State News

TO: NWCDN STATE NEWS

BY: Dill Battle, Spilman Thomas & Battle, PLLC

With assistance from clerks Carter Capehart, Taiesha Morgan, and Alan Parsons

DATE: August 28, 2024

RE: West Virginia Workers' Compensation News

West Virginia Supreme Court of Appeals

Permanent Partial Disability Calculations and Whole Person Impairment

In the Spring Term of Court in 2024, two decisions by the West Virginia Supreme Court of Appeals have significant impact on apportionment calculations of preexisting awards and conditions in workers’ compensation claims.

Logan-Mingo Area Mental Health, Inc. v. Lester, 902 S.E.2d 768, 2024 WL 2890070 (W. Va. 06/10/2024)

In Lester, the Court clarified the proper usage of the Combined Values Chart of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition to calculate permanent partial disability (PPD) when the claimant has a definitely ascertainable preexisting impairment. Although the holding was narrow, the case has significant impact on the methodology of PPD calculations.

Lester had a previous workers’ compensation injury  in 1999 resulting in a 20% PPD award after application of the Combined Values Chart combining a 14% whole-person impairment for his lumbar spine, and a 7% impairment for his thoracic spine. In 2017, Lester again filed a claim from a fall resulting in more impairment to his lumbar spine and thoracic spine, together with additional impairments to his cervical spine, left shoulder, right knee, and left knee.

After achieving maximum medical improvement for these new injuries, Dr. Bruce Guberman calculated the following whole person impairment: 8% for the cervical spine; 8% for the lumbar spine; 7% for the thoracic spine; 4% for the left shoulder; 4% for the left knee; and 4% for the right knee. He combined these calculations for a total whole-person impairment of 30% when properly applying the Combined Values Chart on page 322 of the AMA Guides Fourth Edition. Dr. Guberman, however, offset the previous lumbar and thoracic spine injuries before combining the impairments which resulted in a 19% whole-person impairment from the new injuries. When added with the previous award, this would mean that Lester would receive compensation for 39% PPD even though he only had a whole-person impairment of 30%.

Dr. Rebecca Thaxton performed her own assessment of Lester’s injuries and used a different method of calculating whole-person impairment. She agreed with the total impairment of 30% and then deducted the 20% previous PPD award, resulting in 10% attributable to the new injuries. Lester was awarded 10% PPD in the new claim, which award was affirmed by the Workers’ Compensation Office of Judges (OOJ) but reversed by the Board of Review (BOR) which granted the 19% PPD award.

The Supreme Court of Appeals reversed the BOR and upheld the 10% PPD award granted by the OOJ. In ruling that Dr. Guberman’s methodology was improper, the Court found it dispositive that Lester would receive an award that was 9% higher than his total whole-person impairment. They also held that Dr. Thaxton’s methodology was the proper usage of the Combined Values Chart when offsetting prior awards.

The Court described the correct calculation method in Syllabus Point Two of the decision:

When a claimant has preexisting, definitely ascertained impairments to multiple body parts and then sustains new compensable injuries that affect the previously impaired body parts, the proper method for apportioning the preexisting impairments is to first determine the claimant's total, unapportioned whole-person impairment using the Combined Values Chart of the American Medical Association's Guides to the Evaluation of Permanent Impairment (4th ed. 1993). Then, the total amount of the claimant's preexisting impairment that has been definitely ascertained must be deducted from the total, unapportioned whole-person impairment to calculate the amount of the claimant's Permanent Partial Disability award.

Syl Pt. 2, Logan-Mingo Area Mental Health, Inc. v. Lester, 902 S.E.2d 768, 769 (W. Va. 06/10/2024).

This opinion has significant impact on workers’ compensation claims when the claimant has been granted prior awards, and emphasizes a stronger weight on those previous awards.

Duff v. Kanawha County Comm’n, No. 23-43, 2024 WL 1715166 (W. Va. 04/22/2024)

The West Virginia Supreme Court of Appeals handed down another opinion with significant impact on claims involving the apportionment of preexisting impairment from prior injuries. In Duff, the Court adopted a stricter definition of “definitely ascertainable” as it appears in West Virginia Code § 23-4-9b, resulting in a shifting of the burden of proof to the employer when asserting the existence of prior impairments.

After Duff was injured on the job, he was granted a 13% permanent partial disability award. This was based upon a medical report by Dr. Prasadarao Mukkamala calculating 25% whole-person impairment in the lumbar spine with 12% apportioned to preexisting conditions arising from a long history of back problems in the lumbar and thoracic spine. This award was affirmed by the Workers’ Compensation Board of Review (BOR), and the West Virginia Intermediate Court of Appeals (ICA).

The Supreme Court of Appeals reviewed the findings of three doctors who examined Duff with an eye on the depth of analysis regarding any preexisting conditions and any resulting apportionment. In order to examine the reports, the Court felt it necessary to define the term “definitely ascertainable” in the applicable governing statute W. Va. Code § 23-4-9b which reads as follows:

Where an employee has a definitely ascertainable impairment resulting from an occupational or a nonoccupational injury, disease or any other cause, whether or not disabling, and the employee thereafter receives an injury in the course of and resulting from his or her employment, unless the subsequent injury results in total permanent disability within the meaning of section one, article three of this chapter, the prior injury, and the effect of the prior injury, and an aggravation, shall not be taken into consideration in fixing the amount of compensation allowed by reason of the subsequent injury. Compensation shall be awarded only in the amount that would have been allowable had the employee not had the preexisting impairment. Nothing in this section requires that the degree of the preexisting impairment be definitely ascertained or rated prior to the injury received in the course of and resulting from the employee's employment or that benefits must have been granted or paid for the preexisting impairment. The degree of the preexisting impairment may be established at any time by competent medical or other evidence. Notwithstanding the foregoing provisions of this section, if the definitely ascertainable preexisting impairment resulted from an injury or disease previously held compensable and the impairment had not been rated, benefits for the impairment shall be payable to the claimant by or charged to the employer in whose employ the injury or disease occurred. The employee shall also receive the difference, if any, in the benefit rate applicable in the more recent claim and the prior claim.

W. Va. Code § 23-4-9b (emphasis added).

The Court read the term “definitely ascertainable” to require a medical expert to offer thorough justification for a conclusion that the claimant had a preexisting condition that warranted apportionment, with the AMA Guides offering the appropriate method of calculation. The Court also read this statute to shift burden to the employer to prove apportionment is necessary in any given case, as seen in Syllabus Point Six:

Under West Virginia Code § 23-4-9b (2003), the employer has the burden of proving apportionment is warranted in a workers’ compensation case. This requires the employer to prove the claimant “has a definitely ascertainable impairment resulting from” a preexisting condition(s). This requires that employer prove that the preexisting condition(s) contributed to the claimant's overall impairment after the compensable injury and prove the degree of impairment attributable to the claimant's preexisting condition(s).

Syl. Pt. 6, Duff v. Kanawha County Commission 2024 WL 1715166 (W. Va. 04/22/2024).

With the burden shifted to the employer to prove that apportionment is necessary, the Court looked to evidence presented by the parties’ respective medical experts. Dr. Mukkamala’s report was seen to have offered little reasoning in his conclusion that Duff’s preexisting conditions justified a 12% apportionment. Dr. Bruce Guberman, who performed an examination on behalf of the claimant, also found that Duff had a whole-person impairment of 25%. However, he offered more justification in his report to come to his conclusion that apportionment was not necessary. Dr. David Soulsby also gave a report that apportioned 12% impairment to preexisting conditions, but the report was found to be inadmissible because it lacked a mandatory lower back examination form. Under this new definition of “definitely ascertainable,” the Court held that Dr. Mukkamala’s report did not present enough proof showing that Duff had a definitely ascertainable prior impairment or a proven degree of impairment that would justify apportionment.

In reversing the BOR and ICA, the Court accepted the reasoning of Dr. Guberman and remanded the case to the BOR to grant a PPD award of 25%. It was determined that since neither of the parties requested the Court to remand to the BOR to rehear the claim in accordance with this new standard, the Court declined to do so, determining the final resolution of the issue on its own accord.

In his separate opinion concurring, in part, and dissenting, in part, Chief Justice Armstead disagreed with the shifting of the burden of proof to the employer, likening it to a treatment as an affirmative defense. He found the Majority’s opinion at odds with prior West Virginia case law requiring the employee to prove his or her claim by “proper and satisfactory proof.” Casdorph v. W. Va. Office Ins. Comm'r, 225 W. Va. 94, 99, 690 S.E.2d 102, 107 (2009). Chief Justice Armstead would have affirmed the rulings of both the BOR and ICA, allowing the apportionment of the prior injury.

Justice Bunn concurred in part and dissented in part. She disagreed with the majority’s handling of remand. She wrote that the parties should not be held to findings of fact on appeal under a new standard without being given the chance to present evidence in accordance with that standard.

The case is a significant change in the way apportionment of preexisting impairment is proven. Greater certainty is now required on behalf of the employer to overcome a presumption that the claimant’s impairment is the result of the injuries that brought rise to the claim. This can be very difficult when claimants are not examined for the necessary impairment ratings under the AMA Guides when the prior injuries did not occur in the context of a workers’ compensation claim. The Supreme Court refused a petition for reconsideration, and employers will have to adapt to this new interpretation.

Compensability

In the fall term 2023, the West Virginia Supreme Court of Appeals discussed the “increased risk” test to analyze compensability of a fall down a set of stairs and found the employee’s act of descending a short staircase did not increase his risk of injury and affirmed the rejection of the claim. Hood v. Lincare Holdings, Inc., 21-0754, 894 S.E.2d 890 (W. Va. Nov 08, 2023).

In Hood v. Lincare Holdings, Incthe Court ruled that the fall was not compensable because the employee was injured while employed but not as a result of his employment. Justice Walker succinctly described the facts of the case:

“While descending a short set of stairs from a customer's porch after making a delivery for his employer, Robert Hood felt a “pop” and pain in his right knee. He was later diagnosed with a right knee sprain. Mr. Hood did not slip, trip, or fall, and he was not carrying anything. The West Virginia Workers’ Compensation Board of Review affirmed previous rulings rejecting the claim, and Mr. Hood appeals. Even though Mr. Hood was injured while working, he failed to show that his work caused the injury. We affirm.”

Hood v. Lincare Holdings, Inc., 894 S.E.2d 890, 893 (W.Va., 2023).

The Court explored the jurisprudence in West Virginia and noted the cases and commentaries on this topic in Arthur Larson, Lex K. Larson, Thomas A. Robinson, Larson's Workers’ Compensation (Rev. Ed. 2023)). In Syllabus Pt 4, the Court held: “In the context of workers' compensation law, there are four types of injury-causing risks commonly faced by an employee at work: (1) risks directly associated with employment; (2) risks personal to the claimant; (3) mixed risks; and (4) neutral risks.” In Syllabus Pt 5, the Court held: “The factfinder may use the increased-risk test when deciding whether an employee sustained a compensable injury under West Virginia Code § 23-4-1(a) (2018), in cases where the injury occurred while the employee was engaged in a neutral risk activity. Under the increased-risk test, even if the risk faced by the employee is not qualitatively peculiar to the employment, the injury may be compensable if he faced an increased quantity of a risk.”

Applying these principles to the facts at hand, the Court looked to the “increased risk” test and found the employee’s act of descending a short staircase did not increase his risk of injury and affirmed the rejection of the claim. Hood v. Lincare Holdings, Inc., 894 S.E.2d 890, 895 (W.Va., 2023).

Permanent Partial Disability in Occupational Pneumoconiosis Cases – Lung Transplant

Rockspring Development, Inc. v. Brown, No. 22-0135, 902 S.E.2d 785 (06/11/2024)

In Rockspring, the Court affirmed the Workers’ Compensation Board of Review’s decision affirming Brown's additional 20% PPD award for occupational pneumoconiosis (OP) impairment. Brown contracted OP based upon his coal dust exposure as an underground coal miner. In August 2016, the claims administrator granted him a 30% PPD award based upon his OP. Brown’s pulmonary function study caused the interpreting physician to diagnose him with a severe obstructive ventilatory defect, a mild restrictive ventilatory defect, and a moderate gas transfer defect. The study demonstrated that his “flow-volume loop pattern [wa]s consistent with chronic obstructive pulmonary disease.” Because the results indicated that his OP had worsened, Brown subsequently requested that his PPD claim be reopened. The claims administrator referred him to the OP Board for evaluation.

Members of the OP Board examined Brown and relevant medical records. The OP Board noted the previously diagnosis of asthma and chronic obstructive pulmonary disease in 2015, and that he was treated for pneumonia in 2017. Brown reported to the OP Board he was on the lung transplant list for several years due to progressive massive fibrosis. The OP Board ultimately determined Brown’s condition had worsened to progressive massive pulmonary fibrosis. The OP Board further relied on the October 2017 Vanderbilt pulmonary function testing, which demonstrated significant impairment. Ultimately, the OP Board concluded sufficient evidence justified an additional 20% impairment rating the diagnosis of OP, for a total of 50% when combined with the previous 30% impairment.

On December 6, 2018, the claims administrator granted Mr. Brown an additional 20% PPD award. Rockspring protested this order to the Office of Judges. During the pendency of the protest proceedings, Brown received a bilateral lung transplant on May 3, 2020. Following the surgery, Brown submitted to a pulmonary function study at Vanderbilt on August 3, 2020. The interpreting physician found no obstruction present in Brown's lungs. Because the study occurred after Rockspring's evidentiary development deadline, Rockspring moved the Office of Judges to admit the medical records regarding Brown's lung transplant and subsequent testing into evidence. The Office of Judges granted the motion.

As Justice Bunn wrote in her decision, the lower tribunals were faced with “a rare set of factual circumstances”. Rockspring Development, Inc. v. Brown, 902 S.E.2d 785, 791. The Court found that the Workers' Compensation Board of Review did not clearly err in determining that Brown was entitled to a 50% PPD award for his OP impairment following bilateral lung transplant, although certain medical documentation indicated that Brown’s pulmonary function was normal following transplant, and the OP Board used pre-transplant pulmonary function testing to determine his impairment. Members of the OP Board provided testimony before the Office of Judges that support its decision to use the pre-transplant pulmonary function testing to determine Brown's impairment, including that Brown clinically “still suffers” and that, while he had no discernable pulmonary function impairment due to the transplant surgery, he faces other medical issues due to the transplant and has a shortened life expectancy.

The Court concluded:

“There was undisputed evidence in the record below to demonstrate that Mr. Brown contracted OP and suffered a resulting measurable impairment for many years. In the absence of statutory guidance on whether and how a transplant surgery that occurs during the pendency of the claim impacts an impairment rating, we simply cannot conclude that the Board of Review erred, particularly in light of the deference they are afforded.”

Rockspring Development, Inc. v. Brown, 902 S.E.2d 785, 792 (W.Va., 2024).

Collateral Estoppel

Ruble v. Rust-Oleum Corporation, No. 22-0329, 902 S.E.2d 873 (06/12/ 2024)

The West Virginia Supreme Court of Appeals determined that the plaintiff’s workers’ compensation claim did not preclude a related civil claim from being brought under collateral estoppel. Ruble v. Rust-Oleum Corp., No. 22-0329, 902 S.E.2d 873 (06/12/ 2024). Justice Hutchison summarized the issue presented to the Court: “Specifically, we consider whether collateral estoppel (sometimes called “issue preclusion”) applies such that a finding in a West Virginia workers’ compensation decision may be used to preclude litigation of that issue against a third party in a West Virginia circuit court." Id. at 1.

In Ruble, the plaintiff sued his past and current employers, along with two chemical suppliers, claiming injury suffered at work after breathing in toxic fumes. Id. at 2-3. Contemporaneously, the plaintiff filed a workers’ compensation claim against his most recent employers and chemical suppliers in circuit court. Id. at 3. The administrative claim was denied, for which the plaintiff appealed and was again denied before the West Virginia Workers’ Office of Judges (“the OOJ”). Id. at 3-4. It important to note that there was no hearing before the OOJ, and the only evidence presented included the proffered record from the administrative claim. Id. at 3. The OOJ found that the plaintiff did prove, by a preponderance of the evidence, that he developed an occupational disease “in the course of and as a result of employment.” Id. at 4.   

The plaintiff appealed to the West Virginia Workers’ Compensation Board of Review (“the Board”), and was also denied. Id. 3-4. As a result, the plaintiff voluntarily dismissed their claim against both employers. Id. at 5. The chemical suppliers also moved to have the claims against them dismissed, under the doctrine of collateral estoppel, for which the court granted. Id. at 5-6. The plaintiff appealed the decision of the circuit court. Id. at 6.

Collateral estoppel is a principle that completely bars a claim from being brought if certain elements are met. Id. at 7. The only element that the Court questioned states “the party against whom the doctrine is raised had a full and fair opportunity to litigate the issue in the prior action.” Id. at 7; Syl pt. 1, State v. Miller, 194 W. Va. 3, 6, 459 S.E.2d 114, 117 (1995). The Court analyzed the processes during the workers’ compensation proceedings and found that they were significantly different from the claims in circuit court. Id. Specifically, citing differences in the procedural and statutory rules in the collection, presentation, and development of discovery and evidence. Id. at 9-13. The Court found that it hindered the plaintiff’s ability to prove the claim itself and the subsequent damages. Id. The smaller award amounts allowed in workers’ compensation claims limit workers’ compensation attorney’s from spending large amounts to fully prepare claims against defendants were also noted. Id. at 13-14. For those reasons, the Court found that the plaintiff did not have a “full and fair opportunity to litigate[ ]” his claims before the workers’ compensation tribunals. See id., at 14. The Court mentioned:

“Upholding the circuit court’s dismissal would deter employees from seeking workers’ compensation until any third-party claims have been developed and resolved. . . contrary to the Legislature’s command that employees injured on the job by a third-party are allowed to purse both a workers’ compensation claim and a claim against the third party.”

Id.

Justice Armstead dissented, believing that it “unjustly call[s] into question the applicability of collateral estoppel in relation to a myriad of other administrative proceedings and agencies.” Ruble, No. 22-0329, 14-16 (W. Va. Supreme Court, June 12, 2024) (Armstead, C.J., dissenting). Finding that under the facts, the plaintiff received a “second bite at the apple” to prove causation against a third party, which the doctrine of collateral estoppel and West Virginia case law has prohibited. Id. at 1. See Steel of West Virginia, Inc. v. West Virginia Office of the Insurance Commissioner, No. 11-1607 (W. Va. Supreme Court, November 16, 2012)(memorandum decision). 

For any questions, please contact:

Dill Battle

Spilman Thomas & Battle, PLLC

hdbattle@spilmanlaw.com

304-340-3823

OKLAHOMA TRENDS AUGUST 2024

 CO-WORKER LIABILITY

 The Oklahoma Supreme Court has said a co-worker can be sued by an injured worker in a third-party district court action. The case is Bayouth v. Dewberry, 2024 OK 42.

 A fundamental premise of workers' compensation/tort law is that exclusive remedy prevents an injured worker from maintaining a third-party action for the negligence of a co-worker. BUT THIS CASE IS DIFFERENT.

 On his day off, Employee A had an argument with Employee B and shot and injured him. The incident occurred at the place of their employment. Employee B filed a third-party action in district court against Employee A. An Oklahoma County district judge granted summary judgment for the estate of Employee A, citing the exclusivity of workers' compensation and a co-worker's immunity from third party suit.

 In a 7-2 decision, the Supreme Court said "an employee, who injures another employee, must be acting within the course and scope of their employment when the incident occurs in order to receive the protection of the exclusive remedy provision" of the Administrative Workers' Compensation Act.

The district judge did not make a ruling on whether Employee A was acting within the course and scope of his employment. There is a dispute about that issue, so the case has been remanded to the district court judge to opine on that issue.

 INDEMINITY PROVISIONS SUBCONTRACTORS OVERRULLED

The Oklahoma Supreme Court may have dealt a fatal blow to so-called "indemnity" provisions in contracts with subcontractors in work-related injury cases. Such indemnity agreements are common in the oil and gas industry, the employee leasing business, and in other areas. We have also seen provisions in contracts of janitorial services that indemnify the building owner in the event of third-party liability.

The case is Knox v. Oklahoma Gas and Electric Co., 2024 OK 37. Seven justices concurred in the result, two dissented in part, and two justices dissented to the entire decision. Justice Edmondson wrote the majority opinion.

 The facts—OG&E contracted with sub "A" to develop property for a solar power facility. Sub "A" contracted with Sub "B" who contracted with Sub "C" who was the employer of Mr. Knox who was killed in an accident while performing construction work. His widow brought a wrongful death action in district court. The widow received statutory workers' compensation benefits.

 As is common in oil field operations, the Employer (Sub "C) signed a contract agreeing to indemnify Sub "B" for any sums paid out in a third-party claim.

 Here is what we believe the opinion holds:

 (1) An employee cannot sue his or her employer BOTH in workers' comp and under common law negligence theories. (That's exclusive remedy) The dual capacity doctrine does not appear in the Administrative Workers' Compensation Act.

 (2) An employer cannot be held liable twice, under workers' comp, and by an indemnity agreement with another party. The Supreme Court opinion reasons that an employer cannot agree to indemnify a third party guilty of negligence if the third-party claim is based upon the same physical injury covered by workers' compensation. An employer is allowed to agree to indemnify contractors above in the case of an INTENTIONAL TORT, just not in negligence cases. 

 Parties other than the employer can still be sued based upon common law negligence in a traditional third-party case.  But those third parties cannot look to a subcontractor who is the employer for reimbursement for any negligence damages, even though the employer agreed to such terms.

 There have been claims in which a drilling contractor, the employer of the injured worker, signed an indemnity agreement with the owner of the oil or gas well. Because of the indemnity agreement, the drilling contractor paid BOTH the comp claim and the third-party negligence tort claim. It appears this will no longer be the case.   

 This decision could be far-reaching. Insurance risk managers must look at a general contractor for possible third-party liability because indemnity agreements won't prevent damage awards any longer.

Coming and Going, Part I

Course and scope of employment, specifically the question of whether an employee was merely “coming and going” to/from work at the time of an injury, is one of the trickier aspects of Texas workers’ compensation jurisprudence, often hinging on minute details of the particular claim. Any guidance in this arena is therefore highly coveted, and the Texas Court of Appeals in Amarillo has just provided some much-needed clarity in Old Republic Insurance Company v. Evans, No. 07-23-00326-CV, 2024 WL 3249336.

The employee in the case was tragically killed in a motor vehicle accident on his way to work in the early morning. He left home on his motorcycle, arrived at work, and entered the building by scanning his security badge. However, he realized that he left his company laptop at home and felt he could not proceed in his work duties without it. Thus, he departed, returned home to claim the laptop, and drove to work again, during which time he was involved in the fatal collision.  

The Administrative Law Judge at the Contested Case Hearing determined that the decedent was not in the course and scope of his employment at the time of his death, but the Appeals Panel reversed. A trial court jury concurred that the decedent’s work day commenced when he arrived to work and that he needed his computer to further the business affairs of the employer, hence he was still in the course and scope of employment at the time of his death.  

The Court of Appeals disagreed, reasoning that the decedent was under no express direction from his employer to return home to recover the computer, and thus he was not on a special mission that would otherwise have provided an exception to the coming and going rule. The fatal injury was therefore deemed non-compensable.  

The complicated analysis required for “coming and going” cases is illustrated here by the fact that the decision kept switching back and forth, from the ALJ, to the Appeals Panel, to the trial court, to the court of appeals. See, like we said, “tricky.”  

Copyright 2024, Stone Loughlin & Swanson, LLP 

52 Pick Up

On July 2, the DWC announced a revised DWC Form-052 “Supplemental Income Benefits (SIBs) Application,” which went into effect on June 20 and became immediately available on the TDI website.  

A great many changes on the new form are immediately noticeable.  Gone is the requirement from the old DWC Form-052 to supply the treating doctor’s name and phone number, the name of the injured worker’s prior employer, and the claimant’s county of residence. New items include the adjuster’s fax number, the claimant’s email address, and a section to specify whether the application is for the first quarter of SIBs or a subsequent one.  

The work status chart has been streamlined, while the grid pertaining to wages earned during the qualifying period allows for more information (pay period dates and whether wages were earned weekly, biweekly, or monthly). Also new: the adjuster may now check a box pertinent to the reason for a quarter’s denial from a list provided, or include a written explanation otherwise.  Formerly, a written explanation was required.  

The certification that accompanies a claimant’s signature has been modified to attest that the applicant has either been searching for work or is completely unable to work, but the warning that an administrative or criminal penalty can follow from intentionally providing false information to obtain benefits has been excised.  

Most notably, the weekly work search log has been modified substantially. The applicant is no longer asked to supply the method by which a work opportunity was sought (in person, phone, fax, mail, email/web), nor is he/she asked to indicate what was submitted to the potential employer (cover letter, application, or resume). The form now asks only if a job was offered, not whether it was accepted or if the employer was “not hiring.”  The column for recording the day of the work search now reads “Date you applied” rather than merely “date,” aligning with the requirement that job applications must be included with the submission of the DWC Form-052.  
 

Copyright 2024, Stone Loughlin & Swanson, LLP

Coming and Going, Part II

Another month, another round of new hires and exits at the Division of Workers’ Compensation.

We recently reported on the departure of the Deputy Commissioner of Appeals, who oversees the Division’s Appeals Panel. We are pleased to report that the position has been filled by former Ft. Worth Administrative Law Judge Kara Squier, who has been a Division employee for more than a decade. We congratulate her on the promotion!

Pam Delgado, the Administrative Law Judge in Corpus Christi, retired on July 12. The Division has posted her position but has yet to fill it. No word yet on what life post-DWC might have in store for Judge Delgado, but whatever it may be, we thank her for her service and wish her the best.

As one vacancy opens, another closes. Kathryn Labowitz, recently of Bailey & Galyen, is the newest Administrative Law Judge in Dallas. Ms. Labowitz graduated from the University of Texas at Arlington with a BA in political science before obtaining her JD from Baylor Law School in 2003. In the interim, her practice took her into the fields of family law, personal injury, probates, and toxic tort litigation. We are excited to see what her experience will bring to the DWC.  

Mariana Kuznetsov, formerly a Proceedings Resolution Officer, has been promoted to Benefit Review Officer. She began presiding over BRCs in July. Our congratulations to her!
 

Copyright 2024, Stone Loughlin & Swanson, LLP  

A Judgment Disorder

“He who represents himself has a fool for a client.” That morsel of legal wisdom, well-known among those in the profession, is generally attributed, perhaps apocryphally, to Abraham Lincoln. Well, if the gentleman from Springfield ever did say it, no one bothered to tell Phyllis Lee.  

Ms. Lee, was a Grand Prairie ISD employee. Without legal counsel, she filed a petition for judicial review of a Decision and Order and Appeals Panel affirmance that her injury does not extend to or include “adjudgment disorder” (whatever that is) along with “depressed mood, psychological factors adversely affecting medical conditions, or major depression.” She further accused the School District of “due process violations, fraud, and conspiracies” committed against her.  

The school district scored a victory at the trial court level, where Ms. Lee’s suit was dismissed summarily for not having been filed within the thirty days allotted under the Administrative Procedure Act (APA). But the Austin Court of Appeals sided with the still-unrepresented Ms. Lee, reversing the decision and remanding the case back to the trial court. The Court of Appeals confirmed that Ms. Lee’s deadline to file her petition was forty-five days under Texas Labor Code Section 410.252, which is the statute that applies to all Appeals Panel decisions, and not thirty days per Section 2001.176 of the APA.  

So, this time, anyway, it seems Lee got the better of Lincoln.  

Copyright 2024, Stone Loughlin & Swanson, LLP

One Big Trucking Fraud

Frances Hall, the widow of San Antonio-based trucking mogul Bill Hall, Jr., was sentenced to ten years deferred adjudication and ordered to pay $150,000.00 in restitution for her role in a workers’ compensation fraud on July 10 by the 147th District Court in Austin pursuant to a plea agreement entered the prior May.  She is also ordered to undergo unspecified “treatment,” per the probation department’s recommendation.  

Mrs. Hall co-founded Bill Hall Jr. Trucking with her husband. The Division’s fraud unit found that Mrs. Hall underreported payroll information and concealed payroll reports to her workers’ compensation insurance carrier between 2006 and 2016, which allowed her to avoid paying approximately $9 million in work comp premiums. 

Mrs. Hall was convicted in September 2016 of felony murder in the death of her husband, but received only a two-year prison sentence. She has since been released.

Copyright 2024, Stone Loughlin & Swanson, LLP

CGI (Computer-Generated Impairment)

On July 15, the DWC revealed its proposed revision to Texas Administrative Code §133.30, “Telemedicine, Telehealth, and Teledentistry Services.” The change would permit treating doctors (not Designated Doctors or Required Medical Examiners) to perform MMI evaluations remotely via telemedicine. The certifying doctor would only be permitted to determine if MMI has been attained and, if so, to provide a determination of no permanent impairment. The rule change specifies that “The term (telemedicine services) does not include an examination to assign an impairment rating” under Rule 130.1.  

The new “telecertification” Rule references Rule 130.2, subsection (a)(2), which currently allows a treating doctor to provide an MMI certification without scheduling an examination, so long as the injured employer has been released from treatment without the expectation of further treatment and is not receiving Temporary Income Benefits.  

Thoughts on the rule draft can be submitted to RuleComments@tdi.texas.gov by 5:00 p.m. on August 12, 2024.  

Copyright 2024, Stone Loughlin & Swanson, LLP

Temporary Total Disability (TTD) Benefits and Credit for Wages Paid
General Motors, LLC v. Giovanni Smith, 2024-CA-0367-WC (7/12/24 KY Court of Appeals, To Be Published, not final)
 

Smith was employed by GM for 13 years working on the assembly line. In February of 2021, he began having pain in his right hand and wrist which he reported in March. He was pulled off the line on August 10, 2021 due to his injury and moved to a different position until March 29, 2022, when he first went off work. He underwent carpal tunnel surgery on July 13, 2022 and was released to full duty, without restrictions, on September 12, 2022. He returned to a different position following surgery and testified that he did not believe he could return to his pre-injury position. Smith testified that his position from August 2021 through March of 2022 involved cleaning and make-work projects, or no work at all. Dr. Bloemer (PL IME) diagnosed an arthritic condition as well as CTS due to work, opining that Smith is incapable of returning to his pre-injury position. Dr. Nicoson (Def IME) found the CTS to be work-related but felt the arthritis was not. He assessed permanent restrictions that would not prevent a return to the pre-injury position. Both doctors agreed that Smith reached MMI on October 13, 2022.
 
The ALJ awarded TTD from August 1, 2021 to October 13, 2022, with no credit for wages paid and PPD benefits with a 3x multiplier. GM appealed, arguing that TTD should not begin until March 29, 2022 or, in the alternative, that they should receive a credit for wages paid during this time. The Court of Appeals affirmed the TTD award, finding that Smith was not at MMI and had not reached a level of improvement that would permit a return to employment. The Court also upheld the denial of the credit because GM failed to provide paystubs showing the net wages after taxes. GM also appealed the application of the 3x multiplier. The Court of Appeals upheld the award of the 3x multiplier, finding that the substantial evidence supported the award.

The Governor signed SB 206 affecting workers compensation. It is effective 1/1/25.

NOTICE. The notice deadline in section AS 23.30.100(a) has been shortened from 30 days to 15 for Employee to report the injury to Employer.

REEMPLOYMENT: While the Board has to notify people of their rights sooner, the time frames for Employer’s mandatory referral was extended from 90 days to 120 days. The tuition amount went up to $22,150 and can be adjusted every 5 years to account for inflation. The SCODDOTS are replaced with the OIN database published by the US Dept of Labor. This is more objective than having rehab specialists develop job descriptions in every claim. This is a good change—updated objective job descriptions including jobs that didn’t exist back in the day when SCODDOTs were created.

A major change is the adoption of a “stay at work” program as AS 23.30.043. It will be developed by the rehab specialist and provided to the employee, employee, program coordinator, and attending physician. The board has to adopt regulations to develop the standards and procedures a rehab specialist must use to develop the stay at work plan. It is apparent that the employer will need to be responsive and be involved in this process. Fortunately, there is an opt-out provision. An employer may elect not to participate or continue to participate in the stay at work plan at any time before completion of the plan. This section is vague, with the discretion left to the board to implement regulations and procedures.  This is a process that we should try to be involved in as employer representatives and provide perspective on how this will impact real life. 

In addition, a last minute addendum was tacked on that resulted in a major change is the presumption of compensability for PTSD for a number of professions mostly related to first responders. AS 23.30.118. The notice timeline, presumption standard and rebuttal standard are all altered by this bill.

 The PTSD has to be diagnosed by a psychologist or psychiatrist. The diagnosis must come within 3 years after the last day of employee’s employment. We are not sure where/why this timeline came from as it is different from 2-year latent injury, and it doesn’t seem to be tied to any particular event, just general employment as a reason in one of the identified positions is sufficient to trigger the presumption of compensability. It also eliminates the comparison with others in a similar role. A broad category that it may apply to is “employees who are certified under state law to perform emergency medical services.” It appears broad enough to potentially include home health care workers and medical providers.

 Relevant definitions are in AS 18.08.200:

(9) “emergency medical services system” means a system that provides for the arrangement of personnel, facilities, and equipment for the effective and coordinated delivery of health care services, including trauma care, under emergency conditions, occurring either as a result of the patient's condition or of natural disasters or similar situations, and that is administered by a statewide network that has the authority and resources to provide effective administration of the system;

(13) “provider of emergency medical services” means a person whose occupation or profession is, or has been, the delivery or administration of emergency medical services; a person who has a fiduciary position with, or has a fiduciary interest in, a health activity, facility or other health agency, or a legal or financial interest in the rendering of any component of emergency medical services.”

Once the presumption has attached, there is a secondary change in the legal standard for rebuttal. The phrase “may be rebutted by a preponderance of the evidence that the employee’s PTSD resulted from factors that were not work related” is problematic because it means that we cannot controvert based on “substantial evidence.” Preponderance of the evidence is a factual determination by a trier of fact. This means that once the presumption of compensability is triggered by a psychologist or psychiatrist as minimally as, “Jane Doe has been diagnosed with PTSD and is unable to work. She was a nurse within the last 3 years,” there is no ability to controvert and the claim must go to hearing to establish whether the preponderance of evidence demonstrates that the PTSD resulted from factors that are not work related. The presumption for compensability “may be rebutted by a preponderance of the evidence that the employee’s PTSD resulted from factors that were not work related.” This appears to create an entirely new standard when compared to AS 23.30.010(b) which is that the work stress must be the predominant cause of the work injury.

In a practical application it means that large groups of first responders could all be taken off work at once with no recourse for Employers until after a merits hearing (which can take 9 months or more). There are also likely butterfly effect ramifications and increased stress that will result from understaffing. Without the comparison and controversion abilities there is little opportunity for mitigation. This portion of the legislation really deserved public comment and more thought.