Starwood Hotel & Resorts et al. v. Lopez

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Starwood Hotel & Resorts et al. v. Lopez (A18A0552, decided May 15, 2018)

ISSUE: Did the Superior Court and Administrative Law Judge err in
finding that the employer/insurer effectively controverted a claim, entitling the
claimant to a doctor of her own choosing, and payment of unauthorized medical
expenses when they filed a WC-14 challenging whether they were still liable for
benefits?

DISCUSSION: The Court of Appeals found that the Superior Court and Administrative Law Judge erred.

The claimant worked as a banquet server for a hotel owned by Starwood. On
July 6, 2014, she slipped and fell on her elbow. A few days later her supervisor
insisted she go the doctor and she was shown the panel of physicians. She went
to a medical center from the panel and was diagnosed with an elbow fracture.

When she returned to work in November 2014 the hotel changed ownership. She
continued to work at the hotel in a less physically demanding position. In July
2015 she began having pain in her elbow again, and stopped working. While
working for the new owner, the claimant began treating with two doctors on her
own. She did not seek authorization from Starwood, or the new owner before
going to those doctors.

The Administrative Law Judge found that the claimant had undergone a change
in condition for the worse and found that Starwood was liable for payment of
temporary total disability benefits.

The Administrative Law Judge also concluded that Starwood’s WC-14 amounted
to a controvert of the claim entitling the claimant to a physician of her own and
that Starwood was liable for any outstanding and reasonably necessary medical
expenses.

The Appellate Division agreed with the Administrative Law Judge that the
claimant had a change in condition for the worse. However, the Board concluded
that the ALJ had erred in finding that the WC-14, seeking an opportunity to prove
that they were no longer responsible, amounted to a controvert of the claim.
Specifically, the Board highlighted that Starwood “did not controvert medical
treatment, nor did it otherwise deny any request by [Lopez] for additional
treatment from an authorized provider.”

The Superior Court reversed the Appellate Division and agreed with the ALJ that
the hearing request amounted to a controvert.

The Court of Appeals reversed the Superior Court and held that there was
evidence to support the Board’s findings that the WC-14 did not constitute a
complete controvert of the claim.

 

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