Ball v. Prince Telecom. ( 2015 )

IN THE SUPERIOR COURT OF THE STATE OF DELAWARE
IN AND FOR NEW CASTLE COUNTY
CARMEN BALL, )
)
Claimant-Appellant, )
)
v. ) C.A. No.: N15A-01-004 CLS
)
PRINCE TELECOM, )
)
Employer-Appellee. )
)
On Appeal from the Industrial Accident Board.
AFFIRMED.
ORDER
Heather A. Long, Esq., Kimmel, Carter, Roman, Peltz & O’Neill, P.A., 56
West Main Street, Christiana, Delaware 19702. Attorney for Claimant-
Appellant.
Christopher T. Logullo, Esq., Chrissinger & Baumberger, 3 Mill Road,
Wilmington, Delaware 19806. Attorney for Employer-Appellee.
Scott, J.
1
On this 30th day of October, 2015, upon consideration of the Appellant
Carmen Ball’s (“Ms. Ball”) appeal from a decision of the Industrial Accident
Board (“the Board”), it appears to the Court that:
1. Ms. Ball was injured in a compensable work injury on January 11, 2012, while
employed with Prince Telecom (“Employer”). As a result of her work injury,
Ms. Ball began treating with Dr. Joseph Richards of Rehabilitation Associates
of the Main Line. The parties agree that Dr. Richards is an out-of-state
provider and is not a certified provider under the Delaware Health Care
Practice Guidelines. 1
2. As part of her treatment plan, Ms. Ball received injections provided by Dr.
Richards in March and April 2014. Employer denied payment of these bills on
the basis that Ms. Ball has reached her maximum medical improvement and no
further treatment was authorized.2 At the Board hearing, Employer asserted
two bases for denial of the claims at issue: (1) Ms. Ball was examined by
Employer’s medical expert in January 2014, who opined that Ms. Ball needed
no further medical care because she was at her maximum medical
improvement; and (2) pursuant to the ruling in Wyatt v. Rescare Home Care,3
1
See Claimant-Appellant’s Opening Br. At 2, 8; see Employer-Appellee’s Answering Br. at 1.
2
See the Board’s September 26, 2014 Order.
3
81 A.3d 1253 (Del. 2013).
2
treatment by a non-certified provider is not payable unless it is pre-authorized,
and no further treatment had been authorized in Ms. Ball’s case. 4
3. The Board found that Employer’s denial of Ms. Ball’s claims were proper
because employers cannot send bills to Utilization Review for treatment
performed by a non-certified provider. The Board held that, under the
Delaware Healthcare Payment System, when Utilization Review is
unavailable, an employer need only deny payment. Furthermore, the Board
held that a claimant’s remedy where such denial is disputed is to file a Petition
to Determine Additional Compensation Due. On appeal, Ms. Ball argues that
the Board’s decision should be reversed and remanded because Employer’s
first reason for termination is invalid, and that its second reason for termination
cannot be considered because it was proffered more than 30 days after
Employer’s denial of Ms. Ball’s claims.
4. The Court’s review of a Board decision is limited to whether the Board’s
findings were supported by substantial evidence and whether the decision is
free from legal error. 5 Where substantial evidence supports the Board’s
conclusions, the Court will not disturb that conclusion absent an error of law. 6
Substantial evidence is “such relevant evidence as a reasonable mind might
4
See the Board’s September 26, 2014 Order.
5
Thompson v. Christina Care Health Sys., 25 A.3d 778, 781-82 (Del. 2011).
6
General Motors Corp. v. Freeman, 164 A.2d 686 (Del. 1960).
3
accept as adequate to support a conclusion.” 7 The Court will review the entire
record determine whether the Board could have fairly and reasonably reached
its conclusion.8 The Court does not, however, sit as a trier of fact and will not
substitute its judgment for that rendered by the Board.9 As such, the Court
shall not weigh the evidence, determine questions of credibility or make its
own findings of fact. 10 The Board’s decision is reviewed de novo for errors of
law. 11 In the absence of legal error, the Board’s decision is reviewed for abuse
of discretion. 12 The Court will find an abuse of discretion when the Board’s
decision “exceeds the bounds of reason in view of the circumstances and has
ignored recognized rules of law or practice so as to produce injustice.” 13
5. In this case, the Court finds that the Board’s decision was supported by
substantial evidence and free from legal error. Employer had Ms. Ball
examined by its own medical expert, who opined that Ms. Ball needed no
further medical care because she had reached her maximum medical
improvement. The Court finds there is substantial evidence in the record to
support that this was basis for Employer’s initial reason for denying Ms. Ball’s
March and April claims for treatment with Dr. Roberts.
7
Pearson-Gaines v. Pepco Holdings, Inc., 981 A.2d 1159, 1161(Del. 2009)(quoting Olney v.
Cooch, 425 A.2d 610, 614 (Del. 1981)).
8
National Cash Register v. Riner, 424 A.2d 669 (Del. Super. 1980).
9
Johnson v. Chrysler Corp., 213 A.2d 64, 66 (Del. 1965).
10
Id.11
Ahold USA Holdings, Inc. v. Jones, 2014 WL 7723572 (Del. Super. Dec. 19, 2014).
12
Id.13
Id.4
6. Furthermore, the Board did not err as a matter of law in stating that, under the
Delaware Healthcare Payment System, when Utilization Review is
unavailable, an employer need only deny payment. In this case, it is
undisputed that Dr. Roberts is an out-of-state provider and is not a certified
provider under the Delaware Health Care Practice Guidelines. As such,
Utilization Review was unavailable for Ms. Ball’s claims for her treatment
with Dr. Roberts. It then follows that Employer only needed to deny payment
of Ms. Ball’s claims. Disputing the denial, Ms. Ball’s remedy was to file a
Petition to Determine Additional Compensation Due. Thus, the Board did not
err as a matter of law.
7. For the foregoing reasons, the Court finds that the Board’s decision was
supported by substantial evidence and free from legal error. Accordingly, the
Board’s decision is AFFIRMED.
IT IS SO ORDERED.
/s/Calvin L. Scott
Judge Calvin L. Scott, Jr.
5