CERES MARINE TERMINALS v. Armstrong
59 Va. App. 694
| Va. Ct. App. | 2012Background
- Armstrong sustained a compensable injury on July 14, 2000; treatment included surgery on January 6, 2005 by a surgeon and assistant of the medical provider.
- The medical provider billed $30,013.75 for the surgery; the employer paid $5,123.76.
- The medical provider requested the Commission to award the unpaid balance; the request followed payment disputes and explanations that the payment should reflect the applicable fee schedule.
- A deputy commissioner found the employer failed to rebut the medical bill’s prima facie evidence and the Commission awarded $25,664.22 to the medical provider as unpaid balance.
- The full Commission affirmed the deputy; the employer sought review with several assignments of error, including prevailing-rate proof, application of the Longshore fee schedule, and timeliness/laches/spoliation arguments.
- On appeal, the Virginia Court of Appeals held the Commission properly placed the burden on the employer, found insufficient evidence of the prevailing rate in the community, and deemed laches and spoliation arguments waived.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Burden of proof for excessiveness of the medical bill | Employer argues burden should shift to medical provider and that fee schedule proves prevailing rate. | Medical provider argues the bill is prima facie evidence of reasonableness and employer bears burden to show excessiveness. | Employer bears burden to prove excessiveness; evidence insufficient to show prevailing-rate excessiveness. |
| Evidence of the prevailing rate in the community | Employer contends Longshore fee schedule establishes prevailing rate for Armstrong's surgery. | Medical provider argues Longshore rate does not prove the community prevailing rate for this surgery. | Commission properly rejected the Longshore schedule as sole proof and found insufficient evidence of the community prevailing rate. |
| Whether to consider regular or reasonable rate apart from prevailing rate | Employer seeks to compare bill to regular/Medicare-based reasonable rates. | Act limits liability to charges prevailing in the community for similar treatment; no separate regular/regular-reasonable standard applies. | No independent regular/ reasonable-rate standard; only the prevailing-rate standard applies. |
| Laches | Employer argues laches should bar the claim due to late filing. | Medical provider argues no timely basis to invoke laches; arguments not adequately supported with authorities. | Waived due to failure to provide authorities under Rule 5A:20(e). |
| Evidence spoliation | Employer asserts spoliation of records should affect determination. | Medical provider bears responsibility; insufficiency of evidence to support spoliation claim. | Waived for lack of legal authorities under Rule 5A:20(e). |
Key Cases Cited
- Fairfax Cnty. Sch. Bd. v. Humphrey, 41 Va. App. 147 (2003) (construction of Workers' Compensation Act; substantial rights; humanitarian purpose)
- Cross v. Newport News Shipbuilding & Dry Dock Co., 21 Va. App. 530 (1996) (commission's interpretation of the Act entitled to great weight)
- Rabineau v. McDonald's/RJK Corp., No. 156-99-57 (Va. W.C.C. Oct. 15, 1993) (1993) (precedent recognizing medical bill as prima facie evidence of reasonableness)
- Gens v. Workmen's Comp. Appeal Bd., 158 Pa. Cmwlth. 313, 631 A.2d 804 (1993) (employer bears burden to prove medical charges are inappropriate in workers' comp.)
- Bogle Dev. Co. v. Buie, 19 Va. App. 370, 451 S.E.2d 682 (1994) (medical bill as prima facie evidence of reasonableness; rebuttal by employer permitted)