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Salem: Appeals Board Issues Key Evidence Opinions on Medical Records

  • State: Tennessee
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Within the past two weeks, the Tennessee Workers' Compensation Appeals Board has made significant evidentiary rulings about the admissibility of Form C-32 and medical records.

Jane Salem

Jane Salem

The opinions examined their admissibility at two different stages of the case — one at summary judgment and the other at an expedited hearing. The procedural posture makes a substantial difference.

C-32 at the summary judgment stage

Looking at the cases in chronological order, a pro se litigant was unsuccessful in the Board’s June 21 opinion, Sadeekah v. Abdelaziz dba Home Furniture and More.

Sadeekah appealed a grant of summary judgment, arguing that the trial court erred by excluding a C-32 that he filed seven calendar days before the hearing. The employer, Abdelaziz, filed an objection the day after the C-32 was filed.

The trial court held that Sadeekah hadn’t provided sufficient notice of his intent to use that form as required by Section 50-6-235(c)(2).

The Appeals Board affirmed, reminding that a C-32 can be used instead of a deposition if notice of intent to use it is provided to the opposing party “not less than twenty (20) days before the intended use.” The C-32 was signed by the doctor approximately 60 days before the summary judgment hearing.

The board wrote, “Employee has offered no explanation as to why he failed to inform employer of his intent to offer [the doctor’s] Form C-32 as evidence at least 20 days before the summary judgment hearing as required by [the statute].” Further, the board observed that the employer took prompt action, filing its objection the very next day after the C-32 was filed.

Evidentiary rulings are discretionary, and here, the judges found no abuse.

The board also rejected Sadeekah’s argument about his proof of medical causation. In addition to relying on the excluded C-32, he filed medical records in response to the motion for summary judgment.

The board explained that at the summary judgment stage, parties must comply with the requirements of Rule 56 of the Tennessee Rules of Civil Procedure. Rule 56.04 allows consideration of “pleadings, depositions, answers to interrogatories and admissions on file, together with the affidavits, if any.”

“Medical records, standing alone, are not included in that list,” the judges wrote. “Thus, the records of [the doctors] were not presented to the trial court in any admissible form at the summary judgment stage of the case.”

Moreover, even if the records could be considered, in this case they didn’t contain an opinion that the injury arose “primarily out of and in the course and scope of employment,” as the statute requires.

As an aside, Sadeekah also challenged the interpreter’s accuracy at the summary judgment hearing, afterward filing a motion for a “redo.” The trial court treated it as a motion to alter or amend the judgment under Tennessee Rule of Civil Procedure 59.04 and denied it.

Sadeekah filed a statement from a court reporter who was unable to transcribe the recorded hearing because the interpreter, whose accented English was difficult to understand, “spoke over everyone.”

The board was unpersuaded. “We find no case law, and none has been cited to us, supporting employee’s argument that inadequate translation services can form the basis of a motion for relief under Rule 59,” they wrote. The judges reasoned that Sadeekah didn’t identify any particular statements that were misinterpreted or that the trial court’s determinations were based on any misinterpreted arguments.

C-32 at the expedited hearing stage

In the board’s June 25 opinion, Mosley v. HG Staffing LLC, the employer objected at an expedited hearing to a C-32 that didn’t bear an original signature or have a statement of the physician’s qualifications and was incomplete.

The trial court concluded that, despite these deficiencies, the document was a signed medical record, which is admissible at an expedited hearing under the court’s rules. The trial court awarded benefits, and the board affirmed both rulings.

The board recapped some of the relevant rules as to the authentication and admissibility of medical records. Medical records are “self-authenticating and admissible when signed by a physician or accompanied by a form signed by a medical provider or records custodian certifying that the records are true and accurate” under Rule 0800-02-21-.16(2)(b).

However, a trial court can exclude this evidence for reasons other than authenticity if a proper objection is made under the Rules of Evidence. Also, “[l]etters or written statements addressing medical causation signed by a physician are admissible at an expedited hearing and need not be in affidavit form,” per Rule 0800-02-21-.15(2).

At a compensation hearing, however, signed statements may be excluded through valid objection under the Tennessee Rules of Evidence.

“With respect to the lack of an original signature, although the Form C-32 in its current form would not be admissible at a compensation hearing as the physician’s direct testimony, that does not preclude the trial court from considering it a signed medical record,” the judges wrote.

“Importantly, employer did not object to the information or opinions contained in the Form C-32 based on any particular rule of evidence but objected to the lack of an original signature and a statement of qualifications as required by the statute,” the board continued. “[S]ection 50-6-235 does not preclude a trial court from considering a causation statement contained in a signed Form C-32 at an expedited hearing pursuant to Rule 0800-02-21-.15(2).”

The board added that the statute doesn’t require a physician to respond to every question included on Form C-32. An incomplete form, if admissible, can be given the appropriate weight by the judge as to the missing information.

Jane Salem is a staff attorney in the Tennessee Court of Workers' Compensation Claims, Nashville. This entry is republished with permission from the court's blog.

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