*1 95. HIETT, EULA MAE Aрpellant, Petitioner v. SCHOOLS, PUBLIC
MISSOULA COUNTY Respondent/Insurer/Employer. No. 02-043. 10, 2002. Heard October
Submitted
2002.
October
August
Decided
For E. McKenna & McKenna, Missoula. Respondent: (argued), Towe,
For Leo Kimberly S. Ward L. Browning, Kaleczyc, Hoven, Berry & Helena. Lawyers’
For Amicus Montana Trial Association: Patrick R. Halverson, Plath, Sheehy (argued), Sheehy Billings. & Opinion JUSTICE COTTER delivered the of the Court. (Hiett) appeals Eula Mae Hiett Workers’ ¶1 (WCC) Court’s payment determination that she was not entitled to prescription drugs. part certain We affirm in and and remand reverse in part. presents appeal-did Hiett one issue on err
¶2 WCC when prescription drugs determined that she was not entitled to pain depression resulting to control from her compensable injury? back
FACTUAL AND PROCEDURAL BACKGROUND Hiett, old, 1,1996, years working On March then 59 had been years County sixteen aas custodian for the Missoula Public Schools’ (School District). day, 30-gallon On this she lifted a trash can compression suffered fractures of her T6 and T8 thoracic vertebrae. injury, At the time of the the School District was a member of a Group Insurance pool school self-insurance known as Montana Schools (MSGIA). Authority accepted liability MSGIA for Hiett’s condition and disability paid sought medical benefits. Hiett treatment from Dr. (MMI) Sable who found her to at maximum medical permanently sedentary light- in June 1996. Hiett was restricted to duty work. July 1996, In part-time Hiett returned to as a custodian work with work, however, aggravated
modified duties. This her back thereafter, she was forced to stop. Shortly diagnosed Dr. Sable her anxiety and depression triggered by inability her to work as a custodian because of her injury. prescribed work-related He various anxiety medications to address her and depression and MSGIA accepted liability for examined psychiatrist these medications. A also Hiett and concurred with Dr. Sable’s conclusion. September 1996, approved jobs Dr. Sable a number of for Hiett. upon
Based his dеtermination that Hiett had MMI reached and his approval jobs, of a temporary number MSGIA terminated Hiett’s (TPD) partial disability tentatively benefits and calculated her (PPD) permanent partial disability 26%, $17,290. at Hiett was unable obtain the desired job School District that had approved by been Dr. qualified. Sable because she was not A two-hour per day job was offered but she turned it down because it would have *3 cost her get more to to and from work than she would earned. A have approved jobs during few other were available the last four months of 1996 but Hiett did not apply 1996, for them. In Decembеr the School District 3, terminated Hiett’s employment, January effective 1997. (SSD) began receiving Hiett then Security Disability Social September 1996, retroactive to application submitted her for retirement Employees System. to the Public Retirement negotiations 1997, Settlement began January in ¶8 over Hiett’s entitlement to PPD and Negotiations rehabilitation benefits. July 1997, terminated in agreement with a settlement under which $27,930. Hiett received agreement closed rehabilitation benefits but reserved “further hospital prior medical and benefits.” At no time attorney to settlement did tell Hiett or her MSGIA that continued payment contingent upon obtaining for medications Hiett was employment. working nor, At the time Hiett settled her claim she was not with exception July of the short-term modified custodial in position
1996, 1, sustaining injury. had she worked since her March 1996 Subsequent settlement, occasionally selling to the she worked tickets high sporting May at school She also from to events. worked assisted-living facility. November 2000 as an attendant at a retirement However, job upon being hospitalized drug had leave that for she to taking. medications she had been withdrawal from May for Hiett’s medication from 1996 until paid MSGIA August It from 1996 until January paid anti-depressants her January 1999, adjuster, a claims Charles January 1999. new file, Upon file. a he Edquest, took over Hiett’s case review “secondary constituted concluded that Hiett’s medications services,” payment and discontinued for these medications because working. Edquest did not contact Hiett to determine Hiett was not time, notify that he working at that nor did he her whether she was discontinuing prescription her She learned that was benefits. when, 1999, paying for her medicine in the fall of insurance was not refill and was told there was attempted prescriptions she to one оf the $1,600 She then told that outstanding pharmacist. bill with was insurance had been made for ten months. payment no early Edquest in Edquest Hiett’s counsel contacted October 1999. part because he agreed pay past prescriptions, then to for Hiett’s inadvertently notify prescription to her that benefits were had failed however, passed, and the bills to discontinued. Several months be the first requested Hiett mediation. After unpaid remained so mediation, $1,200 prescriptions was made. Other bills Edquest offered administrative reasons for outstanding remained delay agreed again pay to them. but оnce obligation that contested its ultimately Hiett was notified MSGIA working. not She for further medications Hiett was pay to because upon being a second mediation told benefits were requested pending opinion postponed discontinued. The second mediation was essential to her well- Hiett’s doctor that Hiett’s medications were receipt of a letter to this being Upon allow her to work. would working for the at which time Hiett was September effect Hiett’s medication for as facility, agreed pay retirement MSGIA long as she worked. unpaid as of December still remainеd Some bills time, By this therefore, a third mediation.
2000; requested Hiett result, facility. the retirement As a however, job Hiett had left her agreement regarding Hiett’s entitlement could not reach parties position prescriptions. *4 MSGIA maintained payment further paid while “secondary” benefits and would such benefits were Compensation petitioned Hiett the Workers’ employed. Hiett was paying ruling, agreed to continue Pending the court’s MSGIA Court. injury-related Hiett’s medications. 2001, and April 11, Hiett held on At the trial before WCC 99 6, 2001, the its Edquest September both testified. On WCC issued Fact, Findings Judgment holding Conclusions of Law and that Hiett drugs not entitled for her unless the prescription was to and, employment medications would enable her to return to once employed, working. enable her to continue The WCC also concluded penalty respect that Hiett was entitled to a to those benefits agreed pay pay MSGIA to failed The but to within reasonable time. findings court’s and detail conclusions will be discussed further below.
STANDARD OF REVIEW employs This Court two standards of review for decisions of the Compensation findings Workers’ Court: to we review of fact substantial, if they supported by evidence, determine are credible Geiger v. they wе review conclusions of law to determine if are correct. Fund, Uninsured Employers’ 332, 13, 242, 13, 2002 MT 313 Mont. ¶ ¶ (citations omitted). 259, 62 P.3d cases, compensation workers’ ¶ the law in effect at the injury time of the claimant’s establishes Compensation benefits. State Ins. Fund right claimant’s substantive to McMillan, v. 168, 6, MT 155, 6, 347, 306 Mont. 31 P.3d ¶ ¶ ¶
DISCUSSION Hiett legal advances several theories for her contention that reaching WCC erred in its conclusion that she was not entitled to the seeks, benefits she one of which the WCC misinterpreted statutory misconstrued the provisions. relevant Because we resolve this case under the court’s interpretation, wе need not by address the other theories advanced Hiett. (the Act), 1915, Workers’ Act first enacted in
provided “protection for the safety in all places workmen employment and for inspection regulation places of employment ....’” Chapter Montana, later, Laws of 1915. Several revisions Legislature public revised the policy behind the law to include: objective
It is an system of the Montana compensation workers’ provide, regard fault, wage without supplement and medical benefits to a suffering injury worker from a work-related disease.... (1995).
Section Despite Aсt, many changes, Montana’s like similar workers’ compensation throughout acts country, primarily was created to compensation assure and medical without workers
requiring employers them to sue their and surmount a difficult burden proof. employers We note as well that benefit from the Act in that it injured protects by employees’ potentially them from suits and from high damage awards. benefits, providing In medical care the Act allows “Primary
“primary “secondary medical services” and medical services.” medical services” are defined as: prescribed by treating physician,
treatment for conditions resulting injury, necessary achieving from the stability. (1995).
Section MCA “Secondary services” are defined as:
those medical or that are considered not appliances services medically necessary for medical The services and tubs, appliances spas include but are not limited to or hot work hardening, physical programs restoration and other restoration designed disability impairment, to address and not or programs by individuals, clinics, hospitals, or equipment groups, offered rehabilitation facilities. (1995). 39-71-116(29)(a),
Section
MCA
above,
stability,”
synonymous
in the
“Medical
as used
statutes
“a
healing”
healing”
“maximum
and “maximum mеdical
and means
healing process
in the
further material
would
when
Section
reasonably expected
primary
not be
from
medical treatment.”
(1995).
39-71-116(17), As will
below in further
be discussed
detail,
synonymous
the WCC concluded that medical
was also
supported by authority
with MMI. Such a conclusion is
from other
(Idaho 1995),
Dohl v. PSF Industries
See,
jurisdictions.
example,
provisions including of § (1) chapter compensation provided under this addition to the separate apart an additional benefit following must be compensation actually provided, furnished:
(a) injury subject happening compensable After the insurer shall furnish provisions chapter, other of this resulting from reasonable medical services for conditions injury or the injury periods for those as the nature of the process recovery requires.
(b) only upon secondary medical services The insurer shall furnish services cost-effectiveness a clear demonstration returning employment. worker to actual (f) Notwithstanding (l)(a), may subsection insurer not be furnish, required to after the worker has achieved medical stability, palliative or maintenance care except: (i) provided when to a worker who has been determined to be permanently totally disabled and for it is medically whom necessary to monitor administration of prescription medically medication to maintain the worker in a stationary condition; or
(ii) when to monitor the status of a prosthetic device. (g) If treating the worker’s physician palliative believes that *6 maintenance care that would otherwise not compensable under (l)(f) subsection appropriate is to enable the worker to continue current employment or that there is a clear probability of returning the employment, worker to the treating physician shall first request approval from the insurer for the treatment. If approval granted, is not treating physician may request approval department from the for the department treatment. The appoint panel shall physicians, including at least treating one physician from the specialty area of which the worker is being treated, pursuant to rules that the department may adopt proposed review the treatment and determine its appropriateness. care,” “Maintenance 39-71-704(l)(f),
¶21 аs used in (1995), MCA § above, is designed defined as “treatment provide the optimum state of health minimizing while recurrence of the clinical status.” Section (1995). 39-71-116(16), MCA “Palliative care” means “treatment designed to reduce or symptoms curing ease underlying without (1995). cause of the symptoms.” 39-17-116(20), Section MCA bar, In the case at the WCC was Hiett, asked to determine if who reached maximum medical improvement in June is entitled to ongoing payments for depression medication. The recognized court in its Conclusions of Law that “the statutes regarding poorly medical services are extremely written and raise difficult questions statutory interpretation.” It observed that it was statutory faced with a construction dilemma-it could construe the statutes in a resulting outcome, manner in an absurd or insert language into the statute put by that was not there legislature. ultimately The WCC that, absurd, concluded seemingly while there statutory authority was no paying prescriptions Hiett’s unless the prescriptions were either a returning cost-effective means of her to 39-71-704(l)(b), qualified MCA
employment under § appropriate maintenance care physician-requested palliative or (1995). 39-71-704(l)(g), Section enable her to return to work. avoided Hiett maintains that this “absurd” result could have been medical services” interpreted “primary the definition of had court designed to “maintain” medical to include medical services way analysis, its statutory painstakingly In the worked WCC’s them to the facts in Hiett’s through applicable applying statutes analytical path by taken the WCC is illustrative case. The present, so we trace it here. conundra the various statutes meanings “primary court deconstructed the definition, single stability,” merged them into a services” and “medical stability” healing process “a in the and concluded thаt “medical is reasonably expected material would not be when further stability.” Recognizing achieving medical treatment from circuitous, nonetheless felt definition was the WCC that such a achieved, no that once medical constrained to conclude a claimant’s materially improve further medical treatment would considered condition, any further treatment could not be and therefore MMI Having equated services.” “primary medical continuing medications that Hiett’s stability, the WCC concluded and could not be primary medical services beyond MMI were not as such. reimbursеd on recurring emphasis Throughout analysis, placed the WCC “primary in the definition “achieving” as used word (“treatment (1995)
medical services” found § resulting conditions by treating physician, prescribed *7 added)). achieving stability.” (emphasis medical injury, necessary for Act, the WCC felt is not defined the Although the term “achieve” “achieved”) (or MMI, reached conclude that once Hiett constrained to medications coverage prescription entitled to continued she was not are defined primary services because such provision under the above stability.” “necessary achieving mеdical to as and limited services reached, is over. words, MMI is the “achievement” In other once reach medical not all claimants who fully The realized that WCC require and actually deteriorate there, and that some stability remain stability. hypothesized The court again reach further treatment drug stability through reaches medical a claimant situation where drug of the then, discontinuation upon therapy, stops therapy, instance, the court In this status. therapy, relapses to non-MMI primary medical again become a reasoned, drugs would once primary- inquiry: this “Does analysis led the WCC to This service. drug claimant terminate secondary require services distinction that again liable for the therapy relapse before the insurer once written, therapy? Applying primary provision services appears so, provision requires payment unless some other medications once the worker has reached MMI.” engaged analysis in a court then detailed 39-71- §§ 704(l)(b), (l)(f), (1995), (l)(g) and MCA and concluded provisions applicable that none of these were to Hiett’s circumstances. 39-71-704(l)(b), (1995), requiring It reasoned that an insurer § secondary designed furnish cost-effective medical services to return injured an did not “since employment, apply worker to to Hiett’s case has failed to her to [Hiett] demonstrate her medications will enable employment.” parsed return to actual The WCC next the definition of services,” i.e., “secondary medical “those medical services ... not (§ medically necessary stability” 39-71-116(29), MCA), for medical noting that the definition did not “achieving” include the word but phrase “medically instead contained the necessary for medical stability.” opined “medically necessary The WCC that for medical stability” incorporated the concept “achieving” stability both medical and “maintaining” medical The WCC determined that because Hiett’s medications were for her to maintain stability, prescriptions “secondary her were not services” either. Ultimately that simply statutory WCC concluded there was no
authority authorizing payment drug therapy for an worker’s after a worker has reached medical except “where the employment medications would return the claimant or enable 39-71-704(l)(b) employed claimant working. (l)(g), to continue § MCA.” As it contemplated was not that Hiett would return to employment, the court denied Hiеtt’s claim. analysis appreciate in-depth We the WCC’s
scheme, agree and we with the court’s view that the statutes are confusing poorly agree also the court’s written. We with 39-71-704(l)(b), (f), (1995), (g), determination that and MCA do not §§ however, apply disagree, to Hiett’s situation. We the WCC’s Hiett reached MMI is not conclusion law because has she employment. entitled to a return to absent stability” Based on definition of “medical found at § 39-71- 116(17), acknowledge we that MMI is reached when the underlying further condition has stabilized to the that no reasonably material expected would be However, question presented medical treatment. here is how or at *8 104 stability?
what does one “achieve” medical The statutes do not through tell us. start-stop-start Is it the routine of medical services by hypothetical, through reaching the in it described court or is maintaining plateau stability? a Since neither or statutes our case address this pivotal question, apply law we must rules legislature construction to determine meant when what spoke “achieving” in terms of a claimant previously “[w]hen We have noted that more than one interpretation possible, promote justice, reject is in order to we an will interpretation an in that leads to unreasonable result favor of another that will lead to a reasonable result.” Rausch v. State 210, 25, Fund, 203, 29, 29, 29. Ins. 2002 MT 311 Mont. 54 P.3d ¶ ¶ ¶ also, (1984), 211 Mont. Co-op., See Johnson v. Marias River Elec. Inc. 518, 524, 668, Moreover, attempt “[t]his 687 P.2d Court must 1-2-102, give Legislature, discern and effect to the intention of the § MCA; omitted], [citation and construe each statute so as to avoid an ” give purpose absurd result ‘and to effect to the of the statute.’ State Price, 530, 26, 320, 26, v. 2002 MT 310 Mont. 50 P.3d 26 ¶ ¶ ¶ (citations omitted). above, act As we noted the intention of the is to suffering provide medical benefits to a worker from a work-related also, injury 39-71-105, or disease. Section MCA. See S.L.H. v. State Fund, 362, 33, 303 364, 33, Compensation Mut. Ins. 2000 MT Mont. ¶ ¶ (The enacting statutes legislature’s objective 15 P.3d these ¶ resulting compensate impairments was to workers for valid injuries job.). suffered on “achieving,” interpreted We conclude that WCC word 39-71-116(25) 39-71-704(1)0),
it is used in too §§ conceded, narrowly. folly interpreting As the WCC “achievement” encompass only experience well-being, the first while ignoring relapse that occur as soon as inevitable will removed, experience possible that is leads to an medication made unjust once achieved unreasonable result. Some medical results “end,” truly “attainment,” “completion”-the complete constitute an a a healing fracture, carpal surgery tunnel resolves of a which “Achieving” a qualify claimant’s condition can as such achievements. relatively attitude in the pain healthy or a mental level tolerable condition, however, “end.” face of a chronic is not such a discrete Rather, Temporary pain freedom from ongoing process. it is an depression if have meaningless eight hours later intolerable health Reaching physical of tolerablе and mental returned. level it can injury can “achieved” when be sustained. after chronic conclusion, are mindful of the Act’s references reaching this we care,” “palliative care” and as used and definitions of “maintenance 39-71-116(16) 39-71-704(l)(f), (1995), and as defined in §§ § *9 (1995), care” is defined as (20), respectively. and “Maintenance state of health....” designed provide optimum treatment to “the designed is defined in terms of treatment “to reduce “Palliative care” only symptoms....” categories play or ease These of care come into after stability interpret phrase one hаs “achieved” medical as we the here. point, ability relapse through proper More the the to avoid a to “optimum” care is not the Cadillac of treatments-it is not an affairs, symptoms state of nor is it care which will reduce below that Thus, already appropriate level reached with medication. we find no irreconcilability reach and tension or between the conclusion we here the “palliative” Act’s reference “maintenance” or care. at a Accordingly, order to arrive reasonable result will intended, the the Act purposes interpret
serve which was we the phrase “achieving” stability stability medical and “achieved” medical 39-71-116(25) 39-71-704(1)0), as used in and §§ respectively, stability. to mean the sustainment of medical Given this interpretation, a claimant “primary is entitled to such medical permit services” as are him or her to sustain medical stability. The dissent authority maintains that this Court has exceeded its
by “inserting” language and, result, into the statute as a has “made law,” new and that disregarded “overriding legislative we have the intent” of the 1993 changes creating defining and the categories “primary” “secondary” of and medical services. While we do dispute not principle that “cost containment” was a upon which the revising based, legislative history 1993 bill the statutes was the also purpose states as a provide timely of the revisions the intention “to and medical Unfortunately, effective services to workers.” as noted above, legislature meaning “achieving” was silent as to the medical as used in “primary the definition of provide guidance concerning services.” Not does the statute fail to very us, legislative term that is critical to the case before but the history help brought offers no either. Thus are we bаck to Rausch and interpretation possible, Price-when more than one is in order to justice give statute, of the promote purpose and effect to we will reject interpretation that leads to an unreasonable or absurd result in favor of another that leads to a reasonable result. Furthermore, recognizing and financial while business presented legislature, interpretation to the do not find our
concerns we all, legislators’ intent. After of the statute to be conflict with the “timely purpose provision stated of the revisions was the recurring cycle tempоrary provision effective” medical A services. medicine, condition, medicine for a chronic withdrawal claimant as relapses-which reintroduction soon the dissent recognizes which, us, inevitable-hardly in the case before is qualifies “timely” as either or “effective” medical care. Accordingly, we conclude that Hiett entitled to receive prescription drugs necessary for those for her to sustain
CONCLUSION foregoing reasons, and remand matter to For we reverse this entry judgment the Workers’ Court for consistent however, Opinion. affirm, with this We the court’s conclusion that pеnalty respect Hiett is entitled to a to those benefits MSGIA agreed pay pay but failed to time. within reasonable LEAPHART,
JUSTICES NELSON REGNIER concur. dissenting. DISTRICT JUDGE FAGG *10 like respectfully outset, I I to state the dissent. At the would ¶40 majority opinion fairly thoroughly is and has well-written analyzed opinion. majority good argument the The a WCC also makes on-going payments prescription this claimant should be entitled to for However, put, majority’s the pain depression simply medication. argument legislature. policymaker, should be made to the As the legislature arguments change can the made and the law consider which, correctly found, the that Hiett is not entitled to as WCC is drugs unless the medications would for her and, her once her to employment employed, enable to return to enable working. continue Today majority failing the concludes the WCC erred when
¶41 thing I conclude the word “achieve” means the same as “sustain.” only can entitle her to disagree. Hiett’s reservation of medical benefits correctly majority statutes. As the benefits available under Montana out, are defined as “treatment . . . points “primary medical services” 39-71-116(25), stability.” necessary achieving medical Section MCA (1995) added). hand, (emphаsis “secondary On the other medical services” are defined as “medical services ... are considered not 39-71-116(29)(a), medically necessary stability.” medical Section (1995). concluded, cited in jurisdictions The WCC as have other synonymous is majority opinion, the that medical Thus, healing,” and MMI. healing,” “maximum “maximum medical statutory authority for correctly determined there was no WCC MMI, they continuing payment prescriptions beyond Hiett’s were primary not medical services. Today’s changes “primary decision Montana law and redefines necessary achieving sustaining
medical service” as treatment legislature intentionally But it is the 1993 obvious attempt By amended the statutes noted in an to cut costs. above ruling, majority job. has made law. That is not this Court’s new previously legislative This Court has held that intent should be plain meaning language used, determined if possible, of the applied and that a statute should be read and as a whole in order to give effect purpose to the statute’s and avoid absurd results. S.L.H. v. Fund, 362, 17, State MT Mutual Ins. 303 Mont. ¶ 17, 15 P.3d A plain, reading commonsense ¶ ¶ statutory provisions majority discussed in opinion yields general, overriding legislative conclusion as to a intent. The legislature was attempting to reduce costs.1 The “plain meaning” of “achieve” is “to accomplish; carry out successfully.” edition, English Dictionary, Shorter 5th 2002. Yet Oxford majority arrives at expansive interpretation, an adding “sustainment,” which scope “primary widens the medical benefits.” Adding language inappropriate, to statute is particularly doing when coverage legislature so increases costs and specifically intended to curtail. majority reasons that denying Petitioner her
depression yield medication would an “absurd” result. IWhile do not majority fault strong for its distaste for the scheme as written, I аbsurdity cannot conclude that it constitutes an which would permit change us to the written law. As (1995), written, § worker will receive up point they to the reach their
maximum state of healing-or stability.” Thus, “medical we come to unpleasant situations such as the one before us. Eula Mae Hiett *11 beyond Indeed, point This debate. even counsel for both Petitioner and Amicus, arguments brief, acknowledged legislature’s in oral and/or via have obvious cost-cutting legislature’s motives. Amicus refers to the motive for these statutes as Curiae, being, Petitioner is the legislature’s steady 18, 2002, “simply April p.19. to save costs.” Briеf of Amicus dated very primary secondary notes distinction between medical services costs, product cutting of a 1993 Amendment aimed at and documents the away originally purpose march from the WCA’s stated in an effort money.’ beginning continuing present, to save “It is well known that in 1987 and to the Legislature compensation response the Montana tinkered to a has with worker’s Appellant, 12, 2002, proposed p.21. business crisis in the state.’” Brief of dated March depression reached medical As her medication at longer that no fit under either the definition of or secondary servicеs, longer no entitled to her she was relapsed medication. But if and when she to a sub-maximum medical level, drugs “primary medical those would become services,” again and would be covered. mind. Many such an Many descriptions approach come far it calls might agree majority approach is not off when such unjust.” “unreasonable and But that is not a reason for a court to six-year-old diagnosed rewrite a law. A child could be with leukemia tomorrow, anyone if for his require pay no law would cent However, care, unjust. think most would it unreasonable and requiring coverage. for us to The same would not be cause write law right it, for the principle applies here. When it comes down to the basis I majority’s holding sympathy is their for the Petitioner. would leave redefining changing legislature, the Montana who hears law to daily legislative sessions, and can sympathetic pleas during their weigh accordingly. properly sympathies those and write law page, I affirm the In a 17% summary, would WCC. analyzed single-spaced opinion, painstakingly Montana law statutory authority continuing correctly concluded there was no Montana prescriptions. Hiett’s Hiett should receive those benefits allows, expand and it is not for this Court to those benefits or law Montana law. foregoing dissent of DISTRICT joins JUSTICE RICE JUDGE FAGG. foregoing joins CHIEF GRAY in the dissent of JUSTICE DISTRICT JUDGE FAGG.