Watkins v. Lake Charles Memorial Hospital
144 So. 3d 944
La.2014Background
- Dustin Watkins suffered a neonatal stroke causing lifelong brain injury; trial awarded extensive past and future medical and custodial/attendant care, with the PCF responsible for amounts beyond defendant physician limits.
- 2003 judgment found Dustin in need of future custodial/attendant care; appellate courts affirmed. The district court in 2006 ordered the PCF to make quarterly, advance payments (to a special needs trust) upon plaintiff's affidavit certifying no change in condition.
- In 2011 the PCF stopped advance payments after discovering online information suggesting Dustin no longer lived with his mother (the primary caregiver) and requested an independent medical exam (IME); payments paused despite no court modification of the 2006 order.
- Plaintiff sought court relief; after hearing the district court found the PCF unreasonably ceased payments, awarded accrued amounts through March 26, 2012 (24-hour care until that date, reduced to six hours/day thereafter), and assessed attorney fees against the PCF.
- The PCF appealed, arguing it may deny claims it reasonably believes are not actually incurred or necessary and that it need not obtain prior judicial modification to stop payments after suspecting abuse or changed circumstances.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether PCF must obtain judicial modification before discontinuing advance payments ordered by prior judgment | Watkins: PCF must comply with court order until modified; may not unilaterally stop payments | PCF: MMA grants PCF authority to evaluate and refuse payment when expenses not actually incurred or are unnecessary without prior court approval | Court held PCF must seek judicial modification; must obey district court's ruling/orders until modified or set aside |
| Whether district court could award custodial payments beyond the two quarterly affidavits submitted in 2011 | Watkins: court has continuing jurisdiction and could award accrued and prospective payments; parties stipulated prospective disputes would be heard | PCF: awards should be limited to periods supported by submitted affidavits and actually-incurred care | Court upheld award for accrued custodial care through March 26, 2012, noting parties’ stipulation and court’s continuing jurisdiction |
| Whether PCF reasonably discontinued payments based on IME and internet evidence | Watkins: PCF acted arbitrarily relying on social media and delayed IME; evidence supported ongoing need | PCF: had good reason to suspect abuse/fraud and to suspend payments pending evaluation | Court found PCF’s cessation unreasonable on the record; credited treating experts and caregiver testimony over PCF’s IME |
| Whether attorney fees should be awarded for PCF’s failure to pay within 30 days | Watkins: entitlement under LSA-R.S. 40:1299.43(E)(2) because PCF unreasonably failed to pay | PCF: denial was reasonable and justified; fees inappropriate | Court affirmed attorney-fee award, concluding PCF willfully violated the 2006 mandate (some justices dissented on fees) |
Key Cases Cited
- Kelty v. Brumfield, 633 So.2d 1210 (La. 1994) (explains PCF/agency primary role in administering future medical benefits and limits on court role)
- Hanks v. Seale, 904 So.2d 662 (La. 2005) (addresses payment timing and PCF obligations under the MMA)
- Hall v. Brookshire Brothers, Ltd., 848 So.2d 559 (La. 2003) (discusses future medical expense payment mechanics and judicial interest issues)
- Bijou v. Alton Ochsner Med. Found., 679 So.2d 893 (La. 1996) (procedure for claim submission to PCF for future medical benefits)
- Bartee v. Children’s Clinic of Southwest La., 910 So.2d 470 (La. App. 3 Cir. 2005) (PCF administrative rules cannot supersede district court’s continuing jurisdiction under the MMA)
- Williamson v. Hospital Serv. Dist. No. 1 of Jefferson, 888 So.2d 782 (La. 2004) (context on PCF liability limits and statutory scheme)