Vela v. State, Dep't of Public Safety ( 2015 )


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    146 P.3d 801
    , 805 (2006) ("[T]his court affords no deference to the district
    court's ruling in judicial review matters.").
    We conclude that the appeals officer erred in his
    interpretation of NRS 616C.495.      See City of N. Las Vegas v. Warburton,
    
    127 Nev. 682
    , 686, 
    262 P.3d 715
    , 718 (2011) (stating this court reviews
    questions of law, like statutory interpretation, arising out of
    administrative appeals de novo). When a person seeks to reopen his or her
    workers' compensation claim after accepting a permanent partial
    disability (PPD) lump sum payment, NRS 616C.495 controls. Under NRS
    616C.495(2)(a)(1)'s plain terms, a person can reopen his or her workers'
    compensation claim after accepting a PPD lump sum payment if he or she
    satisfies the requirements of NRS 616C.390.'
    Here, Vela accepted a PPD lump sum payment, and then
    sought to reopen her workers' compensation claim. However, instead of
    looking only towards the requirements of NRS 616C.390, as instructed by
    NRS 616C.495, the appeals officer relied on NRS 616C.495(2)'s language
    that "Mlle claimant's acceptance of [the PPD lump sum payment]
    constitutes a final settlement of all factual and legal issues in the case,"
    and other appeal dates and waiver language which arose over the course
    of Vela's workers' compensation claim. As a result, the appeals officer
    precluded Vela from reopening her claim. This was error. In assessing
    whether Vela could reopen her claim, the appeals officer should have
    focused entirely on NRS 616C.390. See Day v. Washoe Cnty. School Dist.,
    'All of the paperwork signed by Vela in accepting her PPD lump
    sum payment mirrored the language of NRS 616C.495, and thus, aligns
    with the statutory interpretation of NRS 616C.495 as set forth.
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    121 Nev. 387
    , 390, 
    116 P.3d 68
    , 70 (2005) (explaining in a case featuring
    similar facts that when an injured employee seeks to reopen his or her
    workers' compensation claim, the pertinent analysis falls under NRS
    616 C .390).
    Under NRS 616C.390, an insurer must reopen a claim if (1)
    "[the] application to reopen a claim is made in writing within 1 year after
    the date on which the claim was closed," (2) "[t]he application is supported
    by medical evidence demonstrating an objective change in the medical
    condition of the claimant," and (3) "[t]here is clear and convincing evidence
    that the primary cause of the change of circumstances is the injury for
    which the clam was originally made." NRS 616C.390(4).
    Vela satisfied NRS 616C.390's first requirement because she
    filed her application to reopen her claim only 15 days after her claim had
    closed. The appeals officer's factual findings support this, as he found that
    Vela "requested reopening only two weeks after the closure of her claim."
    While it is not clear what the appeals officer precisely found in regards to
    the second element, his findings generally, along with evidence in the
    record, support the conclusion that Vela's application to reopen was
    supported by medical evidence demonstrating an objective change in her
    medical condition. 2
    Finally, as to NRS 616C.390's third requirement, the appeals
    officer found that Vela had "not shown that her worsening of condition is
    primarily related to the industrial strain of her lumbosacral spine." We
    conclude, based on the record as a whole, that this finding by the appeals
    2 This conclusion is supported by Dr. Lynch's diagnosis and reliance
    on an X-Ray and an MRI, and Dr. Hall's affirmation of that diagnosis.
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    officer was clearly erroneous.   See Day, 121 Nev. at 389, 116 P.3d at 69
    ("While this court will not substitute its judgment for that of the agency as
    to the weight of the evidence, this court will reverse an agency decision
    that is clearly erroneous in light of reliable, probative, and substantial
    evidence on the whole record." (internal quotations omitted)). In making
    his decision, the appeals officer gave more weight to office paperwork and
    Dr. Hall's expert opinion (who only spent 30 minutes in total on the case),
    over Dr. Lynch's expert opinion (a board-certified spinal neurosurgeon who
    treated Vela), Dr. Rappaport's expert opinion (who treated Vela), and Dr.
    Nagy's expert opinion (a board certified neurosurgeon). 3 Thus, we
    conclude that Vela satisfied all the requirements necessary to reopen her
    workers' compensation claim after the awardS of her lump sum payment.
    We further conclude that CCMSI is equitably estopped from
    limiting Vela to treatment for a lumbar strain because (1) CCMSI covered
    her treatment by Dr. DeMordaunt even when he treated her for more than
    a strain, (2) CCMSI's claim manager Hickson told Vela over the phone she
    could reopen her claim for surgery, and (3) CCMSI never issued a letter to
    Vela pursuant to NRS 616C.065(7) denying coverage of her spinal
    conditions beyond a strain. See Dickinson v. American Medical Response,
    
    124 Nev. 460
    , 467, 
    186 P.3d 878
    , 883 (2008) ("Equitable estoppel may be
    invoked against a party who claims a statutory right in administrative
    3 We have considered the parties remaining arguments and conclude
    that they are without merit. Specifically, the argument CCMSI raised in
    its answering brief that it cannot be held responsible for payment to Dr.
    Lynch because Dr. Lynch was not on the insurer's panel of treating
    physicians, as well as the argument that Vela never requested a change of
    physician pursuant to NRS 616C.090, are not appropriate for this appeal.
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    workers' compensation proceedings, when the invoking party has
    reasonably relied on the other party's words or conduct to her detriment.")
    Accordingly, we
    ORDER the judgment of the district court REVERSED AND
    REMAND this matter to the district court for proceedings consistent with
    this order, and instruct the district court to enter an order reversing the
    appeals officer's decision.
    Gibbons
    ,   J.
    cc: Hon. James E. Wilson, District Judge
    James Georgeson, Settlement Judge
    Nevada Attorney for Injured Workers/Carson City
    Attorney General/Carson City
    Beckett, Yott, McCarty & Spann/Reno
    Carson City Clerk
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Document Info

Docket Number: 66820

Filed Date: 12/18/2015

Precedential Status: Non-Precedential

Modified Date: 12/21/2015