The opinion
FILED
Dec 08, 2022
12:19 PM(CT)
TENNESSEE COURT OF
WORKERS' COMPENSATION
CLAIMS
TENNESSEE BUREAU OF WORKERS’ COMPENSATION
IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT MURFREESBORO
STEVEN QUALLS, ) Docket No. 2022-02-0451
Employee, )
v. )
FEDERAL MOGUL, ) State File No. 800994-2002
Employer, )
And )
INDEMNITY INSURANCE ) Judge Brian K. Addington
COMPANY OF NORTH AMERICA, )
Carrier. )
EXPEDITED HEARING ORDER DENYING MEDICAL BENEFITS
Decision on the Record
Mr. Qualls sought an order that Federal Mogul furnish medical benefits for an
alleged back injury. Federal Mogul disputed the back condition arose primarily out of and
in the course and scope of employment. The Court holds Mr. Qualls did not introduce any
medical evidence proving that his condition arose out of and in the course and scope of his
employment and denies the requested medical benefits.
Claim History
Mr. Qualls alleged a work injury to his back while picking up a heavy box on June
24, 2022.1 After his shift, he went to the emergency room because his pain worsened. The
emergency room doctor documented the history provided: “The onset was [sic] past two
weeks, gradually worsening. Type of injury: none. The location where the incident
occurred was at home. . . . [S]tates he lifts heavy objects at work and felt worsening pain
today.” He received an injection for the pain, and the doctor released him with light-duty
restrictions with instructions to follow up with his primary doctor. Mr. Qualls notified his
supervisor, who told him to obtain more specific restrictions from his doctor.
1.
Mr. Qualls’s Petition for Benefit Determination listed the injury date as June 25, 2022. Later, he realized
the injury happened on June 24 instead.
Four days later, Mr. Qualls saw his primary provider, nurse Jennifer Dyer. She
noted the following in her records:
Pain continues and is radiating down leg did not schedule with [orthopedist]
so will refer to neurosurgeon based on symptoms. [He] tells me he is unsure
really how it happened. States he thought he blew his back out but unsure
how. He does work at an auto parts store and does a lot of lifting.
Later, Ms. Dyer documented in an office memo that Mr. Qualls never told her or
the emergency room doctor that he injured his back at work. She wrote that she would not
change anything in her records and recommended he contact someone else. Further, Ms.
Dyer completed a questionnaire stating that Mr. Qualls’s back pain was not primarily
related to a work injury..2
In August, Federal Mogul provided a physician panel from which Mr. Qualls
selected; however, it is unknown whether he ever saw the selected physician.
In September, Mr. Qualls sought unauthorized treatment with Dr. Jeffrey Peterson,
an orthopedic surgeon. In his office note, Dr. Peterson wrote, “He states that while at work
in June he bent over and picked up a heavy box and felt pain in his back.” Dr. Peterson
noted his physical findings from the examination but did not address any future care,
prescribe medications, suggest any options for Mr. Qualls’s treatment, or state whether his
pain was caused by the alleged work injury.
In addition to medical proof, the parties submitted affidavits of Mr. Qualls and two
of his supervisors, Victor Stewart and John Kleinschmidt. Mr. Qualls’s affidavit described
lifting a heavy box on June 24 and having back pain. The affidavits of Mr. Stewart and
Mr. Kleinschmidt stated that Mr. Qualls did not report an injury or say that his work
restrictions were due to a work injury. The two supervisors also stated the first time they
learned of his workers’ compensation claim was after Mr. Qualls filed the Petition for
Benefit Determination.
Findings of Fact and Conclusions of Law
Mr. Qualls must present sufficient evidence to show he is likely to prevail at a final
hearing. See Tenn. Code Ann. § 50-6-239(d)(1) (2022). He has not done so.
To meet this burden, Mr. Qualls must show to a reasonable degree of medical
2
Nurses,cannot offer- causation opinions. Dorsey v. Amazon.com, 2015 TN Wrk. Comp. App. Bd. LEXIS
13, at *9 (May 14, 2015).
2
certainty that lifting the box at work contributed more than fifty percent in causing the need
for his medical treatment, considering all causes. Tenn. Code Ann. § 50-6-102(12).
Here, Mr. Qualls submitted no medical proof that he injured his back at work on
June 24, 2022. Instead, the records show he sought treatment for back pain that started at
home two weeks before the alleged work injury. Further, the office note of Dr. Peterson
only recites the history provided by Mr. Qualls. It does not address whether his current
symptoms are primarily related to the alleged injury. Therefore, the Court holds Mr. Qualls
is not likely to prevail at a hearing on the merits that he is entitled to benefits.
IT IS, THEREFORE, ORDERED as follows:
1. Mr. Qualls’s request for medical benefits is denied.
2. This case is set for a Status Hearing on January 31, 2023, at 1:00 p.m. Central
Time. The parties must call (855) 543-5044. Failure to call may result in a
determination of the issues without the party’s participation.
ENTERED December 8, 2022.
/S/ Brian K. Addington
__________________________________
Brian K. Addington, Judge
Court of Workers’ Compensation Claims
3
Appendix
Exhibits:
1. Affidavit of Steven Qualls
2. Employee’s Choice of Physician Medical Panel
3. Wage Statement
4. Declaration of Victor Stewart
5. Declaration of John Kleinschmidt
6. Medical records-Ascension Saint Thomas
7. Medical records-The Health Group of McMinnville
8. Questionnaire
9. Medical records of Dr. Jeffrey Peterson
Technical Record:
1. Petition for Benefit Determination
2. Dispute Certification Notice
3. Request for Expedited Hearing
4. Employer’s Expedited Hearing Brief
5. Employer’s Expedited Hearing Exhibit List
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CERTIFICATE OF SERVICE
I certify that a copy of this order was sent as indicated on December 8, 2022.
Name Mail Email Service sent to:
Christopher Markel, X cmarkel@markelfirm.com
Employee’s Attorney jdickey@markelfirm.com
Chris Rowe, X cgrowe@mijs.com
Employer’s Attorney
_____________________________________
Penny Shrum, Clerk of Court
Court of Workers’ Compensation Claims
WC.CourtClerk@tn.gov
5
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
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.gov/workforce/injuries-at-work/
wc.courtclerk@tn.gov | 1-800-332-2667
Docket No.: ________________________
State File No.: ______________________
Date of Injury: _____________________
___________________________________________________________________________
Employee
v.
___________________________________________________________________________
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):
□ Expedited Hearing Order filed on _______________ □ Motion Order filed on ___________________
□ Compensation Order filed on__________________ □ 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): _________________________________________ ☐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 I 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