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Selley v. Liberty Northwest Insurance Corp.3/23/2000
APPEAL FROM: Workers' Compensation Court State of Montana The Honorable Mike McCarter, Judge presiding.
Submitted on Briefs: September 2, 1999
Clerk
1. From the Decision and Judgment of the Workers' Compensation Court (WCC), State of Montana, Darci Selley (Selley) appeals. The WCC held that Liberty Northwest Insurance Corporation (Liberty) was not estopped from refusing to recognize and reimburse Selley's treating physician notwithstanding the fact that Liberty had been reimbursing that physician for a period of two years. We reverse and remand.
2. The dispositive question on appeal is whether the WCC erred in holding that Liberty was not estopped from asserting § 39-71-116(30), MCA (1993), as a defense?
Factual and Procedural Background
3. This case was submitted to the WCC for decision based on a stipulated set of uncontested facts and exhibits which reveal the following. On January 7, 1995, Selley was injured while working for Turn of the Century, Inc., which was insured at that time by Liberty. Upon submission of Selley's claim, Liberty accepted liability and began to pay both wage loss and medical benefits. When her claim was approved by Liberty, Selley selected Richard A. Nelson, M.D. (Dr. Nelson), a neurology and psychiatry specialist, as her treating physician. Liberty then fully reimbursed Dr. Nelson for his care and treatment of Selley through the first quarter of 1997. Liberty's claims examiner, Jim Belknap, first learned on January 9, 1997, that Dr. Nelson does not have admitting privileges at any hospital near his medical practice.
4. Up until approximately seven years prior to this case, Dr. Nelson had admitting privileges at both St. Vincent Hospital and Deaconess Hospital in Billings. However, at that time, he resigned his privileges at both hospitals because he had moved his residence to a location near Columbus, Montana. Columbus lies approximately fifty miles, one way, from his Billings office. Because both hospitals required that a doctor reside within a prescribed number of miles of the hospital or be able to reach it within a specified time-limit, Dr. Nelson's new residence precluded him from meeting these requirements. Therefore, he resigned.
5. Upon discovering in 1997 that Dr. Nelson did not have admitting privileges at any hospital near his practice, Liberty provided notice to Selley that it would refuse further reimbursement to Dr. Nelson on the basis that he did not qualify as Selley's "treating physician" pursuant to § 39-71-116, MCA. Liberty's refusal affected only prospective reimbursement of Dr. Nelson, and Liberty did not refuse payment of any of Dr. Nelson's bills incurred prior to its notice of refusal.
Discussion
6. Did the WCC err in concluding that Liberty was not estopped from refusing Selley further coverage because Dr. Nelson does not qualify as a treating physician under § 39-71-116(30), MCA (1993)?
7. We review a workers' compensation decision to determine whether there is substantial evidence to support the court's findings of fact. Houts v. Kare-Mor, Inc. (1993), 257 Mont. 65, 68, 847 P.2d 701, 703. Regarding questions of law, this Court must determine whether the Workers' Compensation Court's interpretation of the law is correct. Dilling v. Buttrey Foods (1991), 251 Mont. 286, 289, 825 P.2d 1193, 1195. Since the facts are not in dispute, the resolution of this appeal turns upon an interpretation of the law.
8. The disputed statute reads in relevant part:
(30) "Treating physician" means a person who is primarily responsible for the treatment of a worker's compensable injury and is:
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