# Amaya, Tanya v. Sims Recycling Solutions, Inc. > Tennessee Court of Workers' Compensation Claims · February 5, 2020 · 2020 TN WC 17 URL: https://www.frixlaw.com/law-library/cases/4560539 ## Case - **Court:** Tennessee Court of Workers' Compensation Claims - **Decided:** February 5, 2020 - **Citations:** 2020 TN WC 17 - **Precedential status:** Published - **Opinion:** Opinion - **Judges:** Kenneth M. Switzer - **Cited by:** 0 later opinions in the Frix Law Library ## Citator (automated) - No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases. - Full citator and citing cases: https://www.frixlaw.com/law-library/cases/4560539 ## Opinion text 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 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/4560539. Public record. Not legal advice.