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Local 400 Health & Welfare Fund v. Dominick11/27/1991
This appeal raises the issue of the liability of an health care insurer to pay benefits on a claim when the beneficiary has previously certified her condition to be work-related.
Lucinda Dominick and her husband, John, are beneficiaries under a comprehensive health care plan sponsored by Local 400 Health and Welfare Fund ("the Fund"). In 1978, Lucinda Dominick, sustained injuries from a fall while working at Cook United, Inc. The Industrial Commission of Ohio determined her condition to be compensable.
Three years later, Dominick had surgery to repair a herniated disc which she believed was causally related to the fall suffered in 1978. Dominick filed a C-85A claim with the Bureau of Workers' Compensation seeking to reactivate her claim and requested an additional allowance for necessary surgery in the amount of $6,020.83. Dominick's physician, Dr. Pete Poolos, certified to the Bureau that her surgery was performed by reason of a work-related injury.
The Bureau District Hearing Officer, however, denied Dominick's application to re-activate the claim. He found that Dominick's back injury was unrelated to the original injury and, therefore, was not work-related. Dominick appealed to the Regional Board of Review which, in turn, affirmed the District Hearing Officer's determination. The Industrial Commission refused to hear the claim.
Dominick appealed that order to the court of common pleas. Before trial commenced, she entered into a settlement of her claim with her employer, Cook United, for three thousand dollars. As part of the settlement, Cook United expressly denied liability for compensation . Shortly thereafter, Cook United filed for bankruptcy and Dominick could not recover any portion of the settlement.
After exhausting all administrative remedies, Dominick submitted her surgical bill to the Fund under her husband's health care plan, in which she was a named dependent. The Fund then filed this action seeking a declaratory judgment that, under the terms of the health care plan, the Fund was not required to pay. The Fund posited that Dominick's injury, by her admission and her doctor's opinion, was work-related. After a bench trial, the court found in favor of Dominick and ordered the Fund to pay the surgical bill plus costs. The court denied, however, Dominick's motion for attorney fees. It is from these orders that this appeal and cross-appeal are taken.
The Fund raises one assignment of error, claiming the trial court's judgment was against the manifest weight of the evidence. Dominick complains that the court erred in not awarding attorney fees. We will address the Fund's argument first.
The standard for reviewing a challenge to the manifest weight of the evidence in a civil case is whether the judgment is "supported by some competent, credible evidence going to all the essential elements of the case *." Seasons Coal Co. v. Cleveland (1984), 10 Ohio St. 3d 77, citing C.E. Morris Co. v. Foley Construction Co. (1978), 54 Ohio St. 2d 279. An appellate court is "guided by a presumption that the findings of the trier-of-fact were indeed correct." Seasons Coal Co., supra, at 80. Moreover, we are mindful that the evaluation of witness credibility primarily lies with the trier of fact. State v. DeHass (1967), 10 Ohio St. 2d 230.
The Fund refused to pay Dominick's surgical bill since she averred she believed her back condition was related to the on-the-job fall in 1978. Plaintiff also relies on the opinion of Dominick's treating physician, Dr. Poolos, who opined her recent injury may have been work-related. Dr. Poolos stated "her original injury to the disc may very well have occurred then [in 1978], a
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