W.C. No. 4-117-758Industrial Claim Appeals Office.
April 7, 2003
FINAL ORDER
The respondents seek review of an order of Administrative Law Judge Harr (ALJ) which awarded medical benefits. We affirm.
The claimant was employed as a maintenance supervisor for the respondent-employer from 1990 to 2000. In September 2000 the claimant began working as a general contractor for his own construction business called PJC Inc.
It is undisputed the claimant suffered a work-related injury on October 9, 1991, when an elevator he was riding in stopped abruptly. The claimant fell to the floor and then to his side. Between 1991 and 2001 Dr. Friermood treated the claimant for neck pain radiating down his left side. In 2001 the claimant reported a worsening of his neck pain with symptoms radiating down his right side. In 2002 Dr. Friermood diagnosed post-traumatic arthritis which he attributed to the 1991 industrial injury. (Friermood reports January 14 and 22, 2002).
The respondents admitted liability for authorized medical treatment which they paid through March 2002. The respondents denied all further medical benefits based on Dr. Hughes’ opinions that the industrial injury stabilized by 1998 and that the claimant’s “right-sided” symptoms are the result of an occupational disease caused by the claimant’s work with PJC Inc.
No formal claim for workers’ compensation was ever filed by the claimant. However, when the respondents refused to continue paying medical benefits under their admission of liability, the claimant filed an application for hearing on the issue of medical benefits. At the hearing, the respondents argued the claimant suffered an intervening injury at PJC Inc. which is the cause for the need for all further medical treatment. The respondents also argued a claim is barred by § 8-43-103(2), C.R.S. 2002, which provides that:
“the right to compensation or benefits provided by said articles shall be barred unless, within two years after the injury or after death resulting therefrom, a notice claiming compensation is filed with the division.”
The statute further provides this limitation shall not apply to any claimant to whom compensation has been paid, but the “furnishing of medical surgical or hospital treatment by the employer shall not be considered payment of compensation or benefits within the meaning of this section.”
The ALJ found the claimant recognized the nature, seriousness, and probable compensable nature of his injury by October 7, 1993, and the statute of limitations for filing a claim would begin to run at that time. No claim was filed, but relying on § 8-43-203(2)(d), C.R.S. 2002, and Williams v. Industrial Commission, 723 P.2d 749 (Colo.App. 1986), the ALJ found the respondents are bound by their admission of liability for medical benefits. The ALJ further determined that the claimant proved the additional treatment recommended by Dr. Friermood is reasonably necessary to treat the 1991 injury. Consequently, the ALJ ordered the respondents to provide additional medical benefits pursuant to their admission.
I.
On review, the respondents renew their contention that a claim was barred by the statute of limitations. Accordingly, the respondents argue the ALJ erroneously awarded further medical benefits. We disagree.
As stated in Martin v. Industrial Commission, 43 Colo. App. 521, 608 P.2d 366, 368 (1980) (decided under the predecessor statute), an insurer’s payment of medical benefits does not toll or extend the statute of limitations. However, the respondents admitted liability for medical benefits and did not seek to withdraw the admission. Further, §8-43-203(2)(d), C.R.S. 2002, requires that insurers make payments “according to admitted liability.” Consequently, the ALJ did not err in concluding the respondents are bound by their admission of liability for medical benefits. HLJ Management Group v. Kim, 804 P.2d 250 (Colo.App. 1990); cf. Pacesetter Corporation v. Collett, ___ P.3d ___ (Colo.App. No. 00CA2099, May 10, 2001).
The issue here is whether the recommended medical treatment is reasonably needed to relieve the effects of the 1991 injury, and thus is within the scope of the respondents’ admitted liability. Sims v. Industrial Claim Appeals Office, 797 P.2d 777 (Colo.App. 1990). It is well established that a general admission of liability for authorized medical benefits reserves the respondents’ right to contest the necessity of any specific treatment. See Snyder v. Industrial Claim Appeals Office, 942 P.2d 1337 (Colo.App. 1997); Williams v. Industrial Commission, supra. Where reasonableness or necessity is disputed, it is the claimant’s burden to prove that the disputed treatment is reasonably necessary to cure or relieve the effects of the industrial injury Williams v. Industrial Commission, supra.
Here, the ALJ found the claimant sustained his burden to prove that the additional treatment recommended by Dr. Friermood is reasonable and necessary to cure or relieve the effects of the 1991 injury. Furthermore, it is undisputed Dr. Friermood is an authorized treating physician. Therefore, the ALJ properly ordered the respondents to comply with their general admissions by providing the disputed medical benefits.
The circumstances in Williams v. El Paso County, W.C. No. 3-961-519
(December 17, 1992), on which the respondents rely, are distinguishable. In that case we reversed an ALJ’s determination that an insurer had “waived” the statute of limitations defense by filing a Final Admission of Liability for previously-paid medical benefits. In so doing, we held that the employer only admitted liability for a specific amount of medical expenses and insofar as the claimant sought additional medical benefits she was required to file a timely notice of claim.
Here, the respondents did not file a limited admission for such a specific amount of medical benefits. Rather, the respondents filed two general admissions of liability for “authorized” medical treatment. Because the admission was open-ended, the claimant was not required to file a formal claim for compensation insofar as he was seeking such admitted authorized medical treatment. Rather, the claimant was only required to prove that the requested treatment was reasonable and necessary to cure or relieve the effects of the 1991 injury, and thus was within the scope of the respondents’ admitted liability.
II.
The respondents also contend the ALJ erred in failing to find the need for further treatment is the result of an intervening injury. Again, we disagree.
Although the claimant is required to prove a causal connection between the industrial injury and the need for treatment, the claimant is not required to prove causation by medical certainty. Rather, it is sufficient if the claimant presents evidence of circumstances indicating with reasonable probability that the condition for which he seeks medical treatment resulted from or was precipitated by the industrial injury, so that the ALJ may infer a causal relationship between the injury and need for treatment. See Industrial Commission v. Riley, 165 Colo. 586, 441 P.2d 3 (1968). It is the ALJ’s prerogative to assess the sufficiency and probative value of the evidence to determine whether the claimant has met his burden of proof. Wal-Mart Stores, Inc. v. Industrial Claim Appeals Office, 989 P.2d 251 (Colo.App. 1999). We must uphold the ALJ’s factual determinations if supported by substantial evidence in the record. Section 8-43-301(8), C.R.S. 2002; Ackerman v. Hilton’s Mechanical Men, Inc., 914 P.2d 524 (Colo.App. 1996). Under this standard, we are bound by the ALJ’s credibility determinations unless his findings are rebutted by such hard, certain evidence that the ALJ would err as a matter of law in crediting particular testimony. Halliburton Services v. Miller, 720 P.2d 571 (Colo. 1986).
The record contains conflicting medical evidence concerning the cause of the need for additional treatment. The ALJ resolved the conflict by crediting the claimant’s testimony that his job duties for the respondent-employer were more strenuous than his work at PJC Inc., and that he modifies his activities to avoid aggravating the 1991 injury. (Finding of Fact 12). Furthermore, the ALJ found the claimant’s testimony is consistent with Dr. Friermood’s opinions that the claimant’s progressively worsening condition is causally related to the industrial injury. Therefore, the ALJ found Dr. Friermood’s opinions on causation more persuasive than the contrary opinions of Dr Hughes. (Finding of Fact 17).
The respondents are obviously dissatisfied with the ALJ’s credibility determinations. However, based upon this record we cannot say that, as a matter of law, the ALJ erroneously rejected the opinions of Dr. Hughes. Furthermore, the ALJ’s findings are supported by substantial evidence and plausible inferences from the record, and the findings support the conclusion the claimant proved the requisite causal connection between the disputed treatment and the 1991 industrial injury.
IT IS THEREFORE ORDERED that the ALJ’s order dated July 17, 2002, is affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
____________________________________ Kathy E. Dean
____________________________________ Bill Whitacre
NOTICE
This Order is final unless an action to modify or vacate this Order is commenced in the Colorado Court of Appeals, 2 East 14th Avenue, Denver, CO 80203, by filing a petition for review with the Court, within twenty (20) days after the date this Order is mailed, pursuant to §8-43-301(10) and § 8-43-307, C.R.S. 2002. The appealing party must serve a copy of the petition upon all other parties, including the Industrial Claim Appeals Office, which may be served by mail at 1515 Arapahoe, Tower 3, Suite 350, Denver, CO 80202.
Copies of this decision were mailed April 7, 2003 to the following parties:
Paul Ciesiolka, 2000 Bell Ct., Lakewood, CO 80215
Allright Colorado, Inc., P. O. Box 16580, Columbus, OH 43216-6580
National Union Fire Insurance Co., Regulatory Information Services, 175 Water St., 18th floor, New York, N.Y. 10038
Carilyn Dakan, Adjuster, Crawford Company, P. O. Box 6502, Englewood, CO 80155-6502
Joanne Crebassa, Esq., 2629 Redwing Dr., #330, Ft. Collins, CO 80526 (For Respondents)
BY: A. Hurtado