BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
          JUDITH NOBLE,
 
         
 
               Claimant,
 
         
 
          VS.                                        File Nos. 857575
 
                                                              851309
 
         
 
          LAMONI PRODUCTS,
 
                                                         A P P E A L
 
               Employer,
 
                                                       D E C I S I 0 N
 
          and
 
         
 
          LIBERTY MUTUAL INSURANCE CO.,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
              
 
                         STATEMENT OF THE CASE
 
         
 
              Claimant appeals from an arbitration decision awarding 
 
         permanent partial disability benefits as the result of an alleged 
 
         injury on December 10, 1986.  The record on appeal consists of 
 
         the transcript of the arbitration proceeding; joint exhibit I, 
 
         subparts A through H; joint exhibits III and IV; and defendants' 
 
         exhibits A and B. Both parties filed briefs on appeal.
 
         
 
                                      ISSUE
 
         
 
              Those portions of the proposed agency decision pertaining to 
 
         issues not raised on appeal are adopted as a part of this appeal 
 
         decision.  Claimant states the following issue on appeal:
 
         
 
              The deputy erred in concluding that claimant failed to prove 
 
         by a preponderance of the evidence that she sustained an 
 
         occupational disease as a consequence of the rapid and repetitive 
 
         motion required by her employment.
 
         
 
                                 FINDINGS OF FACT
 
         
 
              The findings of fact and review of the evidence contained in 
 
         the proposed agency decision filed September 29, 1989, are 
 
         adopted as final agency action.
 
              
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 2
 
         
 
         
 
                                CONCLUSIONS OF LAW
 
         
 
              The sole issue on appeal is whether claimant has shown that 
 
         she has suffered an occupational disease under Iowa Code chapter 
 
         85A.  Claimant's work activity resulted in a condition known as
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         carpal tunnel syndrome.  Two prior decisions of the Iowa 
 
         Industrial Commissioner address the question of whether carpal 
 
         tunnel syndrome is an occupational disease.  In Peters v. Lamoni 
 
         Auto Assemblies, Inc., File No. 809203, Slip Op., (Iowa Ind. 
 
         Comm'r. App., March 31, 1989), in holding that claimant's carpal 
 
         tunnel syndrome was not an occupational disease, it was noted 
 
         that in Simbro v. DeLong's Sportswear, 332 N.W.2d 886, 889 (Iowa 
 
         1983), a worker with bilateral carpal tunnel syndrome incurred in 
 
         a single cumulative injury process was compensated under section 
 
         85.34(2)(s) and not as an occupational disease.  In Himschoot v. 
 
         Montezuma Manufacturing, File No. 672778, 738235, Slip Op., (Iowa 
 
         Ind. Comm'r. App., April 15, 1988); aff'd on other grounds, No. 
 
         89-341, Slip Op., (Iowa Ct. of App., February 22, 1990), 
 
         bilateral carpal tunnel syndrome was also held to be an injury 
 
         and not an occupational disease.
 
         
 
              Carpal tunnel syndrome is defined as:
 
         
 
              The most common of the nerve entrapment syndromes, carpal 
 
         tunnel syndrome results from compression of the median nerve at 
 
         the wrist, within the carpal tunnel, through which it passes 
 
         along with blood vessels, and flexor tendons to the fingers and 
 
         thumb.  This compression neuropathy causes sensory and motor 
 
         changes in the median distribution of the hand.  ... 
 
         Assembly-line workers and packers and persons who repeatedly use 
 
         poorly designed tools are most likely to develop this disorder.  
 
         Any strenuous use of the hands--sustained grasping, twisting, or 
 
         flexing--aggravates this condition.
 
         
 
         Diseases, Second Edition; Nurse's Reference Library.  Springhouse 
 
         Corporation, Springhouse, Pennsylvania, page 555, 1987.
 
         
 
              More specifically, carpal tunnel syndrome is one aspect of a 
 
         category of entrapment neuropathies known as overuse syndromes, 
 
         or sometimes known as repetitive use syndromes.  Overuse syndrome 
 
         is defined as follows:
 
         
 
              Overuse syndrome may be defined as injuries caused by 
 
              excessive use of body parts so that cumulative effects of 
 
              repeated small trauma occur that exceed physiologic limits. 
 
              (Emphasis added.)
 
         
 
         Entrapment Neuropathies, Second Edition, by David M. Dawson, 
 
         M.D., Mark Hallett, M.D., and Lewis H. Millender, M.D. Little, 
 
         Brown and Company, Boston, page 358, 1990.
 
         
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 3
 
         
 
              Carpal tunnel, in particular, involves increased pressure on 
 
         the median nerve.  Repetitiveness, forcefulness, awkward 
 
         positions, mechanical stress concentration against soft tissues, 
 
         and segmental vibrations on soft tissues and joints cause a 
 
         swelling of the flexor tendons, which in turn crowds the median 
 
         nerve in the carpal tunnel passage and results in decreased 
 
         strength, numbness, or pain.
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
              Claimant's carpal tunnel syndrome was caused by repetitive 
 
         motion in doing assembly line work for defendant employer.  It is 
 
         not necessary that claimant's injury occur in a single traumatic 
 
         event.  An injury may occur over a period of time.  A series of 
 
         micro-traumas sustained by a worker over a period of time that 
 
         results in functional impairment may be compensable as a 
 
         cumulative injury. McKeever Custom Cabinets v. Smith, 379 N.W.2d 
 
         368 (Iowa 1985).
 
         
 
              Claimant asserts on appeal that her carpal tunnel syndrome 
 
         should be compensated under Iowa Code chapter 85A as an 
 
         occupational disease.  Iowa Code section 85A.14 provides as 
 
         follows:
 
         
 
                   No compensation shall be payable under this chapter for 
 
              any condition of physical or mental ill-being, disability, 
 
              disablement, or death for which compensation is recoverable 
 
              on account of injury under the workers' compensation law.
 
         
 
              The existence of section 85A.14 indicates a legislative 
 
         intent to preclude recovery under both chapter 85 and chapter 85A 
 
         for the same injury or condition.  Thus, claimant cannot be 
 
         compensated for both an injury under chapter 85 and an 
 
         occupational disease under chapter 85A for the same work-related 
 
         condition.  A determination must therefore be made whether 
 
         claimant's condition is an injury under chapter 85 or an 
 
         occupational disease under chapter 85A.
 
         
 
              The supreme court of Iowa in Almquist v. Shenandoah 
 
         Nurseries, 218 Iowa 724, 731-32, 254 N.W. 35, 38 (1934) discussed 
 
         the definition of personal injury in workers' compensation cases 
 
         as follows:
 
         
 
              While a personal injury does not include an occupational 
 
              disease under the Workmen's Compensation Act, yet an injury 
 
              to the health may be a personal injury. (Citations omitted.) 
 
              Likewise a personal injury includes a disease resulting from 
 
              an injury. The result of changes in the human body incident 
 
              to the general processes of nature do not amount to a 
 
              personal injury.  This must follow, even though such natural 
 
              change may come about because the life has been devoted
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 4
 
         
 
         
 
              to labor and hard work.  Such result of those natural 
 
              changes does not constitute a personal injury even though 
 
              the same brings about impairment of health or the total or 
 
              partial incapacity of the functions of the human body.
 
         
 
         
 
              A personal injury, contemplated by the Workmen's 
 
              Compensation Law, obviously means an injury to the body, the 
 
              impairment of health, or a disease, not excluded by the act, 
 
              which comes about, not through the natural building up and 
 
              tearing down of the human body, but because of a traumatic 
 
              or other hurt or damage to the health or body of an 
 
              employee. (Citations omitted.) The injury to the human body 
 
              here contemplated must be something, whether an accident or 
 
              not, that acts extraneously to the natural processes of 
 
              nature, and thereby impairs the health, overcomes, injures, 
 
              interrupts, or destroys some function of the body, or 
 
              otherwise damages or injures a part or all of the body. 
 
              (Emphasis added.)
 

 
              
 
 
 
 
 
 
 
 
 
 
 
         
 
              Iowa's occupational disease law was enacted in 1947, and was 
 
         designed to compensate "victims of disease resulting solely from 
 
         the nature of the employment as opposed to traumatic injury..." 
 
         34 Iowa Law Review, 510, 512 (1949).
 
         
 
              One commentator has opined that:
 
         
 
              Chapter 85A was remedial legislation intended to ameliorate 
 
              the proof requirements normally associated with establishing 
 
              a traumatic injury, and to obviate discrimination against 
 
              disabled workers whose productivity has been terminated by 
 
              disease.
 
         
 
         Shepler, "Occupational Disease Claims," 30 Drake Law Review 841, 
 
         841-2, 1980-81.
 
         
 
         Chapter 85A defines occupational disease in section 85A.8 as 
 
         follows:
 
         
 
                   Occupational diseases shall be only those diseases 
 
              which arise out of and in the course of the employee's 
 
              employment.  Such diseases shall have a direct causal 
 
              connection with the employment and must have followed as a 
 
              natural incident thereto from injurious exposure occasioned 
 
              by the nature of the employment.  Such disease must be 
 
              incidental to the character of the business, occupation or 
 
              process in which the employee was employed and not 
 
              independent of the employment.
 
         
 
         NOBLE v. LAMONI PRODUCTS
 
         Page  5
 
         
 
              Such disease need not have been foreseen or expected but 
 
              after its contraction it must appear to have had its origin 
 
              in a risk connected with the employment and to have resulted 
 
              from that source as an incident and rational consequence.  A 
 
              disease which follows from a hazard to which an employee has 
 
              or would have been equally exposed outside of said 
 
              occupation is not compensable as an occupational disease.
 
         
 
              Prior to 1973, chapter 85A set forth a list of specific 
 
         conditions that would constitute occupational diseases.  The list 
 
         of diseases compensable under chapter 85A was contained in 
 
         section 85A.9. Of the 17 enumerated conditions, eight were types 
 
         of poisoning; two involved skin diseases from reactions to 
 
         chemicals or substances; two involved diseases resulting from the 
 
         handling of animals; two involved exposure to radiant energy; and 
 
         one involved exposure to a chemical dust.  The remaining 
 
         condition enumerated was:
 
         
 
              10. Bursitis, synovitis or tenosynovitis.
 
         
 
              This was defined in section 85A.9 as:
 
         
 

 
         
 
 
 
 
 
 
 
 
 
 
 
              10. Any process or occupation involving continued or 
 
              repeated pressure on the parts affected.
 
         
 
              Iowa Code section 85A.8 was amended in 1973. 1973 Session, 
 
         65th G.A., ch. 144, sec. 24.  The 1973 amendment struck the 
 
         references in section 85A.8 to a designated list of diseases, and 
 
         repealed section 85A.9, which set out the list of diseases 
 
         compensable.  The amendment also changed references to silicosis 
 
         in sections 85A.10, 85A.12, and 85A.13 to refer to 
 
         pneumoconiosis, a condition defined in section 85A.13 as the 
 
         characteristic fibrotic condition of the lungs caused by the 
 
         inhalation of dust particles.  Formerly, those sections referred 
 
         only to silicosis and the inhalation of silica dust particles.
 
         
 
              Claimant argues on appeal that the 1973 amendment to section 
 
         85A.8 broadened the application of chapter 85A.  Claimant urges 
 
         that since the list originally contained in section 85A.9 was 
 
         eliminated, the legislature intended to broaden the applicability 
 
         of the chapter by enlarging the scope of the diseases and 
 
         conditions that could be compensated as occupational diseases.  
 
         Although carpal tunnel syndrome was not one of the enumerated 
 
         conditions in section 85A.9 prior to the 1973 amendment, claimant 
 
         nevertheless argues that carpal tunnel syndrome is related to 
 
         bursitis, synovitis, and tenosynovitis, conditions that were 
 
         specifically enumerated as occupational diseases prior to the 
 
         amendment.  Claimant urges that since the amendment was intended 
 
         to broaden coverage, and since related conditions were previously
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 6
 
         
 
         
 
         contemplated by 85A, then carpal tunnel syndrome is contemplated 
 
         by section 85A.8, as amended, also.
 
         
 
              The 1973 amendment clearly did expand the number and type of 
 
         conditions that would qualify for compensation under chdpter 85A.  
 
         Prior to the amendment, only those conditions enumerated would be 
 
         compensated.  Under chapter 85A, subsequent to the amendment, any 
 
         condition meeting the definition of "occupational disease', under 
 
         section 85A.8 and meeting the other requirements of chapter 85A 
 
         could be compensated as an occupational disease.
 
         
 
              To ascertain legislative intent, courts look to the 
 
         legislative history of the statute, applicable preamble or 
 
         statement of policy accompanying the statute.  DeMore by DeMore 
 
         v. Dieters, 334 N.W.2d 734, 737 (Iowa 1983).
 
         
 
              The explanation to Senate File 495, the bill that amended 
 
         sections 85A.8 and 85A.9 in 1973, provided as follows:
 
         
 
                                   EXPLANATION
 
         
 
              This bill amends the workmen's compensation, industrial 
 
              commissioner and occupational disease statutes to require 
 
              coverage of agricultural employers with fulltime employees 
 
              or an annual payroll of $2,500.00 and employers of domestic 
 
              or casual workers paying $200.00 a calendar quarter to 
 
              employees; provide full coverage for work related diseases; 
 
              remove any statute of limitations for medical care and 
 
              related services for work injuries; increase the maximum 
 
              benefit levels on a progressive scale; provide for lifetime 
 
              benefits for permanent total disabilities; provide for 
 
              unlimited healing period for permanent partial disabilities; 
 
              remove the limitation for temporary total disabilities; 
 
              provide lifetime benefits to widows or widowers or until 
 
              remarriage and to dependent children until age 18 or up to 
 

 
              
 
 
 
 
 
 
 
 
 
 
 
              age 25 if in an accredited educational institution or for 
 
              life if disabled; and provide for injured workmen to be 
 
              compensated at a rate based upon 80 percent of his 
 
              "spendable earnings".
 

 
              
 
 
 
 
 
 
 
 
 
 
 
         
 
              Although'significant changes were made in both sections 
 
         85A.9 and 85.61 by this legislation, the explanation fails to 
 
         provide insight into the legislative intent in doing so.
 
         
 
              Claimant argues that the 1973 amendment broadened the 
 
         occupational disease statute, but in McSpadden v. Bia Ben Coal 
 
         Co., 288 N.W.2d 181, 192 (Iowa 1980), the Iowa Supreme Court 
 
         noted that the 1973 amendment both broadened and narrowed the 
 
         application of the workers, compensation law:
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 7
 
         
 
              By the same session law that broadened the definition of 
 
              occupational disease, the legislature narrowed the 
 
              definition of "injury" to exclude occupational diseases as 
 
              defined in section 85A.8.
 
         
 
         McSpadden, at 190.  This referred to 1973 Session, 65th G.A., ch. 
 
         144, sec. 21, which stated:
 
         
 
              Section eighty-five point sixty-one (85.61), subsection five 
 
              (5), paragraph b, Code 1973, is amended to read as follows:
 
         
 
              b.  They shall not include a disease unless it shall result 
 
              from the injury and they shall not include an occupational 
 
              disease as defined in section eighty-five A point eight 
 
              (85A.8) of the Code.  (New language in italics.)
 
         
 
              Carpal tunnel syndrome resulting from workplace activity has 
 
         been recognized only in recent years.  Carpal tunnel syndrome was 
 
         not one of the enumerated occupational diseases in section 85A.9 
 
         prior to its repeal.
 
         
 
              It is noted that the landmark cumulative injury case of 
 
         McKeever Custom Cabinets v. Smith, 379 N.W.2d 368, 374 (Iowa 
 
         1985) was not decided until some 12 years after the amendment of 
 
         chapter 85A.  In other words, at the time 85A was amended in 
 
         1973, there was not the recognition we now have that injuries 
 
         need not occur in a single traumatic event, but can occur from a 
 
         series of micro-traumas over a period of time.  The original 
 
         inclusion of bursitis, synovitis, and tenosynovitis in chapter 
 
         85A in 1947 rather than compensating such conditions as injuries 
 
         under chapter 85 occurred at a time when cumulative trauma 
 
         injuries were not as clearly compensable under chapter 85 as they 
 
         are now post-McKeever.  Because of this, less weight is given to 
 
         the fact that those conditions were originally included in 
 
         chapter 85A.  Since repetitive trauma injuries such as bursitis, 
 
         synovitis, and tenosynovitis did not readily fit into the concept 
 
         of injury under chapter 85 prior to the McKeever decision, their 
 
         placement under chapter 85A in 1947 with exposure conditions was 
 
         more logical than it would be to include those conditions under 
 
         chapter 85A today, post-McKeever.
 
         
 
              It is also noted that the above discussion accepts as a 
 
         given that carpal tunnel syndrome is in fact related to, or a 
 
         variation of, bursitis, synovitis, or tenosynovitis.  Although 
 
         claimant asserts that it is, there is no medical evidence 
 
         introduced into the record by claimant to support this.
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
              Claimant's argument that carpal tunnel syndrome is an 
 
         occupational disease because the legislature broadened the
 
         NOBLE v. LAMONI PRODUCT
 
         Page 8
 
         
 
         
 
         occupational disease statute with the 1973 amendment is not 
 
         persuasive.  The legislature in 1973 both broadened and narrowed 
 
         both chapter 85 and chapter 85A.  Although section 85A.8 was 
 
         clearly broadened by the amendment, it does not necessarily 
 
         follow that bursitis, synovitis and tenosynovitis would still be 
 
         compensated under 85A.8 today.  In light of the change to Iowa 
 
         Code section 85.61 by the same legislative session, and the 
 
         subsequent McKeever recognition of repetitive trauma as a 
 
         cumulative injury, and thus compensable under chapter 85, this 
 
         conclusion by claimant is not warranted.  After the 1973 
 
         amendment, bursitis, synovitis and tenosynovitis, which were 
 
         formerly compensated under 85A, are now more clearly compensable 
 
         as injuries under chapter 85.  Thus, contrary to claimant's 
 
         argument, no presumption can be derived from the inclusion of 
 
         bursitis, synovitis and tenosynovitis in section 85A.9 prior to 
 
         the 1973 amendment.  Indeed, the presumption would be that the 
 
         corresponding change in section 85.61 indicates that bursitis, 
 
         synovitis and tenosynovitis would now be compensated under 
 
         chapter 85 as traumatic injuries.
 
         
 
              Normally, matters of statutory construction in workers, 
 
         compensation cases require interpreting the statute liberally in 
 
         favor of the employee and resolving all doubts in favor of the 
 
         employee.  Orr v. Lewis Central School District, 298 N.W.2d 256, 
 
         261 (Iowa 1980); Teel v. McCord, 394 N.W.2d 405, 406-407 (Iowa 
 
         1986).  However, in this case there is not an interpretation of 
 
         the statute that would be in the favor of the employee in all 
 
         cases, due to the differing application of chapters 85A and 85 in 
 
         differing cases.  Although section 85A.16 incorporates many 
 
         provisions of chapter 85 for occupational diseases, it is worth 
 
         noting that chapter 85 and chapter 85A differ in many ways.
 
         
 
              Under section 85A.12, a claimant is required to show that 
 
         the condition complained of arose within one year of the last 
 
         injurious exposure to the work hazard (three years for 
 
         pneumoconiosis) to be eligible for benefits.  This requirement 
 
         does not exist for injuries under chapter 85.
 
         
 
              Similarly, section 85A.10 imposes liability on the employer 
 
         under which the employee was last injuriously exposed.  Again, 
 
         this is unique to occupational diseases under chapter 85A and is 
 
         not applicable to injuries under chapter 85.
 
         
 
              Under chapter 85A, an employee seeking benefits must also 
 
         show that he or she has been disabled as a result of the work 
 
         exposure.  Generally speaking, disablement is not a requirement
 
         
 
         NOBLE v. LAMONI PRODUCTS
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         Page 9
 
         
 
         
 
         for compensation under chapter 85.  A commentator has elaborated 
 
         on the effect of this disablement requirement in compensating 
 
         injured workers:
 
         
 
              Prior to 1973, the Iowa occupational disease law (chapter 
 
              85A) provided that compensation for death or disablement 
 
              shall be paid for seventeen described diseases incurred in 
 
              specified ways.  The occupational disease law is separate 
 
              from the workmen's compensation law.  The workmen's 
 
              compensation law provided that "injury" shall not include a 
 
              disease unless it shall result from injury.  Diseases other 
 
              than those listed in the occupational disease compensation 
 
              law had been compensated under the workmen's compensation 
 
              law as "injuries."
 
         
 
                   There was a difference between compensating disability 
 
              arising from an occupational disease under chapter 85A and 
 
              one arising from an injury under chapter 85.  The 
 
              occupational disease compensation law defines "disablement" 
 
              as actual incapacity to perform work or earn equal wages in 
 
              other suitable employment.  The occupational disease law 
 
              provided, and still provides, that if the employee with the 
 
              disease is able to continue in employment, he receives only 
 
              medical treatment.  Apparently, the employee may not receive 
 
              compensation for a permanent disability unless he also 
 
              suffers "disablement", that is, he cannot perform his work 
 
              or earn equal wages elsewhere.
 
         
 
                   On the other hand, an employee with a permanent 
 
              disability from an injury-caused disease not listed in 
 
              chapter 85A could receive compensation for permanent 
 
              disability even if he was back working.  The reason for this 
 
              difference is that disability from injuries under chapter 
 
              85, unless the disease is restricted to a scheduled member 
 
              (which would be unlikely), is industrial disability 
 
              reduction of earning capacity and not mere reduction of 
 
              earnings.  In determining industrial disability, the 
 
              industrial commissioner considers not only the loss of 
 
              earnings and the doctor's estimates of disability, but also 
 
              the employee's age, intelligence, education, and 
 
              rehabilitation potential.
 
         
 
                   In evaluating disability from an injury or disease 
 
              under chapter 85, the commissioner historically has 
 
              considered that an employee with a permanent impairment has 
 
              lost some of the residual ability to perform physical labor 
 
              which all men possess, and he has awarded compensation even 
 
              though the employee was back
 
         
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 10
 
         
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
              to work and earning as much as, or more than before the 
 
              injury.  In short, compensation is paid for loss of earnings 
 
              under the occupational disease law, chapter 85A, and for 
 
              loss of earning capacity under the workmen's compensation 
 
              law, chapter 85.  The latter test is followed in most 
 
              states.  (Emphasis added.)
 
         
 
         Dahl, The Iowa Workmen's Compensation Law and Federal 
 
         Recommendations, 24 Drake L. Rev. 336, at 342-3, Winter, 1975.
 
         
 
              Finally, there is no recovery against the Iowa Second Injury 
 
         Fund for an occupational disease.
 
         
 
              Thus, because the two chapters differ both in procedural 
 
         requirements and in the method of compensation, whether a 
 
         claimant's injury is compensated under chapter 85 or whether it 
 
         is compensated under chapter 85A may benefit the injured worker 
 
         in some cases and act to his or her detriment in others.  Because 
 
         of this, the normal rule of statutory construction in claimant's 
 
         favor cited above is of no avail here.
 
         
 
              Section 85A.8 defines the term "occupational disease."  It 
 
         does so by adding qualifying conditions to the word "disease." 
 
         The word "disease", is not defined in chapter 85A.  However, it 
 
         is axiomatic that a claimant must suffer a disease to be 
 
         compensated for an occupational disease.  If this were not a 
 
         threshold requirement, then many conditions resulting from 
 
         clearly traumatic injuries that also met the other requirements 
 
         of section 85A.8, such as arising out of and in the course of the 
 
         employment, causal connection, etc., would fit the definition of 
 
         an occupational disease and violate section 85A.14.  For example, 
 
         a worker whose arm is severed by a machine would be able to show 
 
         that the condition was suffered in the course of his employment; 
 
         that it arose out of the employment; that the condition was 
 
         causally related to the employment; that the condition had its 
 
         origin in a risk connected with the employment; that the 
 
         condition flowed from a hazard the employee was not equally 
 
         exposed to outside the occupation; etc.  If the word "disease" 
 
         were not part of the definition, then this worker would have 
 
         suffered an occupational disease and a traumatic injury, a result 
 
         inconsistent with section 85A.14.
 
         
 
              In other words, many of the qualifying conditions in the 
 
         definition of an occupational disease under section 85A.8 
 
         parallel those of an injury under chapter 85.  If "disease", and 
 
         "injury" were interchangeable terms, all injuries compensable 
 
         under chapter 85 might be compensable under chapter 85A as well, 
 
         in direct contradiction of section 85A.14.  Obviously, although 
 
         the word "disease", is not defined in the statute, it is an 
 
         essential part of the definition of an occupational disease in
 
         
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 11
 
         
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
         order to follow the legislative intent expressed in 85A.14 to 
 
         differentiate "injuries" from "diseases."
 
         
 
              Prior to the amendment in 1973, merely suffering a disease 
 
         on the enumerated list in section 85A.9 did not automatically 
 
         indicate compensability.  Before 1973, in order to show an 
 
         occupational disease, a claimant had to show (1) he or she 
 
         suffered a disease; (2) the disease was one of those listed in 
 
         section 85A.9; and (3) the disease was an occupational disease 
 
         under section 85A.8 (i.e., it arose out and in the course of the 
 
         employment, was causally connected to the employment, etc.).
 
         
 
              Subsequent to the amendment, only requirement (2) is 
 
         eliminated.  That is, a claimant no longer has to show that his 
 
         or her condition is one of the enumerated diseases formerly 
 
         listed in section 85A.9.  However, a claimant must still 
 
         establish (1) and (3), that is, that he or she has suffered a 
 
         disease, and that it is an "occupational disease" under section 
 
         85A.8.
 
         
 
              After these threshold criteria are met, the claimant must 
 
         then also establish disablement and meet the one-year requirement 
 
         of section 85A.12 before compensation is due.  The question in 
 
         this case, then, initially is whether carpal tunnel syndrome is a 
 
         "disease."
 
         
 
              When a statute fails to define a word, words and phrases 
 
         shall be construed according to the context and the approved 
 
         usage of the language.  Section 4.1(2), The Code; McSpadden v. 
 
         Big Ben Coal Co., 288 N.W.2d 181 (Iowa, 1980).  Words of a 
 
         statute are to be given their ordinary meaning unless a contrary 
 
         intent is apparent.  Lauhoff Grain Co. v. McIntosh, 395 N.W.2d 
 
         834, 839 (Iowa 1986).
 
         
 
              "Disease" has variously been defined as:
 
         
 
              disease:  ... a condition of the living animal or plant body 
 
              or of one of its parts that impairs the performance of a 
 
              vital function.  Sickness, MALADY.
 
         
 
         Webster's Ninth New Collegiate Dictionary, page 362.
 
         
 
              disease:  an impairment of the normal state of the living 
 
              animal or plant body or any of its components that 
 
              interrupts or modifies the performance of the vital 
 
              functions and is a response to environmental factors (as 
 
              malnutrition, industrial hazards, or climate), to specific 
 
              infective agents (as worms, bacteria, or viruses), to 
 
              inherent defects of the
 
         
 
         NOBLE v. LMONI PRODUCTS
 
         Page 12
 
         
 
         
 

 
         
 
 
 
 
 
 
 
 
 
 
 
              organism (as various genetic anomalies), or to combinations 
 
              of these factors.
 
         
 
         Webster's Third New International Dictionary, page  185.
 
         
 
              disease:  a disordered or incorrectly functioning organ, 
 
              part, structure, or system of the body resulting from the 
 
              effect of genetic or developmental errors, infection, 
 
              poisons, nutritional deficiency or imbalance, toxicity, or 
 
              unfavorable environmental factors.  ...
 
         
 
         Random House Dictionary of the English Language, Second 
 
         Unabridged Edition, page 564.
 
         
 
              disease:  A condition which alters or interferes with the 
 
              normal state of an organism and is usually characterized by 
 
              the abnormal functioning of one or more of the host's 
 
              systems, parts, or organs.  It may be due to an unknown 
 
              cause or may result from an inherent metabolic or structural 
 
              deficiency, including congenital and hereditary defects and 
 
              degenerative processes, or from such factors as stress, 
 
              noxious stimuli, toxic agents, injury, or infection.
 
         
 
         International Dictionary of Medicine and Biology, Volume 1.
 
         
 
              disease:  any deviation from or interruption of the normal 
 
              structure or function of any part, organ, or system (or 
 
              combination thereof) of the body that is manifested by a 
 
              characteristic set of symptoms and signs and whose etiology, 
 
              pathology, and prognosis may be known or unknown.
 
         
 
         Dorland's Illustrated Medical Dictionary, 27th Edition.  W.B. 
 
         Saunders Company, Philadelphia et al.  1988.
 
         
 
              disease:  1.  a condition of abnormal vital function 
 
              involving any structure, part, or system of an organism.  2.  
 
              a specific illness or disorder characterized by a 
 
              recognizable set of signs and symptoms, attributable to 
 
              heredity, infection, diet, or environment.
 
         
 
         Mosby's Medical, Nursing, and Allied Health Dictionary, Third 
 
         Edition.  The C.V. Mosby Company, St. Louis, et al.  1990.
 
         
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 13
 
         
 
         
 
              disease:  morbus; illness; sickness; an interruption, 
 
              cessation, or disorder of body functions, systems, or 
 
              organs.
 
         
 
         Stedman's Medical Dictionary, 25th Edition.
 
         
 
              A review of these definitions of the term "disease" show 
 
         that the term covers a broad range of maladies with a variety of 
 
         causes.  Although a disease may be commonly thought of as an 
 
         illness which is caused by the entry into the body of something 
 
         external that acts adversely thereon, such as a bacteria, virus, 
 
         germ, etc., these definitions are broader and include external 
 
         factors as well, such as climate or industrial factors.  This is 
 
         in keeping with the original list contained in section 85A.9, 
 
         which included infective agents (e.g., animal bacteria) and 
 
         industrial factors (e.g., radiation).  Significantly, it is 
 
         noteworthy that none of the definitions refer to the results of 
 
         trauma as constituting part of the definition of a disease.
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
              In attempting to ascertain legislative intent, it is noted 
 
         that the original legislative scheme set up in chapter 85A from 
 
         1947 through 1973 contained 17 named occupational diseases.  All 
 
         but one, number 10, which dealt with bursitis, synovitis or 
 
         tenosynovitis, had as their causation the invasion of the body by 
 
         a specific infective agent.  Poisons, germs, Radiation and toxic 
 
         dusts constituted the etiology of 16 of the 17 occupational 
 
         diseases.
 
         
 
              The record shows that claimant's carpal tunnel syndrome was 
 
         caused not by an invasion of her body by an outside agent, but by 
 
         external traumatic forces.  Although the external forces were 
 
         spread out over time and were made up of a series of 
 
         microtraumas, nevertheless they were traumas and as such 
 
         constitute injuries, not a disease.  The legislative intent in 
 
         enacting chapter 85A is hereby determined to have been to 
 
         compensate those work-related conditions that result from 
 
         exposure to various agents that would invade the body and act 
 
         adversely on it, and which could not be compensated as a 
 
         traumatic injury under chapter 85.  Claimant's carpal tunnel 
 
         syndrome is hereby determined to be a traumatic cumulative injury 
 
         compensable under chapter 85 and not an occupational disease 
 
         under chapter 85A.
 
         
 
              Claimant argues that compensating her carpal tunnel syndrome 
 
         under chapter 85 is unfair, in that her compensation under that 
 
         chapter will be limited to the scheduled benefits under Iowa Code 
 
         subsections 85.34(2)(a-t).  Claimant urges that compensation as 
 
         an occupational disease would be based on an industrial basis, 
 
         rather than the functional basis utilized in subsections 
 
         85.34(2)(a-t), and produce a more fair result.  Claimant assumes 
 
         that compensation under chapter 85A would always be on an 
 
         industrial disability basis, and nothing in this decision 
 
         addresses that
 
         
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 14
 
         
 
         
 
         question.  Further, the allegation that chapter 85 operates 
 
         unfairly is a legislative policy question and is not a valid 
 
         basis for treating claimant's condition under chapter 85A.
 
         
 
              It is noted that some conditions, such as pregnancy, renal 
 
         failure, menopause, diabetes mellitus, acromegaly, edema, 
 
         tuberculosis, and other conditions may produce carpal tunnel 
 
         syndrome as a symptom.  This decision does not address carpal 
 
         tunnel syndrome resulting from a disease.  This holding is 
 
         limited to the factual situation where a worker's carpal.tunnel 
 
         syndrome is caused by traumatic repetitive work activity.
 
              
 
              WHEREFORE, the decision of the deputy is affirmed.
 
         
 
                                      ORDER
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
              THEREFORE, IT IS ORDERED:
 
         
 
              That defendants pay to claimant twenty (20) weeks of 
 
         permanent partial disability benefits at the stipulated rate of 
 
         one hundred twenty and 65/100 dollars ($120.65) in the total 
 
         amount of two thousand four hundred thirteen dollars ($2,413) 
 
         commencing on February 13, 1988, as stipulated to by the parties.
 
              
 
              That these benefits are to be paid in a lump sum.
 
         
 
              That interest will accrue pursuant to Iowa Code section 
 
         85.30.
 
         
 
              That claimant shall pay the costs of the appeal including 
 
         the transcription of the hearing.  Defendants shall pay all other 
 
         costs.
 
         
 
              That defendants file claim activity reports as requested by 
 
         this agency pursuant to rule 343 IAC 3.1.
 
         
 
              Signed and filed this 7th day of May, 1992.
 
         
 
                                                 BYRON K. ORTON
 
                                            INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Steven C. Jayne
 
         Attorney at Law
 
         5835 Grand Avenue
 
         Suite 201
 
         Des Moines, Iowa 50312
 
         NOBLE v. LAMONI PRODUCTS
 
         Page 15
 
         
 
         
 
         Mr. Joseph A. Happe
 
         Mr. Jon Kurt Hoffmann
 
         Attorneys at Law
 
         500 Liberty Building
 
         Des Moines, Iowa  50309
 
         
 
         
 

 
         
 
 
 
 
 
 
 
 
 
 
 
         
 
 
         
 
 
 
 
 
 
 
 
 
 
 
         before the iowa industrial commissioner
 
         ____________________________________________________________
 
                                       :
 
         JUDITH M. FUNK,               :
 
                                       :
 
              Claimant,                :
 
                                       :
 
         vs.                           :
 
                                       :      File No. 857598
 
         MERCY HOSPITAL OF COUNCIL     :
 
         BLUFFS, IOWA,                 :        A P P E A L
 
                                       :
 
              Employer,                :      D E C I S I O N
 
              Defendant.               :
 
         ___________________________________________________________
 
         
 
         The record, including the transcript of the hearing before the 
 
         deputy and all exhibits admitted into the record, has been 
 
         reviewed de novo on appeal.  The decision of the deputy is 
 
         affirmed and is adopted as the final agency action in this case.
 
         Defendant Mercy Hospital of Council Bluffs, Iowa, self-insured, 
 
         shall pay the costs of the appeal, including the preparation of 
 
         the appeal transcript. 
 
         Signed and filed this ____ day of May, 1992.
 
         
 
         
 
         
 
         
 
                   ________________________________
 
                            BYRON K. ORTON
 
                       INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Marvin L. Vannier
 
         Attorney at Law
 
         221 S. Main
 
         Council Bluffs, Iowa  51501
 
         
 
         Mr. Melvin C. Hansen
 
         Attorney at Law
 
         800 Exchange Building
 
         1905 Harney Street
 
         Omaha, Nebraska  68102
 
         
 
         Mr. Richard D. Crotty
 
         Attorney at Law
 
         311 First Federal Building
 
         Council Bluffs, Iowa  51503
 
         
 
         Mr. Thomas M. Plaza
 
         Attorney at Law
 
         P O Box 3086
 
         Sioux City, Iowa  51102
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
            9998
 
            Filed May 29, 1992
 
            BYRON K. ORTON
 
            MAM
 
            before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            JUDITH M. FUNK,               :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 857598
 
            MERCY HOSPITAL OF COUNCIL     :
 
            BLUFFS, IOWA,                 :        A P P E A L
 
                                          :
 
                 Employer,                :      D E C I S I O N
 
                 Defendant.               :
 
            ___________________________________________________________
 
            
 
            
 
            9998
 
            
 
                 Summary affirmance of deputy's decision filed December 
 
            18, 1991.
 
            
 
 
         
 
         Page   1
 
         
 
         
 
         
 
         
 
         
 
                     before the iowa industrial commissioner
 
         ____________________________________________________________
 
                                       :
 
         JUDITH M. FUNK,               :
 
                                       :
 
              Claimant,                :
 
                                       :
 
         vs.                           :
 
                                       :         File No. 849569
 
         MERCY HOSPITAL OF COUNCIL     :
 
         BLUFFS, IOWA,                 :      A R B I T R A T I O N
 
                                       :
 
              Employer,                :         D E C I S I O N
 
                                       :
 
         and                           :
 
                                       :
 
         AETNA CASUALTY INSURANCE CO., :
 
                                       :
 
              Insurance Carrier,       :
 
              Defendants.              :
 
         ___________________________________________________________
 
                                       :
 
         JUDITH M. FUNK,               :
 
                                       :
 
              Claimant,                :
 
                                       :         File No. 857598
 
         vs.                           :
 
                                       :      A R B I T R A T I O N
 
         MERCY HOSPITAL OF COUNCIL     :
 
         BLUFFS, IOWA,                 :         D E C I S I O N
 
                                       :
 
              Employer,                :
 
              Self-Insured,            :
 
              Defendant.               :
 
         ___________________________________________________________
 
         
 
         
 
                              STATEMENT OF THE CASE
 
         
 
              These are proceedings in arbitration upon the petitions of 
 
         claimant, Judith M. Funk, against her employer, Mercy Hospital of 
 
         Council Bluffs.  The parties stipulated claimant sustained work 
 
         related injuries on April 4, 1987 and on July 16, 1987.  At the 
 
         time of the April 4, 1987 injury, defendant was insured by Aetna 
 
         Casualty Company.  On July 16, 1987, defendant was a self-insured 
 
         employer.
 
         
 
              The cases were joined.  They were heard on July 9, 1991, in 
 
         the Pottawattamie County Courthouse in Council Bluffs, Iowa.  The 
 
         record consists of the testimony of claimant.  The record also 
 
         consists of the testimony of Jane Corrin, Director of Medical and 
 
         Surgical Area, second floor; and the testimony of claimant's 
 
         spouse, Francis Funk.  Additionally, the record consists of joint 
 
         exhibits 1-73.
 
         
 
              The file number for the April 4, 1987, injury is 849569.  
 

 
         
 
         Page   2
 
         
 
         
 
         
 
         
 
         The file number for the July 16, 1987 injury date is listed as 
 
         857598.  For the record many of the exhibits were difficult to 
 
         read and there were many exhibits offered unnecessarily.  A 
 
         number of the records were produced two or three times.  This 
 
         caused undue delay in issuing a written decision.
 
         
 
                                      issues
 
         
 
              The issues to be determined are:  1) whether the work 
 
         injuries are a cause of permanent disability; 2) if so, the 
 
         extent of permanency; 3) whether claimant is entitled to healing 
 
         period benefits for file number 857598; 4) whether claimant is 
 
         entitled to medical benefits pursuant to section 85.27; and, 5) 
 
         the applicable rate for calculating benefits, if any.
 
         
 
                                 findings of fact
 
         
 
              The deputy, having heard the testimony and considered all 
 
         the evidence, finds:
 
         
 
              Claimant is 46 years old.  She is married with four chil
 
         dren.  Claimant has a high school diploma.  She also has a bache
 
         lor of science degree in nursing which she obtained in 1986.  
 
         Claimant described herself as a late bloomer.
 
         
 
              In 1985, claimant commenced her employment with defendant as 
 
         a staff nurse.  Claimant worked part-time.  Once claimant 
 
         received her degree in nursing, she terminated her position and 
 
         commenced employment as a staff nurse at the VA Hospital in 
 
         Omaha.  She held that position until January of 1987 when 
 
         claimant returned to the employ of defendant.
 
         
 
              Claimant worked full time as a nurse on the 11:00 p.m. to 
 
         7:00 a.m. shift.  She was responsible for the primary care of 
 
         patients on the second floor.  This was a medical-surgical wing.
 
         
 
              On April 4, 1987, a semi-comatose patient grabbed claimant 
 
         and at that moment, "claimant's back gave out."  Claimant had a 
 
         difficult time straightening her posture.  She completed her 
 
         shift and sought medical attention at the emergency room where 
 
         she was treated conservatively.  Claimant returned to work on 
 
         April 17, 1987.  On April 18, 1987, claimant left work after only 
 
         two hours because of her severe back pain.  On May 29, 1987, 
 
         claimant again returned to work.  She worked through July 16, 
 
         1987.  However, on July 16, 1987, a patient desired assistance in 
 
         bed.  Claimant provided the assistance but she experienced pain 
 
         across her back and down her left side.  Claimant returned to 
 
         work on July 17, 1987, but she was unable to complete her shift.
 
         
 
              Claimant obtained treatment at the hospital and later from 
 
         Behrauz Rassekh, M.D., a neurosurgeon.  Claimant underwent a 
 
         myelogram on July 29, 1987.  On the next day, Dr. Rassekh 
 
         performed a laminectomy at the L5, S-l level.
 
         
 
              Claimant's condition did not improve.  She underwent a 
 
         second myelogram which revealed abnormalities.  Dr. Rassekh 
 
         performed a second laminectomy on October 6, 1987.
 
         
 
              Claimant participated in physical therapy subsequent to her 
 
         second surgery.  She was released to return to work on January 4, 
 

 
         
 
         Page   3
 
         
 
         
 
         
 
         
 
         1988.  She worked eight days but claimant testified she could not 
 
         work because of back pain.  Claimant continued to treat with Dr. 
 
         Rassekh.  As of June 7, 1988, Dr. Rassekh opined:
 
         
 
              Mrs. Funk was seen again at the clinic.  She is doing 
 
              fairly well.  Her condition has stabilized and leveled 
 
              off.  She continues to have some pain in the back and 
 
              the left hip region and some aggravation by bending and 
 
              lifting otherwise she is up and around.  She walks with 
 
              no difficulty.
 
         
 
              She has no weakness.  Anteflexion of spine at 45 
 
              degrees produces pain.  I do believe she has reached 
 
              maximum recovery and she will have some restriction not 
 
              to lift over 30-35 lbs. and not to do repeated bending.  
 
              She could probably return to occasional rehabilitation.  
 
              Thank you.
 
         
 
              Pursuant to a request from defendant-employer, Ron Schmidt, 
 
         a vocational rehabilitation consultant, commenced rehabilitation.  
 
         He met with claimant in May and June of 1988.  As of July 18, 
 
         1988, claimant was terminated from her employment because she had 
 
         exceeded her leave of absence.  Mr. Schmidt continued to assist 
 
         claimant with her resume' and he also provided job leads.  Mr. 
 
         Schmidt did not obtain a position for claimant.  Claimant also 
 
         conversed with rehabilitation specialist, Karen Stricklett.  Ms. 
 
         Stricklett did not place claimant in a new position.  The reha
 
         bilitation consultant opined there was a 15 to 20 percent loss of 
 
         earning capacity due to claimant's injuries.
 
         
 
              Claimant actively sought employment through October 24, 
 
         1988.  She received no job offers.  After October 24, 1988, 
 
         claimant only participated in a sporadic job search.  Her level 
 
         of motivation had waned.  Even after she was contacted by defen
 
         dant employer relative to the opening of the "Utilization Review 
 
         Coordinator" position, claimant was not hired for the position.  
 
         Claimant testified that as of the date of the hearing, she was 
 
         not employed.
 
         
 
              Numerous physicians have examined claimant.  The treating 
 
         neurosurgeon, Dr. Rassekh, restricted claimant from repeated 
 
         bending and from lifting 30 to 40 pounds.  As of June 7, 1988, 
 
         Dr. Rassekh opined claimant had a 10 to 15 percent functional 
 
         impairment.  Later, Dr. Rassekh modified the impairment rating 
 
         when claimant began experiencing pain down her right lower 
 
         extremity.  The treating physician opined claimant had a 20 per
 
         cent functional impairment rating with five percent due to a nar
 
         rowing of the disk space on the right side at L5-Sl, due to the 
 
         previous two surgeries.
 
         
 
              Claimant was examined by Stanley Bach, M.D., an orthopedic 
 
         surgeon.  He opined claimant had a functional impairment of 30 
 
         percent to the body as a whole.  Dr. Bach did not base his 
 
         impairment rating on the AMA guidelines.  The basis of his opin
 
         ion was that claimant had two less than successful surgeries at 
 
         L-5, S-l, and she had pain as a result of her back condition.
 
         
 
              Claimant also had another medical examination from Leonard 
 
         E. Weber, M.D., on June 5, 1989.  In his report of June 7, 1989, 
 
         Dr. Weber wrote in relevant portion:
 

 
         
 
         Page   4
 
         
 
         
 
         
 
         
 
         
 
              Impression:
 
         
 
                 1.  Lifting incidents on the job on or about April              
 
              4, 1987, and July 16, 1987.
 
         
 
                 2.  L5/Sl disk herniation, presumably far lateral,              
 
              secondary to (l).
 
         
 
                 3.  Left L5 radiculopathy, secondary to (2).
 
         
 
                 4.  Treatment of (2) by two laminectomies at L5/Sl.
 
         
 
                 5.  Residual left low back and left lower extremity             
 
              pain, constant left great and second toe                      
 
              numbness, and hypesthesia, hypalgesia, and               
 
              diminished coolness of a cool tuning fork on the         
 
              dorsum of the medial aspect of the left foot and         
 
              dorsum of the left great toe, secondary to (3).
 
         
 
              Comments and Recommendations:
 
         
 
              This lady apparently had a far lateral disk herniation 
 
              at L5/Sl (though I do not have the operative report).  
 
              Consequent to this injury which developed in the course 
 
              of job activities, she suffered injury to sensory por
 
              tions of the left L5 nerve root.
 
         
 
              Her persistent back and left lower extremity discomfort 
 
              and persistent left lower extremity numbness is conse
 
              quent to the partial injury to sensory portions of the 
 
              left L5 nerve root.  I think that these symptoms will 
 
              be with her indefinitely, though as the years go by 
 
              they may gradually subside.
 
         
 
              Anything that would put a stretch or tug on the left L5 
 
              nerve root would be likely to stir up her symptoms of 
 
              pain and numbness.  This would include forward bending, 
 
              forward stooping, or forward lifting, and all need to 
 
              be avoided.  This would prevent her from return to her 
 
              usual activities as a med-surg nurse.
 
         
 
              Her treatment should be conservative.  I do not know of 
 
              any surgical procedures that would be particularly 
 
              helpful to her and she has tried a TENS unit without 
 
              improvement.  Most physicians would continue the use of 
 
              a muscle relaxant like Robaxin if it seems to help, or 
 
              use one of the non-steroidal anti-inflammatory agents 
 
              like Motrin 800 mg., three times a day; Naprosyn 375 
 
              mg., twice a day; Feldene 20 mg., once daily; or 
 
              Dolobid 500 mg., one half to one twice a day.
 
         
 
              I believe that for practical purposes she has attained 
 
              the point of maximum medical improvement.  She could 
 
              engage in vocational rehab or job retraining, with 
 
              restrictions.  The restrictions would be against lift
 
              ing more than 20 to 30 pounds, all lifting to be done 
 
              from a squat rather than a bent forward position.  She 
 
              should not be engaging in any activities requiring 
 
              repetitive forward bending or twisting, and should not 
 

 
         
 
         Page   5
 
         
 
         
 
         
 
         
 
              be lifting anything from a bent forward position.  She 
 
              should have the ability in job activities to change her 
 
              position from a sitting to a standing position as com
 
              fort dictates.
 
         
 
              I base percent permanent impairment on the "Guides to 
 
              the Evaluation of Permanent Impairment", the third edi
 
              tion published by the American Medical Association.  
 
              Based on these guidelines, the percent permanent 
 
              impairment relative to the job incidents of 4/4/87 and 
 
              7/16/87 would be 16 percent whole person impairment, 
 
              given for two back operations at the same level with 
 
              residual symptoms "failed back surgery", with pain and 
 
              numbness referrable [sic] to the left L5 nerve root 
 
              which prevents several activities.  Additional percent 
 
              impairment could not be given for the limitation of 
 
              lumbar range of motion as the sacral flexion and exten
 
              sion range of motion was exceeded by the tightest 
 
              straight leg range of motion by more than 10 percent, 
 
              the validity criteria for lumbar range of motion.
 
         
 
              Further neurologic testing would not be needed.
 
         
 
              From the evidence offered to the undersigned, it is clear 
 
         claimant was a better than average employee.  She demonstrated 
 
         competency while on the job.  However, claimant was never rehired 
 
         after she had been terminated by defendant-employer in July of 
 
         1988.  Since the date of her termination, claimant has not been 
 
         actively employed.
 
         
 
                       
 
         
 
         
 
         Page   6
 
         
 
         
 
         
 
         
 
         conclusions of law
 
         
 
              The first issue to address is whether claimant has sustained 
 
         an injury which arose out of and in the course of her employment.  
 
         The parties have stipulated that claimant sustained an injury 
 
         which arose out of and in the course of her employment on April 
 
         4, 1987.  Claimant has sustained her burden of proof with respect 
 
         to the July 16, 1987 injury.
 
         
 
              The claimant has the burden of proving by a preponderance of 
 
         the evidence that the alleged injury actually occurred and that 
 
         it arose out of and in the course of employment.  The words 
 
         "arising out of" refer to the cause or source of the injury.  The 
 
         words "in the course of" refer to the time, place and circum
 
         stances of the injury.  Sheerin v. Holin Co., 380 N.W.2d 415, 417 
 
         (Iowa 1986); McClure v. Union, et al., Counties, 188 N.W.2d 283, 
 
         287 (Iowa 1971).
 
         
 
              Claimant is a credible witness.  Her testimony relative to 
 
         the July 16, 1987 injury is undisputed.  Claimant has satisfied 
 
         the requisite burden of proof.
 
         
 
              The next issue in contention deals with causal connection.
 
         
 
              The claimant has the burden of proving by a preponderance of 
 
         the evidence that the injury is a proximate cause of the disabil
 
         ity on which the claim is based.  A cause is proximate if it is a 
 
         substantial factor in bringing about the result; it need not be 
 
         the only cause.  A preponderance of the evidence exists when the 
 
         causal connection is probable rather than merely possible.  
 
         Blacksmith v. All-American, Inc., 290 N.W.2d 348, 354 (Iowa 
 
         1980); Holmes v. Bruce Motor Freight, Inc., 215 N.W.2d 296, 297 
 
         (Iowa 1974).
 
         
 
              The question of causal connection is essentially within the 
 
         domain of expert testimony.  The expert medical evidence must be 
 
         considered with all other evidence introduced bearing on the 
 
         causal connection between the injury and the disability.  The 
 
         weight to be given to any expert opinion is determined by the 
 
         finder of fact and may be affected by the accuracy of the facts 
 
         relied upon by the expert as well as other surrounding circum
 
         stances.  The expert opinion may be accepted or rejected, in 
 
         whole or in part.  Sondag v. Ferris Hardware, 220 N.W.2d 903 
 
         (Iowa 1974); Anderson v. Oscar Mayer & Co., 217 N.W.2d 531 (Iowa 
 
         1974); Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 
 
         (1965).
 
         
 
              The parties have stipulated that the April 4, 1987 injury 
 
         has caused a temporary disability for the period from April 4, 
 
         1987 through April 16, 1987 and from April 19, 1987 through May 
 
         28, 1987.
 
         
 
              The overwhelming evidence establishes that the July 16, 1987 
 
         injury is a cause of disability as well.  It is the determination 
 
         of the undersigned that the July 16, 1987 injury is a cause of 
 
         both temporary and permanent disability.
 
         
 
              While a claimant is not entitled to compensation for the 
 
         results of a preexisting injury or disease, its mere existence at 
 
         the time of a subsequent injury is not a defense.  Rose v. John 
 

 
         
 
         Page   7
 
         
 
         
 
         
 
         
 
         Deere Ottumwa Works, 247 Iowa 900, 76 N.W.2d 756 (1956).  If the 
 
         claimant had a preexisting condition or disability that is mate
 
         rially aggravated, accelerated, worsened or lighted up so that it 
 
         results in disability, claimant is entitled to recover.  Nicks v. 
 
         Davenport Produce Co., 254 Iowa 130, 115 N.W.2d 812 (1962); 
 
         Yeager v. Firestone Tire & Rubber Co., 253 Iowa 369, 112 N.W.2d 
 
         299 (1961).
 
         
 
              Apportionment of disability between a preexisting condition 
 
         and an injury is proper only when some ascertainable portion of 
 
         the ultimate industrial disability existed independently before 
 
         an employment-related aggravation of disability occurred.  Bearce 
 
         v. FMC Corp., 465 N.W.2d 531 (Iowa 1991); Varied Enterprises, 
 
         Inc. v. Sumner, 353 N.W.2d 407 (Iowa 1984).
 
         
 
              The burden of showing that disability is attributable to a 
 
         preexisting condition is placed upon the defendant.  Where evi
 
         dence to establish a proper apportionment is absent, the defen
 
         dant is responsible for the entire disability that exists.  
 
         Bearce, 465 N.W.2d 531; Sumner, 353 N.W.2d 407.
 
         
 
              The situation before this deputy is a classic case under the 
 
         Bearce rationale.  The facts at hand are similar to the facts in 
 
         Bearce.
 
         
 
              In Bearce, claimant sustained a back injury in December of 
 
         1977.  He was off work in 1978 and 1979.  After having completed 
 
         treatment and rehabilitation, a functional capacity evaluation 
 
         was performed.  Claimant was given a 20 percent permanent partial 
 
         impairment and had some restrictions imposed.
 
         
 
              In March of 1981, Bearce returned to his former line of 
 
         work.  He was laid off.  However, he later returned to work with
 
         out restrictions.  Bearce worked for 11 months more until he sus
 
         tained a second injury.  Mr. Bearce was never able to return to 
 
         work with his employer.  The industrial commissioner determined 
 
         Bearce had a 35 percent industrial disability.  However, the 
 
         industrial commissioner determined 25 percent of the industrial 
 
         disability was attributable to the preexisting condition and 10 
 
         percent was attributable to the second injury.  The Bearce case 
 
         was appealed to the Iowa Supreme Court.  There the Court noted at 
 
         535 that:
 
         
 
                 We have spelled out the difference between func
 
              tional and industrial disability:
 
         
 
                      The two methods used to evaluate a dis
 
                   ability, functional and industrial, are dis
 
                   similar.  Functional disability is assessed 
 
                   solely by determining the impairment of the 
 
                   body function of the employee; industrial 
 
                   disability is gauged by determining the loss 
 
                   to the employee's earning capacity.  
 
                   Functional disability is limited to the loss 
 
                   of physiological capacity of the body or body 
 
                   part.  Industrial disability is not bound to 
 
                   the organ or body incapacity, but measures 
 
                   the extent to which the injury impairs the 
 
                   employee in the ability to earn wages.  
 
                   Criteria for the test of industrial disabil
 

 
         
 
         Page   8
 
         
 
         
 
         
 
         
 
                   ity include the extent of functional disabil
 
                   ity, along with the employee's age, educa
 
                   tion, qualification, experiences, and the 
 
                   injury-induced inability of the employee to 
 
                   engage in employment for which the employee 
 
                   is fitted.
 
         
 
              Simbro v. Delong's Sportswear, 332 N.W.2d 886, 887 
 
              (Iowa 1983).
 
         
 
                 The following helpful definitions of impairment and 
 
              disability underscore the difference between functional 
 
              disability or impairment and industrial disability:
 
         
 
                   [I]mpairment means an alteration of an indi
 
                   vidual's health status that is assessed by 
 
                   medical means; "disability," which is 
 
                   assessed by nonmedical means, means an alter
 
                   ation of an individual's capacity to meet 
 
                   personal, social, or occupational demands, or 
 
                   to meet statutory or regulatory requirements.  
 
                   Simply stated, "impairment" is what is wrong 
 
                   with the health of an individual; 
 
                   "disability" is the gap between what the 
 
                   individual can do and what the individual 
 
                   needs or wants to do.
 
         
 
                 American Medical Association, Guides to the 
 
              Evaluation of a Permanent Impairment 2 (3d ed. 1988).  
 
              The distinction between functional disability or 
 
              impairment and industrial disability is critical in 
 
              understanding Larson's statement that apportionment 
 
              does not apply to a "prior condition [which] was not a 
 
              disability in the compensation sense."  By this state
 
              ment Larson means apportionment is not applied to an 
 
              impairment that prior to the accident had no effect on 
 
              the employee's ability to earn wages.  Simply put, the 
 
              "disability" Larson is talking about is industrial dis
 
              ability and not simply functional disability.
 
         
 
                 ....
 
         
 
                 Here Bearce returned to full-time employment, earn
 
              ing full-time wages in November 1983 without any physi
 
              cal restrictions.  He was able to do so because he had 
 
              built up his physical condition.
 
         
 
                 For the next eleven months Bearce did all that was 
 
              expected of him in the radial drill operator's job, a 
 
              job that required considerable physical exertion.  
 
              During this period Bearce sought no medical attention, 
 
              met all work quotas, lost no work, and suffered no drop 
 
              in pay.  In addition there is no record evidence that 
 
              Bearce had sought any medical attention for his lower 
 
              back for two and one-half years before his August 1984 
 
              injury.  In short, there is no record evidence that 
 
              during this eleven month period Bearce was suffering 
 
              from any disability affecting his earning capacity.  
 
              See Diederich v. Tri-City Ry. Co., 219 Iowa 587, 594, 
 
              258 N.W. 899, 902 (1935) (industrial disability is the 
 

 
         
 
         Page   9
 
         
 
         
 
         
 
         
 
              inability on the part of the injured employee to carry 
 
              on the work the employee was doing before the injury, 
 
              or any work which the employee could perform).
 
         
 
                 The extent of industrial disability is a question of 
 
              fact for the industrial commissioner.  As we said, such 
 
              a determination is based on several factors including, 
 
              but not limited to, the extent of functional disability 
 
              or impairment.  Here there is no substantial evidence 
 
              to support a finding that the 1977 injury was in any 
 
              way disabling to Bearce in his employment as a radial 
 
              drill operator at the time of the second injury.  More 
 
              specifically, there is no substantial evidence to sup
 
              port a finding that the prior injury independently pro
 
              duced some ascertainable portion of the industrial dis
 
              ability which existed following the 1984 injury.  In 
 
              fact we fail to see where the commissioner even made 
 
              such a finding.  Without such evidence, the district 
 
              court erroneously concluded that the commissioner was 
 
              correct in applying the apportionment rule.
 
         
 
         Bearce at 535-537.
 
         
 
              The case before this deputy is similar to Bearce.  In the 
 
         present case after the injury on April 4, 1987, Dr. Rassekh 
 
         returned claimant to work on May 29, 1987.  No functional impair
 
         ment rating was given.  No restrictions were placed on claimant.  
 
         She returned to her same position, at the same rate of pay, and 
 
         on the same shift.  Claimant continued without difficulty.  She 
 
         performed all tasks requested and she met at least average stan
 
         dards for a nurse on her floor.  She was even given a salary 
 
         increase.
 
         
 
              It was only after the second injury that claimant incurred 
 
         any permanent functional impairment or for that matter any indus
 
         trial disability.  After the second injury, claimant attempted a 
 
         return to her former position.  She was assigned 12 hour shifts 
 
         which proved too difficult for her to maintain.  Dr. Rassekh 
 
         imposed restrictions after the second injury.  Claimant was ter
 
         minated from her position as a primary staff nurse on the 
 
         medical/surgical floor.  Claimant was provided with a number of 
 
         functional impairment ratings subsequent to the second injury.
 
         
 
              It should be noted for the record that while certain physi
 
         cians may have apportioned functional impairment ratings to each 
 
         of the respective work injuries, these segregated functional 
 
         impairment ratings do not change the outcome of the case.  The 
 
         significant industrial disability event occurred on July 16, 
 
         1987.  As in Bearce, the industrial disability in the present 
 
         case is all attributable to the second injury.  The July 16, 1987 
 
         injury directly impacts upon the claimant's ability to earn 
 
         wages.  All industrial disability in this matter is assigned to 
 
         the July 16, 1987 injury date.
 
         
 
              The next issue to determine is the nature and extent of 
 
         claimant's industrial disability.  Claimant alleges she was 
 
         totally disabled after the July 16, 1987 injury.  Such is not the 
 
         case, however.
 
         
 
              Functional impairment is an element to be considered in 
 

 
         
 
         Page  10
 
         
 
         
 
         
 
         
 
         determining industrial disability which is the reduction of earn
 
         ing capacity, but consideration must also be given to the injured 
 
         employee's age, education, qualifications, experience and inabil
 
         ity to engage in employment for which the employee is fitted.  
 
         Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 
 
         (1963).  Barton v. Nevada Poultry, 253 Iowa 285, 110 N.W.2d 660 
 
         (1961).
 
         
 
              A finding of impairment to the body as a whole found by a 
 
         medical evaluator does not equate to industrial disability.  
 
         Impairment and disability are not synonymous.  The degree of 
 
         industrial disability can be much different than the degree of 
 
         impairment because industrial disability references to loss of 
 
         earning capacity and impairment references to anatomical or func
 
         tional abnormality or loss.  Although loss of function is to be 
 
         considered and disability can rarely be found without it, it is 
 
         not so that a degree of industrial disability is proportionally 
 
         related to a degree of impairment of bodily function.
 
         
 
              Factors to be considered in determining industrial dis
 
         ability include the employee's medical condition prior to the 
 
         injury, immediately after the injury, and presently; the situs of 
 
         the injury, its severity and the length of the healing period; 
 
         the work experience of the employee prior to the injury and after 
 
         the injury and the potential for rehabilitation; the employee's 
 
         qualifications intellectually, emotionally and physically; earn
 
         ings prior and subsequent to the injury; age; education; motiva
 
         tion; functional impairment as a result of the injury; and 
 
         inability because of the injury to engage in employment for which 
 
         the employee is fitted.  Loss of earnings caused by a job trans
 
         fer for reasons related to the injury is also relevant.  
 
         Likewise, an employer's refusal to give any sort of work to an 
 
         impaired employee may justify an award of disability.  McSpadden 
 
         v. Big Ben Coal Co., 288 N.W.2d 181 (Iowa 1980).  These are mat
 
         ters which the finder of fact considers collectively in arriving 
 
         at the determination of the degree of industrial disability.
 
         
 
              There are no weighting guidelines that indicate how each of 
 
         the factors are to be considered.  Neither does a rating of func
 
         tional impairment directly correlate to a degree of industrial 
 
         disability to the body as a whole.  In other words, there are no 
 
         formulae which can be applied and then added up to determine the 
 
         degree of industrial disability.  It therefore becomes necessary 
 
         for the deputy or commissioner to draw upon prior experience as 
 
         well as general and specialized knowledge to make the finding 
 
         with regard to degree of industrial disability.  See Peterson v. 
 
         Truck Haven Cafe, Inc., (Appeal Decision, February 28, 1985); 
 
         Christensen v. Hagen, Inc., (Appeal Decision, March 26, 1985).
 
         
 
              Compensation for permanent partial disability shall begin at 
 
         the termination of the healing period.  Compensation shall be 
 
         paid in relation to 500 weeks as the disability bears to the body 
 
         as a whole.  Section 85.34.
 
         
 
              Claimant is highly educated.  She holds a bachelor of sci
 
         ence degree in nursing.  While it is true claimant is not able to 
 
         work as a staff nurse where she is required to lift patients 
 
         weighing more than 40 pounds, there are still positions in nurs
 
         ing for which claimant is quite qualified.  Claimant can teach.  
 
         Claimant is able to work as an occupational nurse in the indus
 

 
         
 
         Page  11
 
         
 
         
 
         
 
         
 
         trial setting.  She is able to meet the criteria of many insur
 
         ance companies in medical management, per review, or even as a 
 
         qualified vocational rehabilitation specialist.  After reviewing 
 
         the evidence, claimant has all the qualifications for a position 
 
         in rehabilitation management with one of the private consultants 
 
         in either Iowa or Nebraska.  Given her personal experiences, 
 
         claimant is well acquainted with the type of work involved.  The 
 
         rate of pay for any of the aforementioned positions appears to be 
 
         comparable to the wages claimant had been receiving on July 16, 
 
         1987.
 
         
 
              From the evidence presented to the undersigned, it appears 
 
         claimant is well qualified as a "Utilization Review Coordinator" 
 
         for defendant-employer.  Defendant-employer has selected not to 
 
         rehire claimant, a dedicated employee.  This is a factor which 
 
         negatively impacts upon claimant's earning capacity.  It is 
 
         unfortunate for all of the parties that defendant-employer has 
 
         refused to rehire claimant, a very motivated individual.
 
         
 
              After weighing all of the factors relative to industrial 
 
         disability, the undersigned determines claimant has a 50 percent 
 
         industrial disability.
 
         
 
              The next issue deals with the respective healing periods 
 
         involved for each of the two files.  Section 85.34(1) provides 
 
         that healing period benefits are payable to an injured worker who 
 
         has suffered permanent partial disability until (1) the worker 
 
         has returned to work; (2) the worker is medically capable of 
 
         returning to substantially similar employment; or (3) the worker 
 
         has achieved maximum medical recovery.  The healing period can be 
 
         considered the period during which there is a reasonable expecta
 
         tion of improvement of the disabling condition.  See Armstrong 
 
         Tire & Rubber Co. v. Kubli, 312 N.W.2d 60 (Iowa App. 1981).  
 
         Healing period benefits can be interrupted or intermittent.  Teel 
 
         v. McCord, 394 N.W.2d 405 (Iowa 1986).
 
         
 
              For file number 849569, it is crystal clear that the healing 
 
         periods involved are from:
 
         
 
                        April  4, 1987 through April 16, 1987
 
                        April 19, 1987 through May 28, 1987
 
         
 
              For file number 857598, the healing period is as follows:
 
         
 
                        July 16, 1987 through January 3, 1988
 
                        January 17, 1988 through June 7, 1988  (The
 
         date Dr. Rassekh opined claimant had reached maximum medical 
 
         improvement.)
 
         
 
              Additionally, for file number 857598, claimant is entitled 
 
         to healing period benefits from November 4, 1989 through March 
 
         20, 1990, the date of the final bone scan.  Dr. Rassekh relates 
 
         that condition to the previous two surgeries and as of March 20, 
 
         1990, claimant decided she would not pursue a third surgical pro
 
         cedure.  At that point, claimant had reached maximum medical 
 
         improvement.
 
         
 
              The next issue to determine is the issue dealing with the 
 
         proper weekly rate for each of the respective injury dates.  At 
 
         the time of the April 4, 1987 injury, claimant was paid $9.81 per 
 

 
         
 
         Page  12
 
         
 
         
 
         
 
         
 
         hour.  Additionally, claimant received "choice dollars."  These 
 
         choice dollars could be used toward the purchase of health insur
 
         ance or could be used as cash.  The amount equaled an additional 
 
         $.26 per hour.  The amount was subject to state and federal 
 
         taxes.
 
         
 
              Section 85.36 of the Iowa Code provides that:
 
         
 
              85.36 Basis of Computation.
 
         The basis of compensation shall be the weekly earnings 
 
         of the injured employee at the time of the injury.  
 
         Weekly earnings means gross salary, wages, or earnings 
 
         of an employee to which such employee would have been 
 
         entitled had the employee worked the customary hours 
 
         for the full pay period in which the employee was 
 
         injured, as regularly required by the employee's 
 
         employer for the work or employment for which the 
 
         employee was employed, computed or determined as 
 
         follows and then rounded to the nearest dollar:
 
         
 
              1.  In the case of an employee who is paid on a weekly 
 
              pay period basis, the weekly gross earnings.
 
         
 
              Section 85.61(3) defines "Gross earnings."  The section 
 
         reads:
 
         
 
                 3.  "Gross earnings" means recurring payments by 
 
              employer to the employee for employment, before any 
 
              authorized or lawfully required deduction or withhold
 
              ing of funds by the employer, excluding irregular 
 
              bonuses, retroactive pay, overtime, penalty pay, reim
 
              bursement of expenses, expense allowances, and the 
 
              employer's contribution for welfare benefits.
 
         
 
              Under 85.61(3) the choice dollars are part of the regular 
 
         gross earnings.  They are not dollars for welfare benefits since 
 
         the employee could use the money for any purpose.  Claimant's 
 
         gross weekly wage is thus, $397.55 per week per the parties' 
 
         stipulation.  At the time of the April 4, 1987 injury, claimant 
 
         was married and entitled to four exemptions.  Her weekly benefit 
 
         rate for file number 849569 is $253.79 per week.
 
         
 
              For the injury of July 16, 1987, the same rationale is 
 
         applied with respect to the choice dollars.  Per the stipulation 
 
         of the parties, the gross average weekly wage is $426.36 and her 
 
         weekly benefit rate is $275.46.
 
         
 
              The next issue to address is the issue of medical benefits 
 
         pursuant to section 85.27.
 
         
 
              The employer shall furnish reasonable surgical, medical, 
 
         dental, osteopathic, chiropractic, podiatric, physical rehabili
 
         tation, nursing, ambulance and hospital services and supplies for 
 
         all conditions compensable under the workers' compensation law.  
 
         The employer shall also allow reasonable and necessary trans
 
         portation expenses incurred for those services.  The employer has 
 
         the right to choose the provider of care, except where the 
 
         employer has denied liability for the injury.  Section 85.27.; 
 
         Holbert v. Townsend Engineering Co., Thirty-second Biennial 
 
         Report of the Industrial Commissioner 78 (Review decision 1975).  
 

 
         
 
         Page  13
 
         
 
         
 
         
 
         
 
         Claimant has the burden of proving that the fees charged for such 
 
         services are reasonable.  Anderson v. High Rise Constr. 
 
         Specialists, Inc., file number 850096 (Appeal Decision 1990).
 
         
 
              Claimant is not entitled to reimbursement for medical bills 
 
         unless claimant shows they were paid from claimant's funds.  See 
 
         Caylor v. Employers Mut. Casualty Co., 337 N.W.2d 890 (Iowa App. 
 
         1983).
 
         
 
              Claimant requests payment for the following medical benefits 
 
         which were all incurred subsequent to November 4, 1990:
 
         
 
                       JUDITH FUNK UNPAID MEDICAL EXPENSES
 
         
 
              PROVIDER                      PAID BY             AMOUNT
 
         
 
              Myrtue Hospital PT            Claimant            198.70
 
              Myrtue Hospital               Claimant            194.40
 
              Myrtue Hospital               Claimant             29.15
 
              B. Rassekh                                        480.00
 
              Mercy Hospital                                  1,108.80
 
              Stanley Bach, M.D.            Claimant             50.00
 
              X-rays at Bach's Office       Claimant             88.00
 
              Nebraska-Iowa Radiology       Claimant            105.00
 
              Myrtue Hospital               Claimant             50.00
 
              Pamida Pharmacy               Claimant             74.00
 
         
 
              Dr. Rassekh, the treating physician, causally related 
 
         claimant's condition in November of 1990 to claimant's two previ
 
         ous surgeries.  Therefore, it is the determination of this deputy 
 
         that defendant, self-insured employer, is responsible for:
 
         
 
              Myrtue Hospital               $  472.25
 
              B. Rassekh                       480.00
 
              Mercy Hospital                 1,108.80
 
              Nebraska-Iowa Radiology          105.00
 
              Pamida Pharmacy                   74.00
 
         
 
                                    Total   $2,240.05
 
         
 
              Claimant is entitled to the payment of certain bills under 
 
         section 85.39.
 
         
 
              Section 85.39 permits an employee to be reimbursed for sub
 
         sequent examination by a physician of the employee's choice where 
 
         an employer-retained physician has previously evaluated 
 
         "permanent disability" and the employee believes that the initial 
 
         evaluation is too low.  The section also permits reimbursement 
 
         for reasonably necessary transportation expenses incurred and for 
 
         any wage loss occasioned by the employee attending the subsequent 
 
         examination.
 
         
 
              Defendants are responsible only for reasonable fees associ
 
         ated with claimant's independent medical examination.  Claimant 
 
         has the burden of proving the reasonableness of the expenses 
 
         incurred for the examination.  See Schintgen v. Economy Fire & 
 
         Casualty Co., file number 855298 (Appeal Decision, April 26, 
 
         1991).  Defendants' liability for claimant's injury must be 
 
         established before defendants are obligated to reimburse claimant 
 
         for independent medical examination.  McSpadden, 288 N.W.2d 181 
 

 
         
 
         Page  14
 
         
 
         
 
         
 
         
 
         (Iowa 1980).
 
         
 
              The charges covered under section 85.39 and payable by 
 
         defendant, self-insured employer are:
 
         
 
              Stanley Bach, M.D.                 $ 50.00
 
              X-rays Stanley Bach, M.D.            88.00
 
                                       Total     $138.00
 
         
 
              Finally, there is the issue dealing with taxation of costs.  
 
         Costs are in the discretion of the commissioner pursuant to sec
 
         tion 86.40.  In this case, costs are taxed evenly between the 
 
         defendants.  The costs are:
 
         
 
         1.  Iowa Industrial Commissioner (Filing Fee)     $   65.00
 
               check # 3523 paid 4-13-90
 
         2.  U.S. Post Master (Certified Copy of
 
               Original Notice to Defendants)                   6.00
 
               check # 3539 paid 4-23-90
 
         3.  Pottawattamie County Sheriff (Service
 
               of Subpoena & Subpoena Duces Tecum for
 
               attendance of witness Epperson & Perry)         18.00
 
               check #3719 paid 11-7-90
 
         4.  Blair & Associates (Court Reporter Fee
 
               for Depositions of Epperson & Perry)           347.60
 
               check # 3744 paid 11-27-90
 
         5.  Rehabilitation Management (Fee Charged
 
                by Ronald Schmidt for giving his
 
                Deposition)                                   142.80
 
               check #3745 paid 11-27-90
 
         6.  Blair & Associates (Court Reporter Fee
 
                for Deposition of Schmidt, Epperson
 
                & Perry)                                      143.53
 
               check # 3746 paid 11-30-90
 
         7.  Pottawattamie County Sheriff (Service of
 
                Subpoena on Pauline Huebner for Deposition)    17.00
 
               check # 3860 paid 5-6-91
 
         8.  Dr. B. Rassekh (Professional Fee for
 
                Attending his Deposition on 4/15/91,
 
                Doctor charged $750.00 for l l/2 hr)/)        150.00
 
               check # 3874 paid 5-14-91
 
         9.  Blair & Associates (Court Reporter Fee
 
                for Deposition of B. Rassekh                  261.05
 
               check #3853 paid 5-3-91
 
         10.  Blair & Associates (Court Reporter Fee
 
                 for Deposition of Pauline Huebner &
 
                 Dr. Bach)                                    179.32
 
                check # 3852 paid 5-3-91
 
         11.  Dr. S. Bach (Professional Fee for
 
                 Attending his deposition on 4/25/91)         150.00
 
                check # 3871 paid 5-14-91
 
         12.  Pottawattamie County Sheriff for service
 
                 of Subpoena on Jane Corrin                    16.00
 
                check # 3891 paid 6-6-91
 
                                                 Total     $1,496.30
 
         
 
                                      order
 
         
 
              THEREFORE, IT IS ORDERED:
 
         
 

 
         
 
         Page  15
 
         
 
         
 
         
 
         
 
              With respect to file number 849569, defendants are to pay 
 
         unto claimant temporary total disability benefits for the period 
 
         from April 4, 1987 through April 16, 1987, and from April 19, 
 
         1987 through May 28, 1987, for a total of seven point 
 
         five-seven-one (7.571) weeks at the corrected weekly benefit rate 
 
         of two hundred fifty-three and 79/l00 dollars ($253.79) per week.
 
         
 
              With respect to file number 857598, defendant, self-insured 
 
         employer, is to pay healing period benefits from July 16, 1987 
 
         through January 3, 1988, from January 17, 1988 through June 7, 
 
         1988 and from November 4, 1989 to March 20, 1990, for a total of 
 
         sixty-four point five-seven-one (64.571) weeks at the stipulated 
 
         weekly benefit rate of two hundred seventy-five and 46/l00 dol
 
         lars ($275.46) per week.
 
         
 
              Also with respect to file number 857598, defendant, 
 
         self-insured employer, is to pay two hundred fifty (250) weeks of 
 
         permanent partial disability benefits at the stipulated weekly 
 
         benefit rate of two hundred seventy-five and 46/l00 dollars 
 
         ($275.46) per week commencing on March 21, 1990.
 
         
 
              Defendants shall take credit for benefits previously paid 
 
         claimant.
 
         
 
              Accrued benefits are to be paid in a lump sum together with 
 
         statutory interest at the rate of ten percent (10%) per year pur
 
         suant to section 85.30, Iowa Code, as amended.
 
         
 
              With respect to file number 857598, self-insured defendant, 
 
         shall pay medical expenses in the sum of two thousand two hundred 
 
         forty and 05/l00 dollars ($2,240.05) as aforementioned.
 
         
 
              With respect to file number 857598, self-insured defendant, 
 
         shall pay one hundred thirty-eight and no/l00 dollars ($138.00), 
 
         expenses pursuant to section 85.39, Iowa Code, as amended.
 
         
 
              Costs are evenly taxed to defendants pursuant to rule 343 
 
         IAC 4.33, as aforementioned.
 
         
 
              Defendants shall file claim activity reports as requested by 
 
         this division pursuant to rule 343 IAC 3.1.
 
         
 
         
 
         
 
              Signed and filed this ____ day of December, 1991.
 
         
 
         
 
         
 
         
 
         
 
                                       ______________________________               
 
         MICHELLE A. McGOVERN
 
                                       DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         
 
         
 
         Copies To:
 
         
 
         Mr. Marvin L. Vannier
 
         Attorney at Law
 

 
         
 
         Page  16
 
         
 
         
 
         
 
         
 
         221 S Main
 
         Council Bluffs  IA  51501
 
         
 
         Mr. Thomas M. Plaza
 
         Attorney at Law
 
         701 Pierce St  STE 200
 
         P O Box 3086
 
         Sioux City  IA  51102
 
         
 
         Mr. Melvin C. Hansen
 
         Attorney at Law
 
         800 Exchange Bldg
 
         1905 Harney St
 
         Omaha  NE  68102
 
         
 
         Mr. Richard D. Crotty
 
         Attorney at Law
 
         311 First Federal Bldg
 
         Council Bluffs  IA  51503
 
         
 
 
         
 
         Page   1
 
         
 
         
 
         
 
         
 
         
 
         
 
         
 
         before the iowa industrial commissioner
 
         ____________________________________________________________
 
		                   :
 
         WILMA JEAN BACON (LEEPER),:
 
		                   :
 
              Claimant,		   :
 
		                   :
 
         	vs. 	           :
 
		                   :      File No. 858027
 
         AMERICAN NATIONAL CAN COMPANY,:
 
                  		   :        A P P E A L
 
              Employer,		   :
 
		                   :      D E C I S I O N
 
        		 and       :
 
                  		   :
 
         GALLAGHER & BASSETT,      :
 
                   		   :
 
              Insurance Carrier,   :
 
              Defendants.          :
 
         ___________________________________________________________
 
         
 
         The record, including the transcript of the hearing before the 
 
         deputy and all exhibits admitted into the record, has been 
 
         reviewed de novo on appeal.  The decision of the deputy filed 
 
         February 7, 1991 is affirmed and is adopted as the final agency 
 
         action in this case, with the following additional analysis:
 
         Defendants argue that claimant sustained no loss of earning 
 
         capacity as a result of her July 10, 1987 work injury and that an 
 
         award of industrial disability is inappropriate.  Claimant 
 
         returned to work with no pay loss and no loss of seniority.  
 
         Robert C. Jones, M.D., claimant's treating physician, imposed 
 
         restrictions upon claimant's activities.  Claimant's restrictions 
 
         as a result of her work injury reduce claimant's earning capacity 
 
         and therefore warrant a finding of 20 percent industrial 
 
         disability.
 
         Defendants shall pay the costs of the appeal, including the 
 
         preparation of the hearing transcript.
 
         Signed and filed this ____ day of November, 1991.
 
         
 
         
 
         
 
         
 
                   ________________________________
 
                            BYRON K. ORTON
 
                       INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. John R. Ward
 

 
         
 
         Page   2
 
         
 
         
 
         
 
         
 
         
 
         
 
         
 
         Attorney at Law
 
         840 Fifth Ave.
 
         Des Moines, Iowa 50309
 
         
 
         Mr. Stephen W. Spencer
 
         Mr. Fred L. Morris
 
         Attorneys at Law
 
         Suite 300, Fleming Bldg.
 
         P.O. Box 9130
 
         Des Moines, Iowa 50306-9130
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
            9999
 
            Filed November 26, 1991
 
            Byron K. Orton
 
            JMI
 
            before the iowa industrial commissioner
 
            ____________________________________________________________
 
		                      :
 
            WILMA JEAN BACON (LEEPER),:
 
		                      :
 
                 Claimant, 	      :
 
 		                      :
 
           		 vs.          :
 
 		                      :      File No. 858027
 
            AMERICAN NATIONAL CAN COMPANY,:
 
               			      :        A P P E A L
 
                 Employer, 	      :
 
		                      :      D E C I S I O N
 
            		and           :
 
                      		      :
 
            GALLAGHER & BASSETT,      :
 
                      		      :
 
                 Insurance Carrier,   :
 
                 Defendants.          :
 
            ___________________________________________________________
 
            
 
            
 
            9999
 
            Summary affirmance of deputy's decision filed February 7, 
 
            1991, with short additional analysis.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            WILMA JEAN BACON (LEEPER),    :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :         File No. 858027
 
            AMERICAN NATIONAL CAN CO.,    :
 
                                          :      A R B I T R A T I O N
 
                 Employer,                :
 
                                          :         D E C I S I O N
 
            and                           :
 
                                          :
 
            GALLAGHER & BASSETT,          :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            
 
                 
 
            
 
                              statement of the case
 
            
 
                 This is a proceeding in arbitration upon the petition 
 
            of claimant, Wilma Jean Bacon (Leeper), against American 
 
            National Can Co., employer, and Gallagher and Bassett, 
 
            insurance carrier, defendants, for workers' compensation 
 
            benefits as a result of an alleged injury which occurred on 
 
            July 10, 1987.
 
            
 
                 A hearing was held before the undersigned deputy 
 
            industrial commissioner on January 2, 1991 in Des Moines, 
 
            Iowa.  The claimant was present and testified.  She was 
 
            represented at the hearing by her attorney, Mr. John R. 
 
            Ward.  The employer/insurance carrier was represented by Mr. 
 
            Fredd Morris.  The record in this case consists of the 
 
            testimony of claimant, Mr. Wayne Anderson and Mr. Jim 
 
            Gustafson; and, claimant's exhibits A(1-6) and defendants' 
 
            exhibits 1-4 and 6-10.
 
            
 
                                      issues
 
            
 
                 Pursuant to the prehearing report and order submitted 
 
            and approved on January 2, 1991, the parties stipulated to 
 
            the existence of an employer/employee relationship between 
 
            claimant and employer at the time of the alleged injury; the 
 
            time off work for which claimant now seeks either temporary 
 
            total disability or healing period benefits from July 11, 
 
            1987 to July 19, 1987; October 17, 1987 to November 13, 1987 
 
            and March 8, 1989 to December 17, 1989.  Parties also 
 
            stipulate that the commencement date for permanent partial 
 
            disability, in the event such benefits are awarded, is 
 
            December 18, 1989 and the rate of weekly compensation, in 
 
            the event of an award, is $296.89.  The parties also 
 
            stipulate that defendants paid claimant 43.714 weeks of 
 
            compensation at the rate of $238.64 per week in the amount 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            of $10, 431.91 and that the claimant incurred out-of-pocket 
 
            expenses totaling $320.50.
 
            
 
                 The prehearing report identified the following issues 
 
            for resolution.
 
            
 
                 1.  Whether claimant's alleged injury on July 10, 1987 
 
            arose out of and in the course of her employment;
 
            
 
                 2.  Whether there exists a causal relationship between 
 
            the injury and the resulting disability;
 
            
 
                 3.  The nature and extent of claimant's disability, if 
 
            any;
 
            
 
                 4.  Whether claimant is entitled to medical benefits.
 
            
 
                                 findings of fact
 
            
 
                 The undersigned has carefully considered all the 
 
            testimony given at the hearing, arguments made and the 
 
            evidence contained on the exhibits herein, and makes the 
 
            following findings.
 
            
 
                 Claimant was born on June 23, 1945 and completed the 
 
            tenth grade of school.  She worked at various times as a 
 
            laundress, mailclerk, assembler and janitor.  On September 
 
            2, 1980 she went to work for American National Can Co.  She 
 
            was hired in the Saran department as an utility person.  In 
 
            this capacity, she kept bad machines and materials.  She 
 
            performed this work for six months and was promoted to bag 
 
            machine operator.  In this capacity, she made 3-layer 
 
            Marflix bags.  From 1983 through 1986 she participated in 
 
            the leadperson program which involved supervising four other 
 
            workers.  For the past two years she has worked as an 
 
            extruder operator.  Claimant testified that she earns 30 
 
            cents more per hour now than when she worked in the Saran 
 
            department. 
 
            
 
                 At the hearing, the claimant testified that on July 10, 
 
            1987 while pulling a box of bags from the box indexer onto a 
 
            hoist with ball bearing rollers, she slipped and fell 
 
            backwards and landed on her buttocks.  Upon resumption of 
 
            her duties she experienced pain and stiffness in her neck.  
 
            She notified her supervisor, Wayne Anderson, regarding the 
 
            incident and requested to be seen by a physician.  She 
 
            presented to Mercy Medical Center Emergency Room where a 
 
            x-ray was taken.  She was given a muscle relaxer and advised 
 
            to see James L. Blessman, M.D., the company doctor.  
 
            According to claimant, Dr. Blessman diagnosed a cervical 
 
            sprain and treated her with ultrasound, hot packs, and 
 
            muscle relaxers.  After therapy, the symptoms subsided and 
 
            Dr. Blessman released her to return to work on July 20, 
 
            1987.  
 
            
 
                 By October 1987, her symptoms had become progressively 
 
            worse and she returned to Dr. Blessman for evaluation and 
 
            treatment.  Her symptoms were referable to posterior neck 
 
            pain extending down the right arm with paresthesias, low 
 
            back pain, and giving way in her right leg.  A CT scan of 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            the neck revealed a marked intrusion of the disc in the 
 
            spinal canal at C6-7.  Dr. Blessman recommended that she 
 
            remain off work and participate in physical therapy.  She 
 
            underwent ten physical therapy treatments and returned to 
 
            work on November 14, 1987.
 
            
 
                 Claimant testified that despite intermittent pain and 
 
            numbness in her neck, right arm and fingers, she was able to 
 
            work until March 7, 1989 when she experienced a significant 
 
            flare-up of her symptoms after rolling and turning boxes 
 
            weighing between 40 and 60 pounds.  She returned to see Dr. 
 
            Blessman and he scheduled an MRI examination.  The results 
 
            indicated severe disc degeneration at C5-6 and C6-7.  On 
 
            June 12, 1989, claimant underwent interior cervical 
 
            interbody fusion at C5-6 and C6-7 by Robert C. Jones, M.D.
 
            
 
                 Dr. Jones released the claimant to return to regular 
 
            work duties on December 18, 1989 and restricted her to no 
 
            more than an eight hour work day.  On November 30, 1990, Dr. 
 
            Jones reported that "I would estimate Wilma Bacon's physical 
 
            impairment to be in the range of ten percent following her 
 
            two level cervical fusion in June 1989 and related to an 
 
            injury on July 10, 1987."  (Exhibit A, Section 2).
 
            
 
                 Claimant testified that she had three weeks of 
 
            accumulated vacation leave and actually returned to work on 
 
            January 3, 1990.  Claimant testified that she works an eight 
 
            hour day and although overtime has been available she has 
 
            not been able to take advantage of it due to her physical 
 
            limitations.  She works ninety percent of the time as an 
 
            extruder operator and earns $12.98 per hour.  She is 
 
            restricted to an eight hour day and limited in her ability 
 
            to push, pull and lift more than 40 pounds.  She has not 
 
            lost any seniority due to her injury.
 
            
 
                 Mr. Wayne Anderson, claimant's supervisor, also 
 
            testified at the hearing.  He stated that the claimant works 
 
            3:00 p.m. to 11:00 p.m. and is able to perform all the 
 
            duties required of an extruder operator.  
 
            
 
                 Mr. Jim Gustafson, coordinator of Human Resources, also 
 
            testified at the hearing.  He described the shift operations 
 
            at the plant and indicated that there is mandatory overtime 
 
            in order to meet customer deadlines.  
 
            
 
                    
 
            
 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            conclusions of law
 
            
 
                 The first issue to be determined is whether claimant 
 
            received an injury which arose out of and in the course of 
 
            her employment.
 
            
 
                 Claimant has the burden of proving by a preponderance 
 
            of the evidence that she received an injury on July 10, 
 
            1987, which arose out of and in the course of her 
 
            employment. McDowell v. Town of Clarksville, 241 N.W.2d 904 
 
            (Iowa 1976); Musselman v. Central Telephone Co., 261 Iowa 
 
            352, 154 N.W.2d 128 (1967). 
 
            
 
                 An employee is entitled to compensation for any and all 
 
            personal injuries which arise out of and in the course of 
 
            the employment.  Section 85.3(1).
 
            
 
                 The injury must both arise out of and be in the course 
 
            of the employment.  Crowe v. DeSoto Consol. Sch. Dist., 246 
 
            Iowa 402, 68 N.W.2d 63 (1955) and cases cited at pp. 405-406 
 
            of the Iowa Report.  See also Sister Mary Benedict v. St. 
 
            Mary's Corp., 255 Iowa 847, 124 N.W.2d 548 (l963) and Hansen 
 
            v. State of Iowa, 249 Iowa 1147, 91 N.W.2d 555 (1958).
 
            
 
                 The words "out of" refer to the cause or source of the 
 
            injury.  Crowe, 246 Iowa 402, 68 N.W.2d 63. 
 
            
 
                 The words "in the course of" refer to the time and 
 
            place and circumstances of the injury.  McClure v. Union 
 
            et al. Counties, 188 N.W.2d 283 (Iowa 1971); Crowe, 246 Iowa 
 
            402, 68 N.W.2d 63.
 
            
 
                 "An injury occurs in the course of the employment when 
 
            it is within the period of employment at a place the 
 
            employee may reasonably be, and while he is doing his work 
 
            or something incidental to it."  Cedar Rapids Comm. Sch. 
 
            Dist. v. Cady, 278 N.W.2d 298 (Iowa 1979), McClure, 188 
 
            N.W.2d 283; Musselman, 261 Iowa 352, 154 N.W.2d 128. 
 
            
 
                 The supreme court of Iowa in Almquist v. Shenandoah 
 
            Nurseries, 218 Iowa 724, 731-32, 254 N.W. 35, 38 (1934) 
 
            discussed the definition of personal injury in workers' 
 
            compensation cases as follows:
 
            
 
                 
 
            
 
                 While a personal injury does not include an 
 
                 occupational disease under the Workmen's 
 
                 Compensation Act, yet an injury to the health may 
 
                 be a personal injury.  [Citations omitted.]  
 
                 Likewise a personal injury includes a disease 
 
                 resulting from an injury....The result of changes 
 
                 in the human body incident to the general 
 
                 processes of nature do not amount to a personal 
 
                 injury.  This must follow, even though such 
 
                 natural change may come about because the life has 
 
                 been devoted to labor and hard work.  Such result 
 
                 of those natural changes does not constitute a 
 
                 personal injury even though the same brings about 
 
                 impairment of health or the total or partial 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
                 incapacity of the functions of the human body. 
 
            
 
                    ....
 
            
 
                 
 
                 A personal injury, contemplated by the Workmen's 
 
                 Compensation Law, obviously means an injury to the 
 
                 body, the impairment of health, or a disease, not 
 
                 excluded by the act, which comes about, not through the 
 
                 natural building up and tearing down of the human body, 
 
                 but because of a traumatic or other hurt or damage to 
 
                 the health or body of an employee.  [Citations 
 
                 omitted.]  The injury to the human body here 
 
                 contemplated must be something, whether an accident or 
 
                 not, that acts extraneously to the natural processes of 
 
                 nature, and thereby impairs the health, overcomes, 
 
                 injures, interrupts, or destroys some function of the 
 
                 body, or otherwise damages or injures a part or all of 
 
                 the body.
 
            
 
                 Claimant has established by a preponderance of the 
 
            evidence that she received a work injury on July 10, 1987.  
 
            At the time of the incident, she was performing her usual 
 
            job at the factory.  Claimant was a credible witness and 
 
            fairly and accurately reported her own perceptions of the 
 
            events which occurred on that day.  Within one hour of the 
 
            occurrence, she reported the incident to her immediate 
 
            supervisor and he did not dispute her assertions.
 
            
 
                 The next issue to be determined is whether there is a 
 
            causal relationship between the claimant's work injury and 
 
            the disability on which she now bases her claim.
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury of July 10, 
 
            1987 is causally related to the disability on which her now 
 
            bases her claim.  Bodish v. Fischer, Inc., 257 Iowa 516, 133 
 
            N.W.2d 867 (1965).  Lindahl v. L. O. Boggs, 236 Iowa 296, 18 
 
            N.W.2d 607 (1945).  A possibility is insufficient; a 
 
            probability is necessary.  Burt v. John Deere Waterloo 
 
            Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955).  The 
 
            question of causal connection is essentially within the 
 
            domain of expert testimony.  Bradshaw v. Iowa Methodist 
 
            Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). 
 
            
 
                 However, expert medical evidence must be considered 
 
            with all other evidence introduced bearing on the causal 
 
            connection.  Burt, 247 Iowa 691, 73 N.W.2d 732.  The opinion 
 
            of experts need not be couched in definite, positive or 
 
            unequivocal language.  Sondag v. Ferris Hardware, 220 N.W.2d 
 
            903 (Iowa 1974).  However, the expert opinion may be 
 
            accepted or rejected, in whole or in part, by the trier of 
 
            fact.  Id. at 907.  Further, the weight to be given to such 
 
            an opinion is for the finder of fact, and that may be 
 
            affected by the completeness of the premise given the expert 
 
            and other surrounding circumstances.  Bodish, 257 Iowa 516, 
 
            133 N.W.2d 867.  See also Musselman v. Central Telephone 
 
            Co., 261 Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
                 As previously stated, the claimant sustained a work 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            injury on July 10, 1987 which was initially treated 
 
            conservatively.  A diminution of her symptoms allowed her to 
 
            return to work for a short period of time until an 
 
            exacerbation occurred in March 1989.  An interior cervical 
 
            interbody fusion at two levels was performed on June 12, 
 
            1989.
 
            
 
                 The defendants dispute that there is a causal 
 
            relationship between the claimant's work injury and her 
 
            disability.  They proposed several alternative causes for 
 
            her neck complaints including an incident where she had some 
 
            candy stuck in her throat and a friend performed a Heimlich 
 
            maneuver to dislodge the candy and an incident in 1985 when 
 
            she fell through a warped deck.  Claimant testified that 
 
            while she did strain some back muscles when she fell through 
 
            the deck, she had no symptoms related to her neck.  As to 
 
            the Heimlich maneuver, Dr. Jones testified in a deposition 
 
            taken on December 10, 1990, that:
 
            
 
                    A.  I can't imagine that a Heimlich maneuver 
 
                 would do anything but put pressure on the abdomen.  
 
                 If the person is standing behind them, the 
 
                 standing -- person standing behind is pretty much 
 
                 going to prevent a person's neck flopping around 
 
                 or hyperextending the neck.
 
            
 
            (Exhibit A, Page 26, Lines 5-10)
 
            
 
                 After carefully reviewing the total evidence in this 
 
            case, and based upon the medical assessments of Drs. 
 
            Blessman and Jones, the undersigned is persuaded that the 
 
            claimant's disability is causally related to her injury of 
 
            July 10, 1987.  To establish compensability, the injury need 
 
            only be a significant factor, not the only factor causing 
 
            the claimed disability.  Blacksmith v. All-American, Inc., 
 
            290 N.W.2d 348, 354 (Iowa 1980).
 
            
 
                 The next issue to be determined is whether claimant is 
 
            entitled to medical benefits.
 
            
 
                 Iowa Code section 85.27 provides, in part:
 
            
 
                    For purposes of this section, the employer is 
 
                 obliged to furnish reasonable services and 
 
                 supplies to treat an injured employee, and has the 
 
                 right to choose the care.  The treatment must be 
 
                 offered promptly and be reasonably suited to treat 
 
                 the injury without undue inconvenience to the 
 
                 employee.  If the employee has reason to be 
 
                 dissatisfied with the care offered, the employee 
 
                 should communicate the basis of such 
 
                 dissatisfaction to the employer, in writing if 
 
                 requested, following which the employer and the 
 
                 employee may agree to alternate care reasonably 
 
                 suited to treat the injury.  If the employer and 
 
                 employee cannot agree on such alternate care, the 
 
                 commissioner may, upon application and reasonable 
 
                 proofs of the necessity therefor, allow and order 
 
                 other care.  In an emergency, the employee may 
 
                 choose the employee's care at the employer's 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
                 expense, provided the employer or the employer's 
 
                 agent cannot be reached immediately.
 
            
 
                 Therefore, the claimant is entitled to reasonable and 
 
            necessary medical expenses incurred pursuant to treatment of 
 
            her work injury.
 
            
 
                 The next issue to be determined is whether claimant is 
 
            entitled to temporary total/healing period benefits, or 
 
            permanent partial or total disability benefits.
 
            
 
                 As a general rule, temporary total disability benefits 
 
            are paid to an injured worker when no permanent disability 
 
            is anticipated; healing period benefits are paid where a 
 
            permanent disability is a result of the work injury.
 
            
 
                 The record conclusively establishes that claimant 
 
            sustained a permanent injury as a result of the July 10, 
 
            1987 incident and is entitled to healing period benefits.  
 
            Claimant underwent surgery on June 12, 1989 and cannot lift 
 
            more than 40 pounds or repetitively push and pull.  The 
 
            parties have stipulated that the claimant was off work 
 
            during three time frames.  The claimant was off work the day 
 
            after the injury, from July 11, 1987 through July 19, 1987 
 
            while she underwent conservative therapy.  She returned to 
 
            work on August 20, 1987 and worked until October 16, 1987.  
 
            She was off work from October 17, 1987 through November 13, 
 
            1987 while she was undergoing physical therapy.  She resumed 
 
            working on November 14, 1987 and worked until March 7, 1989 
 
            when she aggravated her neck symptoms.  She was released to 
 
            return to work by Dr. Jones on December 17, 1989 and the 
 
            parties stipulated that if her injury is found to be a cause 
 
            of permanent disability, the commencement date is December 
 
            18, 1989.
 
            
 
                 While there is no dispute as to the claimant's three 
 
            healing periods, there is a dispute as to the extent of her 
 
            permanent disability.  However, the parties stipulate that 
 
            if the claimant's injury is found to be a cause of permanent 
 
            disability, such disability is an industrial disability to 
 
            the body as a whole.
 
            
 
                 If claimant has an impairment to the body as a whole, 
 
            an industrial disability has been sustained.  Industrial 
 
            disability was defined in Diederich v. Tri-City Railway Co., 
 
            219 Iowa 587, 593, 258 N.W.2d 899, 902 (1935) as follows: 
 
            "It is therefore plain that the legislature intended the 
 
            term `disability' to mean `industrial disability' or loss of 
 
            earning capacity and not a mere `functional disability' to 
 
            be computed in the terms of percentages of the total 
 
            physical and mental ability of a normal man."
 
            
 
                 Functional impairment is an element to be considered in 
 
            determining industrial disability which is the reduction of 
 
            earning capacity, but consideration must also be given to 
 
            the injured employee's age, education, qualifications, expe
 
            rience and inability to engage in employment for which he is 
 
            fitted.  Olson v. Goodyear Service Stores, 255 Iowa 1112, 
 
            125 N.W.2d 251 (1963).  Barton v. Nevada Poultry, 253 Iowa 
 
            285, 110 N.W.2d 660 (1961).
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            
 
                 A finding of impairment to the body as a whole found by 
 
            a medical evaluator does not equate to industrial disabil
 
            ity.  This is so as impairment and disability are not syn
 
            onymous.  Degree of industrial disability can in fact be 
 
            much different than the degree of impairment because in the 
 
            first instance reference is to loss of earning capacity and 
 
            in the latter to anatomical or functional abnormality or 
 
            loss.  Although loss of function is to be considered and 
 
            disability can rarely be found without it, it is not so that 
 
            a degree of industrial disability is proportionally related 
 
            to a degree of impairment of bodily function.
 
            
 
                 Factors to be considered in determining industrial dis
 
            ability include the employee's medical condition prior to 
 
            the injury, immediately after the injury, and presently; the 
 
            situs of the injury, its severity and the length of healing 
 
            period; the work experience of the employee prior to the 
 
            injury, after the injury and potential for rehabilitation; 
 
            the employee's qualifications intellectually, emotionally 
 
            and physically; earnings prior and subsequent to the injury; 
 
            age; education; motivation; functional impairment as a 
 
            result of the injury; and inability because of the injury to 
 
            engage in employment for which the employee is fitted.  Loss 
 
            of earnings caused by a job transfer for reasons related to 
 
            the injury is also relevant.  These are matters which the 
 
            finder of fact considers collectively in arriving at the 
 
            determination of the degree of industrial disability.
 
            
 
                 There are no weighting guidelines that indicate how 
 
            each of the factors are to be considered.  There are no 
 
            guidelines which give, for example, age a weighted value of 
 
            ten percent of the total value, education a value of fifteen 
 
            percent of total, motivation - five percent; work experience 
 
            - thirty percent, etc.  Neither does a rating of functional 
 
            impairment directly correlate to a degree of industrial 
 
            disability to the body as a whole.  In other words, there 
 
            are no formulae which can be applied and then added up to 
 
            determine the degree of industrial disability.  It therefore 
 
            becomes necessary for the deputy or commissioner to draw 
 
            upon prior experience, general and specialized knowledge to 
 
            make the finding with regard to degree of industrial dis
 
            ability.  See Peterson v. Truck Haven Cafe, Inc., (Appeal 
 
            Decision, February 28, 1985); Christensen v. Hagen, Inc., 
 
            (Appeal Decision, March 26, l985).
 
            
 
                 As previously noted, Dr. Jones estimated that the 
 
            claimant's physical impairment is in the ten percent range 
 
            following two level cervical fusion in June 1989.  He 
 
            restricted her to an eight hour work day.  Claimant 
 
            testified that she experiences fatigue when she works a 
 
            seven day schedule and is unable to participate in overtime 
 
            work.  She is limited in her ability to perform certain 
 
            physical activities such as lifting, carrying, pushing, 
 
            pulling, twisting and turning.  Prior to her injury, 
 
            claimant had no neck complaints or work restrictions.  It is 
 
            evident that her injury interferes with her ability to work 
 
            overtime and affects her earning capacity.  Claimant was 42 
 
            years old at the time of her injury and only completed the 
 
            tenth grade of school.  Her work history is primarily 
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            low-level semi-skilled.  She is unable to perform more than 
 
            light work activity and is restricted to less physically 
 
            demanding jobs.  Nevertheless, claimant has retained her 
 
            seniority with American National Can Co., and is capable of 
 
            performing her current job adequately.  A supervisor 
 
            testified that he has received no complaints from the shift 
 
            supervisors indicating that claimant cannot perform the 
 
            extrusion job.  In fact, he noted that she recently 
 
            indicated an interest in reapplying for the lead person job.  
 
            Claimant testified that she did so because such job offers a 
 
            fifty cents per hour increase in pay and it can be performed 
 
            within an eight hour day.
 
            
 
                 Considering all of the elements of industrial 
 
            disability, the undersigned concludes that claimant has 
 
            sustained a permanent partial disability of twenty percent 
 
            for industrial purposes entitling her to 100 weeks of 
 
            permanent partial disability benefits.
 
            
 
                                      order
 
            
 
                 THEREFORE, it is ordered:
 
            
 
                 That defendants pay to claimant healing period benefits 
 
            from July 11, 1987 to July 19, 1987; from October 17, 1987 
 
            through November 13, 1987; and, March 8, 1989 through 
 
            December 17, 1989; at the stipulated rate of two hundred 
 
            ninety-six and 89/100 dollars ($296.89) per week.
 
            
 
                 That defendants pay to claimant one hundred (100) weeks 
 
            of permanent partial disability benefits at the stipulated 
 
            rate of two hundred ninety-six and 89/100 dollars ($296.89) 
 
            per week and that such benefits be paid intermittently 
 
            before and after the healing periods.
 
            
 
                 That all accrued benefits are to be paid in a lump sum.
 
            
 
                 That interest will accrued pursuant to Iowa Code 
 
            section 85.30.
 
            
 
                 That defendants have paid to claimant forty-three point 
 
            seven one four (43.714) weeks of compensation at the rate of 
 
            two hundred thirty eight and 64/100 dollars ($238.64) per 
 
            week prior to the healing for a total of ten thousand four 
 
            hundred thirty-one and 91/100 dollars ($10,431.91) and are 
 
            entitled to a credit for such payment.
 
            
 
                 That defendants shall pay to claimant all reasonable 
 
            medical expenses incurred for treatment of her work injury.
 
            
 
                 That the costs of this action shall be assessed to 
 
            defendants pursuant to rule 343 IAC 4.33.
 
            
 
                 That defendants shall file a claim activity report as 
 
            requested by this agency pursuant to rule 343 IAC 3.1.
 
            
 
                 Signed and filed this ____ day of February, 1991.
 
            
 
            
 
            
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            
 
                                          
 
            ________________________________
 
                                          JEAN M. INGRASSIA
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr John R Ward
 
            Attorney at Law
 
            840 Fifth Avenue
 
            Des Moines Iowa 50309-1398
 
            
 
            Mr Stephen W Spencer
 
            Attorney at Law
 
            218 6th Ave, Ste. 30
 
            PO Box 9130
 
            Des Moines Iowa 50306
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                      1803
 
                      Filed February 7, 1991
 
                      JEAN M. INGRASSIA
 
            before the iowa industrial commissioner
 
            ____________________________________________________________
 
                      :
 
            WILMA JEAN BACON (LEEPER),    :
 
                      :
 
                 Claimant, :
 
                      :
 
            vs.       :
 
                      :       File No. 858027
 
            AMERICAN NATIONAL CAN CO.,    :
 
                      :    A R B I T R A T I O N
 
                 Employer, :
 
                      :       D E C I S I O N
 
            and       :
 
                      :
 
            GALLAGHER & BASSETT,     :
 
                      :
 
                 Insurance Carrier,  :
 
                 Defendants.    :
 
            ___________________________________________________________
 
            
 
            
 
            1803
 
            Claimant awarded 20 percent permanent partial disability 
 
            benefits as a result of a work injury which resulted in an 
 
            interior cervical interbody fusion at C5-6 and C6-7.
 
            
 
 
            
 
 
 
 
 
 
 
 
 
                      BEFORE THE IOWA INDUSRIAL COMMISSIONER
 
            ____________________________________________________________
 
            CARLA S. CRABTREE,    
 
                        
 
                 Claimant,   
 
                        
 
            vs.         
 
                                                 File No. 858107
 
            WATERLOO INDUSTRIES,       
 
                                                  A P P E A L
 
                 Employer,   
 
                                                D E C I S I O N
 
            and         
 
                        
 
            GALLAGHER & BASSETT,       
 
                        
 
                 Insurance Carrier,    
 
                 Defendants.      
 
            ____________________________________________________________
 
            The record, including the transcript of the hearing before 
 
            the deputy and all exhibits admitted into the record, has 
 
            been reviewed de novo on appeal.  The decision of the deputy 
 
            filed July 24, 1991 is affirmed and is adopted as the final 
 
            agency action in this case.
 
            Defendants shall pay the costs of the appeal, including the 
 
            preparation of the hearing transcript.
 
            Signed and filed this ____ day of November, 1992.
 
            
 
            
 
            
 
            
 
                                   ________________________________
 
                                           BYRON K. ORTON
 
                                     INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr. Paul T. Shinkle
 
            Attorney at Law
 
            P.O. Box 523
 
            Cedar Falls, Iowa 50613
 
            
 
            Mr. Jay P. Roberts
 
            Attorney at Law
 
            P.O. Box 178
 
            Waterloo, Iowa 50704
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
            9998
 
            Filed November 23, 1992
 
            Byron K. Orton
 
            PJL
 
            before the iowa industrial commissioner
 
            ____________________________________________________________
 
            _____
 
                        :
 
            CARLA S. CRABTREE,    :
 
                        :
 
                 Claimant,   :
 
                        :
 
            vs.         :
 
                        :        File No. 858107
 
            WATERLOO INDUSTRIES,       :
 
                        :          A P P E A L
 
                 Employer,   :
 
                        :        D E C I S I O N
 
            and         :
 
                        :
 
            GALLAGHER & BASSETT,       :
 
                        :
 
                 Insurance Carrier,    :
 
                 Defendants.      :
 
            ____________________________________________________________
 
            _____
 
            
 
            9998
 
            
 
                 Summary affirmance of deputy's decision filed July 24, 
 
            1991.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            CARLA S. CRABTREE,            :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 858107
 
            WATERLOO INDUSTRIES,          :
 
                                          :    A R B I T R A T I O N
 
                 Employer,                :
 
                                          :      D E C I S I O N
 
            and                           :
 
                                          :
 
            GALLAGHER & BASSETT,          :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            
 
                                   introduction
 
            
 
                 This is a proceeding in arbitration brought by Carla 
 
            Crabtree against Waterloo Industries, employer, and 
 
            Gallagher and Bassett, insurance carrier, as defendants.
 
            
 
                 Claimant sustained an injury on July 23, 1987, which 
 
            arose out of and in the course of her employment.  She seeks 
 
            compensation for permanent partial disability.
 
            
 
                 The case was heard at Waterloo, Iowa on July 3, 1991, 
 
            and was considered fully submitted upon conclusion of the 
 
            hearing.
 
            
 
                 The record in this proceeding consists of the testimony 
 
            of the claimant, and Donald Crabtree.  Additionally, the 
 
            parties offered joint exhibits 1 and 2, which were received 
 
            into evidence.
 
            
 
                                      issue
 
            
 
                 Pursuant to the prehearing report submitted and 
 
            approved at the hearing, the sole issue to be determined in 
 
            this case is the extent of permanent partial disability 
 
            caused by claimant's work related injury.
 
            
 
                                 findings of fact
 
            
 
                 The undersigned deputy industrial commissioner, having 
 
            heard the testimony, and having considered all of the 
 
            evidence, finds the following facts:
 
            
 
                 Claimant was 36 years old at the time of the hearing, 
 
            is married, and has one son.  She has worked for Waterloo 
 
            Industries for approximately 18 years.
 
            
 
                 On July 23, 1987, claimant lacerated the flexor carpi 
 
            radialis and the plamaris longus, on her right wrist while 
 

 
            
 
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            performing her job duties.  She went to the Allen Memorial 
 
            Hospital Emergency Room in Waterloo, Iowa, and underwent 
 
            surgical repair of the tendons.  (Joint Exhibit 1, 
 
            Deposition Exhibit 1)
 
            
 
                 Claimant began physical therapy in August of 1987.  On 
 
            August 27, 1987, claimant returned to her treating 
 
            physician, Jitu Kothari, M.D., with complaints of numbness 
 
            and paresthesia in the median of the right hand.  Dr. 
 
            Kothari ordered nerve conduction studies.
 
            
 
                 On September 2, 1987, claimant returned to Dr. Kothari, 
 
            and her nerve conduction study was within normal limits, 
 
            however she still complained of mild paresthesia in the 
 
            second and third digits of the right hand.
 
            
 
                 Claimant continued to see Dr. Kothari, and on October 
 
            7, 1987, continued to complain of pain and weakness.  Dr. 
 
            Kothari stated in his records that claimant did not have 
 
            clinical signs of carpal tunnel syndrome.  (Jt. Ex. 1, Depo. 
 
            Ex. 1)
 
            
 
                 In November of 1987, claimant was again scheduled for a 
 
            nerve conduction test at the behest of A. K. Nakhasi, M.D.  
 
            This test showed mild carpal tunnel syndrome on the right 
 
            wrist.  Several months later, on clinical examination, 
 
            claimant presented positive tinel and phelan tests on the 
 
            right wrist.  On January 5, 1988, claimant was advised that 
 
            she should undergo carpal tunnel release surgery.  (Jt. Ex. 
 
            1, Depo. Ex. 1)
 
            
 
                 Claimant requested a second opinion, which was 
 
            performed on February 9, 1988 by James Mueller, M.D.  He 
 
            diagnosed carpal tunnel syndrome based on positive on tinel 
 
            and phelan tests.  He agreed with the need for surgical 
 
            release, provided the symptoms did not improve after a 
 
            conservative program was implemented.  (Jt. Ex. 2)
 
            
 
                 Claimant finally underwent surgery for carpal tunnel 
 
            release on April 14, 1989.  (Jt. Ex. 1, Depo. Ex. 1)
 
            
 
                 Claimant had several follow-up visits with Dr. Kothari, 
 
            and on May 22, 1989 she was released to return to work with 
 
            restrictions of, "no repetitive movement with the right hand 
 
            and no use of the vibrating equipment."  On October 10, 
 
            1989, Dr. Kothari gave claimant a 12 percent permanent 
 
            impairment and loss of physical function of the right hand 
 
            due to the right carpal tunnel surgery and the subjective 
 
            complaints of numbness and weakness in the fingertips and 
 
            grip strength.  (Jt. Ex. 1, Depo. Ex. 1)
 
            
 
                         ANALYSIS AND CONCLUSIONS OF LAW
 
            
 
                 The sole issue to be addressed is the extent of 
 
            claimant's permanent partial disability.
 
            
 
                 An employee is entitled to compensation for any and all 
 
            personal injuries which arise out of and in the course of 
 
            the employment.  Section 85.3(1).
 
            
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
                 As provided for under Iowa Code section 85.34, claimant 
 
            is entitled to permanent partial disability compensation 
 
            based upon the extent of the disability.  Claimant has 
 
            sustained a permanent injury to her wrist, and agency 
 
            precedence has ruled that the wrist is part of the hand.  
 
            Ulam v. Midland Mfg.,II Iowa Indus. Comm'r Report 141 
 
            (appeal decision 1981)
 
            
 
                 As noted earlier, Dr. Kothari is the only physician who 
 
            rendered an opinion with respect to the amount of permanency 
 
            claimant has sustained due to the work-related injury.  The 
 
            evidence reflects that there has been an ongoing dispute as 
 
            to whether the delay in surgery caused claimant's disability 
 
            rating to be higher than it would have been had claimant 
 
            undergone the carpal tunnel release surgery when it was 
 
            originally scheduled, in January of 1988.
 
            
 
                 Iowa Workers' Compensation Laws provide that the 
 
            employer has the right to choose the medical treatment, and 
 
            must provide medical treatment promptly and without undue 
 
            inconvenience to the employee.  See Cox v. J.E. Sieben 
 
            Constr., 34 Biennial Rep., Iowa Indus. Comm'r 79 (1980).  It 
 
            is the responsibility of the employer to monitor the course 
 
            of treatment.  Id.
 
            
 
                 Whether the delay in undergoing surgery resulted in a 
 
            greater impairment is irrelevant.  It is defendants' 
 
            responsibility to provide prompt, adequate medical care, and 
 
            the failure to do so will not result in punishing the 
 
            claimant by lowering the amount of functional impairment she 
 
            has sustained due to a work-related injury.
 
            
 
                 In the instance case, it appeared that the defendants 
 
            were trying to shift the burden of monitoring the health 
 
            care to the claimant, a position which is not acceptable to 
 
            the undersigned.  It is clear from the evidence that the 
 
            defendants were in disagreement with Dr. Kothari's 
 
            impairment rating, which is showcased in a letter to Dr. 
 
            Kothari from the insurance company dated October 17, 1989:
 
            
 
                 I am really confused as to how you arrived at 12%.  
 
                 I handle hundreds of carpal tunnel cases 
 
                 throughout the states of Iowa and Wisconsin and 
 
                 the ratings I see are from 0 to 3% with a few 
 
                 exceptions for really bad results.
 
            
 
                 Before I pay out nearly $6,000 I would like to 
 
                 know how you arrived at 12% when your report lists 
 
                 only subjective complaints.  Did you use the AMA 
 
                 Guides as required under the Iowa Act?
 
            
 
                 In response, Dr. Kothari sent the following letter to 
 
            the insurance company on February 9, 1990:
 
            
 
                    This is in response to your inquiry regarding 
 
                 Mrs. Crabtree.  I have reviewed the records of 
 
                 this patient.  The 12% permanent impairment and 
 
                 loss of physical function of the right hand was 
 
                 based on the patient's continual symptoms of 
 
                 numbness in the fingertips.  After reviewing the 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
                 medical records on this patient, it is evident 
 
                 that there was quite considerable length of time 
 
                 involved between the initial diagnosis and the 
 
                 patient's carpal tunnel release surgery.  In 
 
                 general, the longer time involved between the 
 
                 diagnosis and the time of surgery, there are more 
 
                 irreversible symptoms, particularly numbness in 
 
                 the fingertips.  This was the case with Mrs. 
 
                 Crabtree.  That is precisely the reason for the 
 
                 12% disability rating.
 
            
 
                 At no time did a qualified doctor render a different 
 
            opinion with respect to the permanency sustained by 
 
            claimant.  And, it is not acceptable to the undersigned that 
 
            the insurance company should assign an impairment rating to 
 
            claimant's physical condition.
 
            
 
                 As a result, it is found that claimant has sustained a 
 
            12 percent permanent partial disability to her hand.
 
            
 
                                      order
 
            
 
                 THEREFORE, it is ordered:
 
            
 
                 That defendants shall pay claimant permanent partial 
 
            disability benefits for twenty-two point eight (22.8) weeks 
 
            at the rate of two hundred fifty-six and 79/100 dollars 
 
            ($256.79) per week commencing on May 4, 1989.
 
            
 
                 That defendants shall pay accrued amount in a lump sum.
 
            
 
                 That defendants shall pay interest on benefits awarded 
 
            herein as set forth in Iowa Code section 85.30.
 
            
 
                 That defendants shall pay the costs of this proceeding 
 
            pursuant to rule 343 IAC 4.33.
 
            
 
                 That defendants shall file claim activity reports as 
 
            requested by this agency pursuant to rule 343 IAC 3.1(2).
 
            
 
                 Signed and filed this ____ day of July, 1991.
 
            
 
            
 
            
 
            
 
                                          
 
            ________________________________
 
                                          PATRICIA J. LANTZ
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr Paul T Shinkle
 
            Attorney at Law
 
            PO Box 523
 
            Cedar Falls Iowa 50613
 
            
 
            Mr Jay P Roberts
 
            Attorney at Law
 
            620 Lafayette Street
 

 
            
 
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            PO Box 178
 
            Waterloo Iowa 50704