One Particular Mosquito: West Nile Virus Found to be a Compensable Workers’ Compensation Claim

When an employee is injured on the job and the employee’s request for workers’ compensation benefits is disputed, La. R.S. 23:1201.1 allows an employer to request a preliminary determination hearing (“PDH”) with the Office of Workers’ Compensation (“OWC”). If the workers’ compensation judge rules at the PDH that benefits are owed, the employer has ten days to comply with the judge’s ruling. The First Circuit recently ruled that an employer can find “safe harbor” if it technically complies with the rigorous deadlines of the statute, which if missed can have profound consequences, subjecting the employer to penalties and attorney fees.

In Kilbourne v. Dixon Correctional Institute, the court recently affirmed a ruling that found an employer complied with La. R.S. 23:1201.1 and could not be subject to penalties or attorney’s fees when it mailed the disputed workers compensation benefits within ten days of the judge’s ruling at the PDH. The ruling was affirmed even though the employee did not receive payment within ten days of the hearing.

The employer in Kilbourne stopped issuing weekly workers compensation benefits after two doctors found the claimant’s ongoing complaints were unrelated to the work accident and the claimant could return to full duty work. The employee then filed a disputed claim with the OWC and requested reinstatement of his benefits. He also requested an award of penalties and attorney’s fees because he claimed the employer’s suspension of indemnity benefits was arbitrary and capricious. The employer requested a PDH to address these issues.

The OWC judge issued a preliminary determination that although the employee was owed supplemental benefits from the date his payments of benefits stopped, the employer was not arbitrary and capricious in its decision to stop payment. Within ten days of the mailing of the PDH ruling, the employer issued and mailed benefit checks to the employee and filed a form with the OWC to provide notice the employer was paying the benefits. Nevertheless, the employee disagreed with the PDH ruling and the matter went to trial.

At trial, the employee argued that he should have received penalties, attorney fees, and interest on the back benefits paid after the PDH ruling. The employee argued the employer failed to comply with section 1201.1 because he did not receive the indemnity benefits until more than ten days after the PDH ruling. However, evidence showed the benefit payments were postmarked and mailed within ten days of the receipt of PDH ruling.

Accordingly, the trial court found that the employer was immune from an award of penalties and attorney fees pursuant to the “safe harbor” provision of section 1201.1. Interest also could not be owed on back pay when the employer complied with the statute. The First Circuit affirmed this decision on appeal. Although providing the claimant funds within 10 days of the PDH ruling remains the best practice for an employer, this ruling informs employers that they should find safe harbor from what could be significant penalties and attorney’s fees if they meet the technical requirements of the statute and mail their compliance with the judge’s ruling within ten days of the PDH.

Case Reference: Kilbourne v. Dixon Correctional Institute, 2022-0455,(La. App. 1 Cir. 11/4/22) ____So. 3d ___,2022 WL 16706951.

Louisiana is a fact-pleading state. Accordingly, Louisiana law requires that a petition contain “a short, clear and concise statement of all causes of action and material facts arising out of the transaction or occurrence that is the subject matter of the litigation.” See La. C.C.P. art. 891. Generally, the pleader must state what act or omission he will establish at trial. Legal conclusions disguised as factual allegations do not meet the pleading standards required by Louisiana law.

This concept recently was examined in Henderson v. State Farm Mut. Auto. Ins. Co., 2021-0654 (La. App. 4 Cir. 12/17/21), 2021 WL 7162224, where the court considered bad faith allegations the plaintiff tried to assert against an insurer in his petition for damages. At the time of the underlying accident, the plaintiff was a passenger in a Lyft vehicle that was struck by an unknown driver. Steadfast Insurance Company was the Lyft driver’s insurer, and the plaintiff named Steadfast as a defendant to recover damages under its policy.

The plaintiff later amended his petition to seek uninsured/underinsured motorist benefits under the Steadfast policy. He also sought penalties from Steadfast for alleged bad faith and dealing in its insurance practices. In turn, Steadfast filed an exception of no cause of action, arguing that plaintiff’s petition only contained legal conclusions and not specific facts, which were insufficient to support a cause of action. The trial court overruled the exception.

The Fourth Circuit Court of Appeal reversed the decision. Plaintiff’s amended petition alleged that Steadfast “refused to deal with him in good faith, including but not limited to, refusing to issue unconditional (McDill) tenders and taking actions in violation of La. R.S. 22:1892 and La. R.S. 22:1973.” The plaintiff also generally alleged the insurer acted “arbitrarily, capriciously and without probable cause” in its failure to pay money under its policy.

The Court noted that the plaintiff’s allegations were legal conclusions asserted as facts, which could not be considered as well-pleaded factual allegations for purposes of a no cause of action. Importantly, the court reiterated that a court may not consider legal conclusions “clothed as facts,” citing Hooks v. Treasurer, 06-0541, p. 10 (La. App. 1 Cir. 5/4/07), 961 So.2d 425, 431-32. Accordingly, the plaintiff’s allegations, absent additional information, were insufficient to state a cause of action. The plaintiff failed to state specific actions or omissions that would be established at trial. Hence, he failed to state a cause of action.

In a case handled by Keogh Cox lawyers Steve Whitlow and Jenny McLin, a Louisiana court of appeal has affirmed the ruling of a Workers Compensation Judge holding that an employee who made misrepresentations about his claim forfeited his right to workers compensation benefits. Arguello v. Brand Energy, 13-CA-990 (La. App. 5th Cir. 5/21/14), ___ So. 3rd ___.

In ruling for the employer, the trial court found that the claimant had committed three separate violations of La.R.S. 23:1208. The claimant was also assessed with a $500 civil penalty payable to the Kids Chance Scholarship Program.