In Erwin v. Midway Arms, Inc., No. WD 87161, 2025 WL 677007 (Mo. Ct. App. Mar. 4, 2025), the Missouri Court of Appeals issued a decision finding that, while the Employer had initially acted unreasonably, sanctions were not justified because the Employee’s failure to provide requested medical records was also unreasonable.
The Claimant suffered an undisputed work accident that allegedly caused an L5-S1 disc herniation, anxiety, and depression. Following a period of conservative treatment over six months, including physical therapy, the Employer’s doctor found that the Claimant had reached maximum medical improvement (“MMI”) and released the claimant with a sixty-day prescription for narcotic pain pills and muscle relaxant pills. The Claimant alleged that he had ongoing and worsening symptoms after that time, including an allegation that he had become “suicidal from his chronic back pain.” The Employer denied further care and requested that the Claimant provide further medical records regarding his self-directed care. The Claimant’s self-guided course of treatment involved low back surgery and psychiatric treatment.
The case went to trial before an Administrative Law Judge (ALJ), who found the additional self-directed care to be reasonable, necessary, and related, ordered PPD awards, a TTD award, a future medical award, ordered Employer pay $114,950.23 for denied past medical expenses, and, most critically, sanctioned Employer for “unreasonable and outrageous conduct,” ordering payment of “25% of all amounts awarded herein ($189,607.37), or $47,401.84, plus costs of $11,979.52, for total sanctions in the amount of $59,381.36.”
The Commission reversed the ALJ's award as to Employer's responsibility for payment of past medical expenses and reversed the ALJ's award of sanctions, because the Employer's actions did not meet the “unreasonable and outrageous” threshold. Otherwise, the Commission adopted the findings, conclusions, decision, and award of the ALJ. The Commission also specifically found that “Employee did not sufficiently notify Employer” of the need for further treatment.
The Claimant then appealed that Decision the Court of Appeals, who reinstated the ALJ's award for past medical treatment but declined to reinstate the ALJ's award for sanctions.
The Court found that the Claimant had made a valid demand for additional treatment, and had also explicitly identified new and worsening symptoms. Given that the further treatment was eventually found to be reasonable and medically necessary, the Employer was liable.
As for the sanctions though, the Court agreed with the Commission’s position that sanctions were not warranted because of three key reasons:
(1) Doctor's opinion that Employee had reached MMI was a valid basis for denying additional treatment;
(2) Employer attempted to follow up with Employee's self-guided medical care, but Employee refused to cooperate; and
(3) although the Commission agreed that the Doctor's sudden reversal of his opinion on the work-related nature of Employee's injury was not credible, the Commission noted that this new opinion was still a medical opinion that placed causation at issue for the hearing.
The Court emphasized that the Employer did have evidence supporting its’ denial, even if their doctor’s opinion was based on dated and inaccurate information. Furthermore, the Employer had repeatedly requested updated records and information on the Claimant’s self-directed care; if the Employer had received that information, then it could have relayed that to the Employer’s expert for an updated opinion. Accordingly, the Court found that there was “no abuse of discretion in the Commission's conclusion that Employer's conduct did not rise to the level of conduct necessitating sanctions.”
A best practice for defending Missouri Workers’ Compensation claims is to keep in mind that an original expert opinion finding MMI can be undermined by new facts and additional treatment that a claimant can seek on their own. Follow up regularly and explicitly with the claimant or their attorney to make sure that you have the all available information and evidence, and also make sure to provide that information and evidence to your medical expert in order to develop the most reliable opinions possible.