S.E.2d 411 (1998), reh’g denied, 350 N.C. 108, 532 S.E.2d 522
(1999). The Full Commission’s
conclusions of law are reviewable de novo. Whitfield v. Lab. Corp. of Am., 158 N.C. App. 341, 581
S.E.2d 778 (2003).
First, Defendants claim the Full Commission erred in
awarding Plaintiff additional medical compensation because Defendants were
entitled to impose preauthorization requirements on Plaintiff’s receipt of
additional medical treatment. N.C. Gen.
Stat. §97-25.3(a) states in relevant part that “[a]n insurer may require
preauthorization for inpatient admission to a hospital, inpatient admission to
a treatment center, and inpatient or outpatient surgery.” N.C. Gen. Stat. §97-25.3(a) (2005) (emphasis
added). While this section allows an
insurer to impose preauthorization requirements, the statute itself does not
impose such requirements. Thus, in
order to claim the protections afforded by N.C. Gen. Stat. §97-25.3(a),
Defendants must have presented evidence that they actually required preauthorization
for the treatment Plaintiff received.
As the record herein is devoid of such evidence, Defendants did not
prove they were entitled to protection under N.C. Gen. Stat. §97-25.3(a).
Second, Defendants claim the Full Commission erred in
awarding Plaintiff additional medical compensation because Plaintiff sought
medical treatment without obtaining preauthorization from Defendants. N.C. Gen. Stat. §97-25.3(b) states in
relevant part:
(b) An insurer
may not impose a preauthorization requirement for the following:
(1) Emergency
services;
(2) Services rendered in the diagnosis or treatment of an injury or illness for which the insurer has not admitted liability or authorized payment for treatment pursuant to this Article; and
(3) Services
rendered in the diagnosis and treatment of a specific medical condition for
which the insurer has not admitted liability or authorized payment for
treatment although the insurer admits the employee has suffered a compensable
injury or illness.
N.C.
Gen. Stat. §97-25.3(b) (2005).
It is undisputed that Plaintiff did not seek any
preauthorization with respect to the medical treatment she received following
the 7 August 2002 Opinion and Award. It
is also undisputed that Defendants asserted that the condition for which
Plaintiff sought treatment was not causally related to Plaintiff’s compensable
injury of 6 October 1999. Consequently,
even if Defendants had in fact imposed preauthorization requirements on
Plaintiff, since the statute specifically states that an insurer may not impose
preauthorization requirements for services for which the insurer does not admit
liability, Plaintiff was not required to seek preauthorization from Defendants
for such services.
Defendants argue further, however, that the Full Commission
did not make specific findings of fact to support its conclusion that
Defendants are responsible for payment of Plaintiff’s medical expenses despite
a lack of preauthorization. “While the
[Full] [C]ommission is not required to make findings as to each fact presented
by the evidence, it is required to make specific findings with respect to
crucial facts upon which the question of plaintiff’s right to compensation
depends.” Gaines v. L. D. Swain
& Son, Inc., 33 N.C. App. 575, 579, 235 S.E.2d 856, 859 (1977). If the Full Commission’s findings of fact
are insufficient to allow this Court to determine the parties’ rights upon the
matters in controversy, the proceeding must be remanded to the Full Commission
for proper findings of fact. Young
v. Whitehall Co., 229 N.C. 360, 49 S.E.2d 797 (1948).
The Full Commission made the following relevant findings of
fact:
2. On
October 6, 1999, Plaintiff slipped and fell on the floor at work. . . .
Defendants admitted this injury as a medicals-only claim.
. . . .
17. From
August 7, 2002, through the date of the hearing before Deputy Commissioner
Deluca, Plaintiff did not contact Defendants regarding additional treatment for
her back.
. . . .
34. .
. . Defendants have denied that Plaintiff’s current medical treatment is
related to her compensable injury.
These
findings of fact adequately support the conclusion of law that, pursuant to
N.C. Gen. Stat. §97-25.3(b), Defendants could not impose a preauthorization
requirement on Plaintiff because, even though Defendants admitted Plaintiff
suffered a compensable injury on 6 October 1999, Defendants denied liability
for Plaintiff’s treatment on grounds that there was no causal connection
between that compensable injury and the medical treatment at issue. Thus, Defendants’ argument that the Full
Commission failed to make adequate findings of fact lacks merit.
Additionally, Defendants contend that N.C. Gen. Stat.
§97-25.3 is intended to waive preauthorization requirements only when a
defendant is aware of a plaintiff’s injury, change of condition, or medical
treatment, but does not admit liability.
However, where “the language of the statute is clear and is not
ambiguous, we must conclude that the legislature intended the statute to be
implemented according to the plain meaning of its terms.” Hyler v. GTE Prods. Co., 333 N.C. 258,
262, 425 S.E.2d 698, 701 (1993). “The
duty of a court is to construe a statute as it is written. It is not the duty of a court to determine
whether the legislation is wise or unwise, appropriate or inappropriate, or
necessary or unnecessary.” Campbell
v. First Baptist Church, 298 N.C. 476, 482, 259 S.E.2d 558, 563
(1979). Here, the language of the
statute makes it clear that preauthorization requirements cannot be imposed
where an insurer denies liability for the treatment. Had the legislature intended to waive preauthorization
requirements only when a defendant was aware of a plaintiff’s injury, change of
condition, or medical treatment, the legislature could have explicitly drafted
the statute to reflect this intent.
Finally, Defendants contend they should be allowed to raise
the defenses of lack of liability for Plaintiff’s injury and failure to seek
preauthorization in the alternative. As
explained above, a statute must be implemented “according to the plain meaning
of its terms.” Hyler, 333 N.C.
at 262, 425 S.E.2d at 701. As the plain
language of the statue prohibits such defenses from being raised in the
alternative in these circumstances, Defendants’ argument is overruled.
Accordingly, the Full Commission did not err in awarding
additional medical compensation to Plaintiff as Defendants were not excused
from liability for such treatment pursuant to N.C. Gen. Stat. §97-25.3. Thus, the Opinion and Award of the Full
Commission is
AFFIRMED.
Judges McCULLOUGH and CALABRIA concur.