The opinion
FILED
Sep 03, 2020
09:11 AM(ET)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT KNOXVILLE
SHANE M. DAVIS, ) Docket No. 2020-03-0054
Employee, )
v. ) State File No. 9633-2018
HARVEST PARTY RENTALS, )
Uninsured Employer. ) Judge Pamela B. Johnson
EXPEDITED HEARING ORDER DENYING BENEFITS
Decision on the Record
Shane Davis fell at work, but Harvest Party Rentals did not provide workers’
compensation benefits. Mr. Davis filed this claim seeking payment of his medical bills,
additional treatment, and temporary total disability benefits. After a review of the record,
the Court holds Mr. Davis is not entitled to the requested benefits at this time because he
did not file medical records or other documentary evidence that satisfies his burden of
proof.
History of Claim
The Court gleaned the history from the Petition for Benefit Determination, the
Expedited Request for Investigation Report, and the affidavits of Mr. Davis, Mr. Hancock,
and the bookkeeper. Neither party filed medical records or bills, so much is unknown on
this record.
What is known and undisputed is that on September 7, 2019, Mr. Davis lost his
footing while exiting the back of an equipment truck. He landed on both knees and his right
wrist, and he immediately felt pain in his wrist. John Hancock, the owner of Harvest Party
Rentals, told him to go to the emergency room and agreed to pay his medical bills and
wages until he returned to work. Mr. Davis received emergency care and ultimately
required surgery to repair his broken wrist. His treating physician was Dr. William Oros.
The parties disputed Mr. Davis’s ability to return to work. In his affidavit, Mr. Davis
stated that he cannot lift or hold objects with his right hand, or perform his normal job
l
duties, and therefore, he has not returned to work. In contrast, Mr. Hancock wrote in his
affidavit that he paid Mr. Davis wages after the injury although he had not returned to work.
Mr. Hancock further stated that he offered Mr. Davis a job answering phones, which Mr.
Davis refused. Mr. Hancock stated that Mr. Davis voluntarily quit his job, which the
bookkeeper confirmed.
Findings of Fact and Conclusions of Law
At an Expedited Hearing, Mr. Davis must prove that he is likely to prevail at a
hearing on the merits that he is entitled to the requested medical and temporary disability
benefits. See McCord v. Advantage Human Resourcing, 2015 TN Wrk. Comp. App. Bd.
LEXIS 6, at *7-8, 9 (Mar. 27, 2015).
Turning first to medical benefits, the Workers’ Compensation Law requires an
employer to provide medical and surgical treatment made reasonably necessary by a work
injury. Tenn. Code Ann. § 50-6-204(a)(1)(A) (2019). Further, a work injury must arise
primarily out of and in the course and scope of employment, and it must be shown to a
reasonable degree of medical certainty. See Tenn. Code Ann. § 50-6-102(14).
Here, despite the fact that the parties agree that Mr. Davis fell at work, injured his
wrist, and received medical treatment, Mr. Davis did not introduce any medical records
documenting his treatment or the resulting charges. Importantly, Mr. Davis did not
introduce any opinion from a medical doctor that causally relates his need for treatment to
the work incident and confirms that the medical treatment was reasonable and necessary.
At this time, the Court holds Mr. Davis did not show that he is likely to prevail at a hearing
on the merits that he is entitled to payment of his medical bills.
Turning to his request for ongoing treatment, the Workers’ Compensation Law
additionally requires that when the employee has suffered an injury and expressed a need
for medical care, the employer shall provide a panel of three physicians from which the
injured employee shall select one to be the treating physician. Jd. at 50-6-204(a)(3). If an
employer elects to deny a claim, it runs the risk that it will be responsible for medical
benefits obtained from a provider of the employee’s choice and/or that it may be subject to
penalties for failure to provide a panel and/or benefits in a timely manner. McCord, at *10.
Applying these principles, Mr. Davis was justified in seeking treatment on his own
when Harvest Party Rentals did not provide a panel of physicians. However, before the
Court can order Harvest Party Rentals to provide ongoing treatment, Mr. Davis must prove
that the need for continuing treatment is causally related to work.
Harvest Party Rentals did not meet its obligations under the Workers’ Compensation
Law. After learning of Mr. Davis’s injury, it did not provide medical benefits or a panel.
Therefore, the Court refers Harvest Party Rentals to the Compliance Program for
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investigation and assessment of a penalty for its failure to provide a panel.
In addition to medical benefits, Mr. Davis seeks temporary disability benefits. An
injured employee is eligible for temporary disability benefits if: (1) the injured employee
became disabled from working due to a compensable injury; (2) a causal connection exists
between the injury and the inability to work; and (3) the injured employee established the
duration of the period of disability. Jones v. Crencor, 2015 TN Wrk. Comp. App. Bd.
LEXIS 48, at *7 (Dec. 11, 2015).
As stated above, Mr. Davis did not introduce medical records showing he became
disabled due to a work injury and the causal connection between the injury and his inability
to work. Therefore, at this time, the Court holds Mr. Davis did not show that he is likely to
prevail at a hearing on the merits that he is entitled to temporary disability benefits.
IT IS, THEREFORE, ORDERED as follows:
1. Mr. Davis’s requested benefits are denied at this time.
2. Harvest Party Rentals is referred to the Compliance Program for investigation and
assessment of a penalty for its failure to provide a panel of physicians.
3. This case is set for a Scheduling Hearing on January 4, 2021, at 2:00 p.m. Eastern
Time. The parties must call (toll-free) (855) 543-5041 to participate in the
Scheduling Hearing. Failure to appear by telephone might result in a determination
of the issues without the parties’ participation.
ENTERED September 3, 2020.
Pamele E. (zeae
JUDGE PAMELA #/ JOHNSON
Court of Workers’ Compensation Claims
APPENDIX
The Court reviewed the entire case file in reaching its decision. Specifically, the
Court reviewed the following documents, marked as exhibits for ease of reference:
Exhibits:
1. Petition for Benefit Determination
2. Expedited Request for Investigation
Employer’s Objection to Dispute Certification Notice
Dispute Certification Notice
Show Cause Order
Expedited Request for Investigation Report
Amended Show Cause Order
Order Setting Deadline to File Request for Hearing
Request for Expedited Hearing
a. Employee’s List of Co-Workers
b. Affidavit of Shane Davis
10. Docketing Notice for Decision on the Record
11.Employer’s Response
a. Affidavit of James Hancock
i. Harvest Party Rental Pay Stub
b. Affidavit of Kristy Lavella
i. Text Message of Shane Davis
Bo! On! [ON fom ge
CERTIFICATE OF SERVICE
I certify that a copy of this order was sent as shown on September 3, 2020.
Name U.S. Mail Email Service sent to:
Shane M. Davis, xX 406 First Street
Self-Represented Seymour, TN 37865
Employee
Mary Elizabeth Maddox, x mmaddox@fmsllp.com
Employer’s Attorney
Compliance Program xX WCCompliance.Program@tn.gov
|
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Hor peo TH rcee un pur HA dy,
PENN ¥ SHRUM, Court Clerk Pairs
Wc. SERUM, Ce gov
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:
|. 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
concerning 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.pov/workforce/Injurles-at-work/
wc.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):
O Expedited Hearing Order filed on O Motion Order filed on
C1 Compensation Order filed on O 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): [Oo 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 1 of 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
Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
800-332-2667
AFFIDAVIT OF INDIGENCY
I, , having been duly sworn according to law, make oath that
because of my poverty, | am unable to bear the costs of this appeal and request that the filing fee to appeal be
waived. The following facts support my poverty.
1. Full Name: 2. Address:
3. Telephone Number: 4. Date of Birth:
5, Names and Ages of All Dependents:
Relationship:
Relationship:
Relationship:
Relationship:
6. 1 am employed by:
My employer’s address is:
My employer’s phone number is:
7. My present monthly household income, after federal income and social security taxes are deducted, is:
$
8. | receive or expect to receive money from the following sources:
AFDC $ per month beginning
SSI $ per month beginning
Retirement $ per month beginning
Disability $ per month beginning
Unemployment $ per month beginning
Worker's Comp.$ per month beginning
Other $ per month beginning
LB-1108 (REV 11/15) RDA 11082
9. My expenses are:
Rent/House Payment $ permonth Medical/Dental $ per month
Groceries $ per month Telephone $ per month
Electricity $ per month School Supplies $ per month
Water $ per month Clothing $ per month
Gas $ per month Child Care $ per month
Transportation $ per month Child Support $ per month
Car $ per month
Other $ per month (describe: }
10. Assets:
Automobile $ (FMV)
Checking/Savings Acct. $
House $ _ (FMV)
Other $ Describe:
11. My debts are:
Amount Owed To Whom
| hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete
and that | am financially unable to pay the costs of this appeal.
APPELLANT
Sworn and subscribed before me, a notary public, this
day of , 20
NOTARY PUBLIC
My Commission Expires:
LB-1108 (REV 11/15) RDA 11082