The opinion
FILED
Feb 05, 2020
01:40 PM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT NASHVILLE
Tanya Amaya, ) Docket No. 2019-06-1559
Employee, )
V. )
Sims Recycling Solutions, Inc., ) State File No. 21507-2018
Employer, )
And )
Travelers Indem. Co. of Conn., ) Judge Kenneth M. Switzer
Carrier. )
EXPEDITED HEARING ORDER
The Court scheduled an expedited hearing on Ms. Amaya’s request to take place
on February 4, 2020.’ At that hearing, the parties announced they reached several
agreements, which they placed on the record and discussed with the Court. They agreed
as follows:
Ms. Amaya is self-represented at this time.
Sims Recycling previously offered three valid panels (Exhibit 1) from which
Ms. Amaya chose authorized physicians.
Ms. Amaya hurt her right shoulder but now believes she injured the other
shoulder as well from favoring it due to the injury.
A previous authorized treating physician treating her shoulder, Dr. Garside,
declined to see Ms. Amaya again, so Sims Recycling offered another panel
(Exhibit 2) from which Ms. Amaya shall select a physician to offer a second
opinion and/or treat the shoulders.
Ms. Amaya shall return the panel form to counsel for Sims Recycling so his
client can schedule an appointment.
Because Sims offered the relief Ms. Amaya requested, an expedited hearing is
unnecessary.
Sims Recycling filed a motion to dismiss immediately before the hearing,
' Sims provided a certified court interpreter at the hearing.
1 \
arguing that Ms. Amaya did not respond to written discovery. Ms. Amaya
expressed an understanding that whether or not she retains an attorney, she
must respond to the discovery.
Under these circumstances, the Court orders the following:
. Upon receipt of the signed panel-selection form, Sims Recycling shall promptly
schedule an appointment with the chosen physician.
. Ms. Amaya shall provide written discovery responses to Sims Recycling’s
attorney on or before February 18, 2020. Should she fail to do so, the Court
might dismiss her case with prejudice to its refiling.
. The Court schedules a status conference on April 13 at 9:30 a.m. Central time.
You must dial 615-532-9552 or 866-943-0025 toll-free to participate. Failure
to call at the designated time might result in a determination of the issues without
your participation. The Court will also hear Sims Recycling’s Motion to Dismiss
at that time.
. Ms. Amaya may contact an ombudsman at 1-800-332-2667 for assistance with
preparing her responses to written discovery and the motion to dismiss and/or if
she has procedural questions about her case.
. Should the parties reach a full, final settlement before the next hearing, they shall
notify the Court’s staff attorney, Jane Salem (615-770-1709 _ or
jane.f.salem@tn.gov), and prepare the appropriate documents to seek settlement
approval.
ENTERED February 5, 2020.
CDW
JNDGE KENNETH M. SWITZER
Court of Workers’ Compensation Claims
CERTIFICATE OF SERVICE
I certify that a copy of the Expedited Hearing Order was sent as indicated on
February 5, 2020.
Name Certified | Regular | Email | Sent to:
Mail Mail
Ms. Amaya, self- Xx 232 Clipper Ct.
represented employee Nashville TN 37211
Chip Storey, employer’s X | estoreyj@travelers.com
attorney
tejohnso@travelers.com
j}
fanny
Mom
Penny Shrun(,/Clerk of Court
Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov
FORM C-42
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN
Tt is a crime to knowingly provide false, incomplete or misleading information (to any party to a workers' compensation transaction Sor the
purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
In compliance with The Tennessee Workers' Compensation Law, T,C.A, Section 50-6-204
The injured employee shall accept the medical benefits afforded hereunder; provided, the employer shall designate a group of three (3)
or more reputable physicians or surgeons not associated together in practice, if available in that community, from which the injured employee
shall have the privilege of selecting the operating surgeon and the attending physician. If the injury is a back injury, the statutory panel must be
expanded to 4, one of whom must be a chiropractor with treatment limited to 12 chiropractic visits. Further, if the injucy or illness requires the
treatment of a physician or surgeon who practices orthopedic or neuroscience medicine, the employer may appoint a panel practicing orthopedic
or neuroscience medicine consisting of 5 physicians, with no more than 4 physicians affiliated in practice, If the employer provides this panel,
the injured employee shall be entitled to have a second opinion on the issue of surgery, impairment, and a diagnosis from that same panel.
1. Middle Tennessee Occupational Medicine (615) 213-2880
"1237 Heil Qtiaker Blvd. LaVergne tN" 37086
OFFICE ADDRESS CITY STATE ZIP
@ Dr. Austin "Tony" Adams (615) 355-1620
BST Quedek Circle Smyrna PAR 37167
~~ OFFICE ADDRESS Cs CITY STATE Ze
3. U.S. Health Works (615) 984-2850
"YE39 Wad aWood Drive Smyrna PHENYE 37167
OFFICE ADDRESS ~ CITY STATE ZIP
4,
PHYSICIAN'S or CHIROPRACTOR’S NAME PHONE
OFFICE ADDRESS - CITY ~ STATE ZIP 7
5.
PHYSICIAN’S NAME PHONE
OFFICE ADDRESS CITY STATE ZIP
(d)Q1) "The injured employee must submit to examination by the employer's physician ai all reasonable times if tequested to do so by the
employer, but the employee shall have the right to have the employee's own physician present at such examination, in which case the employee
shall be liable to such physician for such physician's services,"
(7) "If the injured employee refuses to comply with any reasonable request for examination or to accept the medical or specialized medical
services which the employer is required to furnish under the provisions of this law, such injured employee's right to compensation shall be
suspended and no compensation shall be due and payable while such injured employee continues such refusal."
According to the provisions of this agreement, I hereby have selected the following physician from the
list provided to me by my employer
Physician chosen: OA (23 \2© les =) Date of injury: Aug, lo “Zo Le
Date of selection: be Nust wn Adams (ee _ .
Date of appointment:
Sims Recycling Solutions “Tonia: Drnaua
4t? New 8inford Rd. ; 305. Cliopey Ch
LaVergne TN 37086 Nee —e) S191]
(615) 751-5796 Staie Zip City State ~ Zip
Phone Phor
Employer’s Signature eile LA Tie 7
(COP SY 4547]
Employee’s SSN
State File Number
CLEAR FORM
LB-0382 (REV. 07/08) RDA 10183
EXHIBIT
A.
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
FORM C-42
EMPLOYEE’S CHOICE OF PHYSICIAN
An employer must provide a partially-completed form listing at least three physicians to an employee upon the
report of a workplace injury. The employee must complete and then sign and date the section below that indicates the
physician chosen. A copy of the fully-completed form should be provided to the employee with the original kept on file
by the employer. If the employee refuses to accept medical services from the chosen physician, the employee’s rights to
benefits may be delayed. NOTE: Employees traveling more than 15 miles one way to or from medical treatment may
seek reimbursement of their travel expenses from the insurance carrier.
TO BE COMPLETED BY THE EMPLOYER:
Employe SIMS Recycling Solutions | Date of injury 08/10/2017 _
Employer Contact Carrie Billingsley Phone (615) 751-5796 Email esreieiplingsleyareimemmesty
Physician Name DF. Colin Crosby (Elite Sports Med) phone (615) 234-1600
Address 2004 Hayes St., Ste. 200 .,, Nashville state IN 7; 37203 _
Physician Name Df. Christopher Kauffman (Hughston Clinic) Phone (015) 834-4722
Address 394 Harding Place, Ste. 200 _,,, Nashville “state IN 7;, 37203
(schedoling
Physician Name UF. Gray Stahlman (TN Ortho Alliance) —_,,... (615) 329-6600 1495
addres ON City - 8 City Blvd —_,, Nashville state TN ip 37209
TO BE COMPLETED BY THE EMPLOYEE:
I have selected the following physician from the list provided to me by my employer:
e , ‘
Physician Name 2 c Gray SPOBlAMA Date Selected 7- LPIE aa
Employee Name [PL VIP GADDIS Phone O£S°SBEP_ GFA
Address ae zc fi Lt; Li ee 7 City Mex Sblitte State 77” _Zip eS. PE
Phone b he CS SEF -OF 4/ Email
Employee Signature TOM“ LAN? © - ____ Date YLP-TE
LB-0382 (REV L1/15) RDA 10183
TRV,GM1831821001180000000,11/14/2018,ECN1831821000314
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, |-B
Nashville, TN 37243-1002
FORM C-42
EMPLOYEE'S CHOICE OF PHYSICIAN
An employer must provide a partiully-completed form listing at least three physicians to an employee upon the
report of a workplace Injury. The employee must complete and then sign and date the section below that indicates the
physician chosen, A copy of the fully completed form should be provided to the employee with the original kept on file
by the employer. If the employee refuses to accept medical services from the chosen physician, the employee’s rights to
benetits may be delayed. NOTE: Employees traveling more than 15 miles one way to or from medical treatment may seek
reimbursement of their travel expenses from the insurance carrier.
TO BE COMPLETED BY THE EMPLOYER:
Employer _ sim. Recycling Solutions Date of Injury _OR/ 10/2017
Employer Contact Phone Email
Physician Name _ Ur, James Walker Phone _(615)479-7408
Address _4¢]9 Hiltsborg Pike (sub City _ Nashville State IN Zip _4/7]5 0000
Physician Name Dr. Stephen Montgomery Phone
Address 4219 Hillsboro Pike #306 City _Nashv tile State_TN Zip 34/715 0000
Physician Name _ Dr. Pamela Auble Phone _ (6153340 4686
Address _ 2700) 2) st_Ave S$. {/40] City _Nashville State_IN Zip _i/2)2 9000
TO BE COMPLETED BY THE EMPLOYEE:
I have selected the following physician from the list provided to me by my employer:
Physician Name 2 ¥- Parteln Dv 4/70 Date Selected
Employee Name _lgiyy Amaya Appt Date/Time
Address _23? Clipper ¢t City Nashville State _ IN Zip 4/711
Phone _(615)58?_69)J Email
Employee Signature 7 AYA LL1BL A Date ff = 2-18
LB-0382 (REV 11/15) RDA 10183
C24299 8/16 F3162C1P18306003207 00001 N
TRV,GM1831821001180000000,11/14/2018,ECN1831821000314
F PLease ENSURE THAT ADDRESS BELOW APPEARS IN ADDRESS AREA OF RETURN ENVELOPE
TRAVELERS)
Travelers Indemnity Co of CT
Po Box 660456
Dallas, TX 75266--045
TRV,GM1831821001180000000,11/14/2018,ECN1831821000314
SB6S6-S97¢S524
alee Ep FED MND deneeatet ceed ta fg Hep Ele pee ek [Af
MRA
Li=78laa St.
UNIAN
PUSIWS ENS
Le
ACIS Ne
ron] ‘ NVA i FF ie
MAIS AYY
GSN
AS - rN
KRIS ARE
ays I AAS
ARN AT SG
SU Wp NY NS
BW AS ZUG
“i WAN Se!
ie SAM
. — Vw ah
SAS eau
i; a
SIRS A
= a AN
GEN WArANG!
NSN SH mo
ays MWA
\
‘* a fps + sere
SN EWE SAS
“GEL ES
S bets\
IN
ISNA
N ‘ S
SIN
Se |
NQ
aBassayday Ad divd 3d THM ADVLSOd
71434 SSANISNA
HOJLHWH GP ON UNHSd TWA SSVTO-LSHi
>=
PZ >
mg uw ¥
R= ao
Bee
=
SHL NI
GFW JI
SaiViS GAaLINN
AYVSSSOIN
395viLSOd ON
Oficina de Compensacion a Trabajadores de Tennessee
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, |-B
Nashville, TN 37243-1002
FORMULARIO C-42
FORM C-42
SELECCION DE MEDICO POR UN EMPLEADO
EMPLOYEE’S CHOICE OF PHYSICIAN
Un empleador tiene que proporcionar un formulario parcialmente completado que enumere al menos tres médicos
a un empleado al reportar una lesién que ocurri6 en el lugar de trabajo. El empleado tiene que completar y luego
firmar y fechar la seccién abajo que indica el médico escojido. Una copia del formulario completado debe ser
proporcionado al empleado y el original se debe mantener en los archivos del empleador. Si el empleado rehusa aceptar
servicios médicos del médico escojido, los derechos a beneficios del empleado pueden ser retrasados. NOTA: Los
empleados que viajan mas de 15 millas de ida 0 de vuelta que tratamiento médico pueden pedir reembolso de sus gastos
de viaje a la compafiia aseguradora
An employer must provide a partially-completed form listing at least three physicians to an employee upon the
report of a workplace injury. The employee must complete and then sign and date the section below that indicates the
physician chosen. A copy of the fully-completed form should be provided to the employee with the original kept on file
by the employer. If the employee refuses to accept medical services from the chosen physician, the employee’s rights to
benefits may be delayed. NOTE: Employees traveling more than 15 miles one way to or from medical treatment may
seek reimbursement of their travel expenses from the insurance carrier.
PARA SER COMPLETADO POR EL EMPLEADOR:
TO BE COMPLETED BY THE EMPLOYER:
Empleador (Employer) Si ms Recycl in g So | uti Ons Fecha de Lesién (Date of Injury) 8/1 0/2 0 1 7
Contacto del Empleador (Employer Contact) Attorney Chi p Storey Teléfono (Phone) © | 56606209
Correo Electrénico (Email) cstorey} @travelers.com
Nombre del Médico (Physician Name) Dr. David West Teléfono (Phone 61 9-837-4360
Direccién (Address) 4300 Sidco Dr Ciudad (City) Nashvil le Estado (State) TN
(Cédigo Postal) Zip 37211
Nombre del Médico (Physician Name) Dr. David Moore Teléfono (Phone 61 9-324-1 600
Direccion (Address) 2021 Chu rch St #200 Ciudad (City) Nashvi lle Estado (State) TN
(Cédigo Postal) Zip 3232
Nombre del Médico (Physician Name) Dr. Ja mes Re nfro Teléfono (Phone 6 1 5-366-8890
Direccién (Address) 394 Harding Place #200 Ciudad (City) Nashville Estado (State) TN
(Cédigo Postal) Zip 37211
EXHIBIT
ot
LB-0382s (REV 11/15)
PARA SER COMPLETADO POR EL EMPLEADOR
TO BE COMPLETED BY THE EMPLOYEE:
He seleccionado el siguiente médico de la lista que mi empleador me proprociond:
Ihave selected the following physician from the list provided to me by my employer:
Nombre del Médico (Physician Name) Fecha Seleccionada (Date Selected)
Nombre del Empleado (Employee Name) Ta nya Amaya Teléfono (Phone) 6155826911
Direccién (Address) 232 C | ipper Cou rt Ciudad (City) Na shvil le Estado (State) TN
(Cédigo Postal) Zip 397211
Teléfono Phone) 9199826911 Correo Electrénico (Email) n/a
Firma del Empleador (Employee Signature) (Fecha) Date
LB-0382s (REV 11/15) RDA 10183
Expedited Hearing Order Right to Appeal:
If you disagree with this Expedited Hearing Order, you may appeal to the Workers’
Compensation Appeals Board. To appeal an expedited hearing order, you must:
1. Complete the enclosed form entitled: “Notice of Appeal,” and file the form with the
Clerk of the Court of Workers’ Compensation Claims within seven business days of the
date the expedited hearing order was filed. When filing the Notice of Appeal, you must
serve a copy upon all parties.
2. You must pay, via check, money order, or credit card, a $75.00 filing fee within ten
calendar days after filing of the Notice of Appeal. Payments can be made in-person at
any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
alternative, you may file an Affidavit of Indigency (form available on the Bureau’s
website or any Bureau office) seeking a waiver of the fee. You must file the fully-
completed Affidavit of Indigency within ten calendar days of filing the Notice of
Appeal. Failure to timely pay the filing fee or file the Affidavit of Indigency will
result in dismissal of the appeal.
3. You bear the responsibility of ensuring a complete record on appeal. You may request
from the court clerk the audio recording of the hearing for a $25.00 fee. If a transcript of
the proceedings is to be filed, a licensed court reporter must prepare the transcript and file
it with the court clerk within ten business days of the filing the Notice of
Appeal. Alternatively, you may file a statement of the evidence prepared jointly by both
parties within ten business days of the filing of the Notice of Appeal. The statement of
the evidence must convey a complete and accurate account of the hearing. The Workers’
Compensation Judge must approve the statement before the record is submitted to the
Appeals Board. If the Appeals Board is called upon to review testimony or other proof
conceming factual matters, the absence of a transcript or statement of the evidence can be
a significant obstacle to meaningful appellate review.
4. If you wish to file a position statement, you must file it with the court clerk within ten
business days after the deadline to file a transcript or statement of the evidence. The
party opposing the appeal may file a response with the court clerk within ten business
days after you file your position statement. All position statements should include: (1) a
statement summarizing the facts of the case from the evidence admitted during the
expedited hearing; (2) a statement summarizing the disposition of the case as a result of
the expedited hearing; (3) a statement of the issue(s) presented for review; and (4) an
argument, citing appropriate statutes, case law, or other authority.
For self-represented litigants: Help from an Ombudsman is available at 800-332-2667.
NOTICE OF APPEAL
Tennessee Bureau of Workers’ Compensation
www.tn.gov/workforce/injuries-at-work/
wce.courtclerk@tn.gov | 1-800-332-2667
Docket No.:
State File No.:
Date of injury:
Employee
Employer
Notice is given that
[List name(s) of all appealing party(ies). Use separate sheet if necessary.]
appeals the following order(s) of the Tennessee Court of Workers’ Compensation Claims to the
Workers’ Compensation Appeals Board (check one or more applicable boxes and include the date file-
stamped on the first page of the order(s) being appealed):
0 Expedited Hearing Order filed on O Motion Order filed on
0 Compensation Order filed on C1 Other Order filed on
issued by Judge
Statement of the Issues on Appeal
Provide a short and plain statement of the issues on appeal or basis for relief on appeal:
Parties
Appellant(s) (Requesting Party): fo Employer] ‘Employee
Address: Phone:
Email:
Attorney’s Name: BPR#:
Attorney's Email: Phone:
Attorney's Address:
* Attach an additional sheet for each additional Appellant *
LB-1099 rev. 01/20 Page lof 2 RDA 11082
Employee Name: Docket No.: Date of Inj.:
Appellee(s) (Opposing Party): [| Employer [- ‘Employee
Appellee’s Address: Phone:
Email:
Attorney’s Name: BPR#:
Attorney’s Email: Phone:
Attorney’s Address:
* Attach an additional sheet for each additional Appellee *
CERTIFICATE OF SERVICE
I, , certify that | have forwarded a
true and exact copy of this Notice of Appeal by First Class mail, postage prepaid, or in any manner as described
in Tennessee Compilation Rules & Regulations, Chapter 0800-02-21, to all parties and/or their attorneys in this
case on this the day of , 20
[Signature of appellant or attorney for appellant]
LB-1099 rev. 01/20 Page 2 of 2 RDA 11082