State News

Mike Brooks, Inc. and Great West Casualty Co. v. James David House, Court of Appeals of Iowa, No. 3-624/13-0303

The Claimant began his employment with Mike Brooks, Inc. on July 26, 2005 as a commercial truck driver. On March 7, 2007 he suffered a back injury after slipping on ice in the truck loading area. Dr. was seen by orthopedic surgeon Dr. David Hatfield, who prescribed physical therapy. After 2 ½ months, the Claimant passed a DOT physical and was returned to work. After continued back pain, he underwent surgery with Dr. Hatfield on January 31, 2008. He returned to work 6-8 weeks later, but continued to feel pain. Dr. Hatfield recommended that he cease working, and on November 13, 2008, performed an anterior fusion and then a posterior fusion the next day.

The Claimant filed a petition with the Agency on December 16, 2009 alleging the back injury of March 7, 2007. At hearing on December 8, 2012, the Claimant testified about an incident on January 4, 2008 where he pushed a heavy door and felt a burning sensation in his back. In the arbitration decision, the deputy awarded permanent total benefits. The deputy found the record did not support the employer’s position that the January 2008 injury was distinct from the March 7, 2007 injury. In regards to the permanent total disability, the deputy concluded that the Claimant could no longer drive a truck and his restrictions precluded him from returning to work as a millwright or welder.

After affirmance by the Commissioner, the employer appealed on the basis of error in finding a causal connection between the Claimant’s March 7, 2007 injury and his disability, that the evidence did not support a finding of permanent total disability and that the deputy ordered an incorrect commencement date for permanent benefits.

The Court first took up the issue of whether the Claimant’s March 7, 2007 injury was the cause of industrial disability. Specifically, the Court addressed the employer’s argument that the Claimant’s January 2008 door pushing incident was the cause of his subsequent back surgeries and claimed disability. The Court first noted that medical causation is a question of fact vested in the discretion of the agency and the agency’s decision would not be overturned if supported by substantial evidence.

In reviewing the record, the Court found the Claimant’s severe pain, surgeries and inability to work due to back pain occurred after the January 2008 incident, as he was working without complaint for several months subsequent to the March 2007 slip and fall injury. The Court also found that the expert testimony regarding causation did not support the finding that the March 2007 injury caused the Claimant’s disability. Specifically, the Court found that Dr. Hatfield’s opinion, which causally related the Claimant’s surgeries and disability to the March 2007 slip and fall, was based upon incomplete information as it appeared Dr. Hatfield was never made aware of the Claimant’s January 2008 incident and therefore could only relate the Claimant’s complaints to the March 2007 injury. The Court also found the opinion of Dr. Kuhnlein, who opined that the increase in severity after the January 2008 incident was a sequela of the original injury, was also faulty as it was based on the previous opinion of Dr. Hatfield which lacked an adequate history.

The Court found that the opinions of Dr. Kunhleing and Hatfield were not based on awareness of all the facts in the case, and as such, were not reliable. As the opinions were not reliable, they could not form the basis for substantial evidentiary support for the Agency’s decision. The Court then reversed and remanded the decision of the Agency. As the Court reversed on the grounds of causation, there was no need to discuss the additional issues raised on appeal.

Quaker Oats Company and Ace Cigna v. Larry Farar, Court of Appeals of Iowa, No. 3-654 / 13-0195

The Claimant began his employment with Quaker Oats in 1975. He worked numerous jobs, all of which involved heavy lifting and use of ladders and stairs. In 1996, the Claimant began to experience knee pain after sustaining a knee injury running a rail car. In 1997, his knee pain worsened and he was diagnosed with chronic right patellofemoral syndrome. These injuries were initially accepted, but in 1999, the employer declined to pay for further treatment.

In 2000, the Claimant reported an increase in knee pain and ultimately underwent a right knee scope with Dr. Craig Dove which revealed significant arthritic changes. Dr. Dove opined that the Claimant’s condition was partially work related, though the Claimant’s obesity contributed to the problem, as the Claimant’s weight would fluctuate anywhere between 320-375 pounds. Quaker denied Claimant’s right knee claim.

The Claimant then began treatment with Dr. Jeffrey Nassif who treated the Claimant with physical therapy and injections. The Claimant next saw Dr. James Pape in 2001 who opined he suffered from bilateral patellofemoral chondromalacia, a degenerative condition. Dr. Pape recommended anti-inflammatories, which continued for several years.

The Claimant returned to Dr. Nassif in 2007, and following an x-ray which revealed severe osteoarthritis of the bilateral knees, knee replacement surgery was recommended. The Clamiant submitted an incident report to Quaker in March of 2008 claiming that he had sustained bilateral knee injuries as a result of repetitive trauma.

The Claimant then began to experience wrist and hand problems in 2008 and 2009, for which he underwent two surgeries, requiring him to miss work for 3 months. The Claimant then underwent knee replacement surgery with Dr. Nassif on March 15 and May 17, 2010. Subsequent to surgery, the Claimant developed deep vein thrombosis and pulmonary emboli conditions.

The Claimant was seen by Dr. Farid Manshadi, who placed him at MMI as of December 9, 2010, and also assigned the Claimant permanent partial impairment of 37% to the left leg and 39% to the right. He was next seen for an independent evaluation by Dr. William Jacobson on December 16, 2010, who assigned 50% permanent partial impairment to each of his legs.

The Claimant also apparently suffered from depression and anxiety, with symptoms beginning in 2008. Dr. Laurence Krain opined in a 2010 report that the Claimant’s inability to work was due to his depressive condition, which he has continued to receive treatment for.

The Claimant’s last day of employment with Quaker was March 12, 2010. He filed a petition with the Workers’ Compensation Commissioner in 2011. After hearing, the deputy found the Claimant’s work activities were a substantial cause of the his bilateral knee condition. It was further found that his deep vein thrombosis and pulmonary emboli were complications of the Claimant’s total knee replacements and were related to his March 14, 2008 cumulative injury. The employer appealed on the grounds that the decision was not supported by substantial evidence and misrepresented the record.

On appeal, the Court noted that medical causation is a question of fact vested in the discretion of the agency and the agency’s decision would not be overturned if supported by substantial evidence. After examining the medical opinions which were contained within the record, the Court found that while the weight of the medical evidence was contrary to the decision reached by the Agency, the Court determined that substantial evidence supported the agency’s finding of causation. Specifically, the Court found the opinion of Dr. Manshadi, who opined that the Claimant’s work caused his knee symptoms, provided enough evidence to sustain the agency’s finding of causation. The Court went on to note that while Dr. Nassif and Dr. Jacobson had opined the Claimant’s employment was not the cause of his bilateral knee condition, the Court’s job was not to determine whether a different conclusion could be reached but whether substantial evidence supported the findings actually made.

The Court further stated that the Agency had specifically given more weight to the opinions of Dr. Manshadi and the Claimant over those of Dr. Nassif and Dr. Jacobson, and that credibility determinations were within the province of the hearing deputy.

The Court next examined the issue of whether Claimant’s DVT and pulmonary emboli were causally related to his alleged cumulative injury. The Court noted that to so find, it would have to be found that the Claimant had sustained a work related injury which required surgery and that said surgery caused the DVT and pulmonary emboli. The Court ultimately found substantial evidence supported the finding that the DVT and emboli were caused by the Claimant’s bilateral knee replacements. Specifically, the Court found substantial evidence in the opinions of Dr. Manshadi and Dr. Nassif who opined that the surgery caused or could have been a contributing factor to the conditions.

In regards to the employer’s argument that the case should be remanded for a more complete record, specifically that the Agency further discuss in greater detail each doctor’s opinions, the Court found that remand was not appropriate. The Court opined that “even when a record is inadequate, remand for additional evidence is generally not appropriate and is only done when there are “good reasons.”” The Court declined to reweigh the evidence presented and remand the case for a more complete record. As such, the decision of the Agency was affirmed in its entirety.

If you have any questions on this, please feel free to call Mark Bosscher or Lee Hook at 515-243-2100. We'd be happy to help answer any questions you might have, big or small!  You can also reach us at www.peddicordwharton.com

Pablo Ledezma v. Procter & Gamble Hair Care, LLC, Cambridge Integrated Services Group, Inc., Court of Appeals of Iowa, No. 3-587/12-2103

The Claimant was injured at work in 2008. The employer and Claimant entered into a settlement agreement on July 23, 2010, which was subsequently approved on September 3, 2010. The agreement indicated that the Claimant had sustained a compensable injury and that he was entitled to temporary, permanent partial and medical benefits.

In July of 2011, the Claimant filed a Petition at Law alleging a bad faith claim based upon a failure to pay his outstanding medical bills as required in the settlement agreement. In August 2012, the defendants filed their motion for summary judgment arguing that the Claimant’s claim  was based in contract and no cause of action existed for bad faith breach of contract and that since all medical bills were paid there was no breach of contract.

The Claimant filed a resistance indicating that the bad faith claim was based upon a delay in payment of medical benefits pursuant to the settlement agreement. The district court granted the motion for summary judgment on the grounds that the claim was a contract claim and not an insurance or workers’ compensation bad faith claim. On appeal, the Court first found that the Claimant had not preserved the issue as to whether any initial denial of benefits was in bad faith. The Court then went on to affirm the district court’s ruling holding that it is well settled law that this was a contract claim and not a bad faith claim.

If you have any questions on this, please feel free to call Mark Bosscher or Lee Hook at 515-243-2100. We'd be happy to help answer any questions you might have, big or small!

Whirlpool Corporation v. Danny Davis, Court of Appeals of Iowa, No. 3-582/12-1962

The Claimant alleged a work injury on April 29, 2008. He had been employed with the employer for 16 years and at the time was working in the paint department. As part of his job he had to maintain sufficient levels of chemicals in the barrels. On his date of injury, one of the barrels was empty. The barrel weighed several hundred pounds and when the Claimant went to replace it, the pallet it was placed on broke, causing the Claimant to hold onto it to keep it from falling. The barrel pulled the Claimant and his foot became stuff in the pallet. As the barrel continued to pull him, he heard a rip in his lower back.

The Claimant immediately reported his injury and was taken by ambulance to Mercy Medical Center. While at the hospital, the Claimant was diagnosed with a lumbar strain and was given pain medication. He was to refrain from lifting and prolonged sitting and to follow up in two days. Two days later, the Claimant say Dr. Momany who would ultimately treat the Claimant’s back until June of 2009. He was diagnosed with mechanical back pain, and three days later reported feeling 20% better. An MRI taken in June of 2008 was unremarkable.

The Claimant then took a leave of absence from the employer between July and August 2008 for problems associated with COPD. The Claimant then asked Dr. Momany to unrestrict him on September 11, 2008 as he had to be unrestricted to bid for a new position and his job was being eliminated. Dr. Momany placed the Claimant at MMI as he was having no significant pain and indicated he had no impairment.

The Claimant saw Dr. Momany again on September 30, 2008 due to feeling a pain in his back while climbing a ladder at work. The Claimant then began to treat with his personal doctor, Wendy Buresh. The Claimant told Dr. Buresh that his back pain had not felt better since the injury occurred and diagnosed the claimant with a low back strain.

The Claimant later followed up with Dr. Momany and was referred for an FCE in October 2008 as it was felt he was approaching MMI. The FCE determined that the Claimant fell into the medium work level and assigned certain restrictions but returned the Claimant to work. On December 22, 2008, the Claimant obtained a seven percent whole person impairment rating from Dr. Mark Taylor.

The Claimant continued to treat with Dr. Buresh for his chronic back pain and unrelated lung condition. He was seen Dr. Gene Gessner at a pain clinic in March and April of 2009 where he received injections and a TENS unit, but the Claimant indicated no improvement. The Claimant also continued to see Dr. Momany, and on June 9, 2009 had to take a leave of absence due to threats of self harm related to his chronic pain.

Dr. Buresh indicated that she believed the Claimant’s complaints were consistent with the type of injury sustained on his date of injury and that he was also experiencing situational depression as a result of the injury. The Claimant then saw Dr. Kuhnlein for an IME on September 4, 2009. Due to the confusion in the record between Claimant’s original date of injury and the potential reinjury in September, Dr. Kuhnlein could not state to a reasonable degree of certainty whether the current complaints were related to his original April injury or a new injury. He then assigned the Claimant 5% impairment and gave him some restrictions.

The Claimant’s last day of employment had been June 9, 2009 as he was kept on medical leave by Dr. Buresh since that time. It was indicated that the pain kept him from doing construction which he did prior to his shifts at Whirlpool. He also continud to hunt and mow his lawn regularly, though limited some by pain.

At hearing, the claimant acknowledged that he had treated with Dr. Meyer, a chiropractor prior to his alleged work injury. Though Dr. Meyer indicated that he was treating the Claimant primarily for cervical pain. The deputy awarded the Claimant permanent total disability benefits, medical expenses and costs. The deputy gave no weight to the opinions of Dr. Momany and indicating that the Claimant’s testimony was credible and corroborated by the record. The deputy indicated that while the Claimant had preexisting depression, it was lit up and aggravated by the work injury.

The decision was affirmed by the commissioner on appeal. The employer appealed to the district court and sought a stay of judgment pending the court’s decision. The district court found the expert opinions cited by the deputy provided substantial evidence and that the employer failed to show irreparable injury if the stay was not granted.

The employer appealed, contesting the findings that the Claimant’s physical and mental conditions were causally related to the April 29 2008 incident; the agency’s findings as to the extent of the Claimant’s disability; that Dr. Buresh was not an authorized treating physician and thus it should not be liable for charges related to the Claimant’s visits to her; and that the commissioner erred in awarding costs in the amount of $1,947. Finally, the employer argued the district court erred in denying its application for stay of judgment.

The Court first addressed the issue of causation and extent of disability and found that the agency’s findings and decisions were supported by substantial evidence, thus those issues were affirmed without significant discussion.

In regards to the medical expenses for Dr. Buresh, the Court noted that the employer had stipulated at hearing that the treatment was reasonable and necessary and that the fees were reasonable. The Court went on to indicate that once he was placed at MMI by Dr. Momany, it was reasonable for the Claimant to seek treatment elsewhere. The Court stated that Iowa law states that even when the employee obtains unauthorized care, upon proof by a preponderance of the evidence that such care was reasonable and beneficial, the employer is liable for the cost of the care. The Court found the visits to Dr. Buresh were related to the Claimant’s low back work injury and affirmed the award of medical expenses.

The Court of Appeals did find that it was error for the commissioner to tax costs of $330 to the employer for the cost of Dr. Momany’s deposition. The Court stated that the costs for deposing an expert witness cannot exceed $150 under Iowa law, thus this taxation of costs was in error.

Finally in regard to the motion for stay, the Court found no abuse of discretion in denying the stay as all the appropriate factors were considered.

If you have any questions on this, please feel free to call Mark Bosscher or Lee Hook at 515-243-2100. We'd be happy to help answer any questions you might have, big or small!

Caitlin Wilson was injured on September 8, 2011 when she dropped a heavy frame on her foot while in the employment of respondent Studio I, Inc. She received $420 per week from September 14, 2011 to October 24, 2011 in temporary disability benefits.  Her doctor advised that she could work light duty at the end of this period, but she did not return to work at this time.  She did return part-time from November 15 - 26, 2011.  She claims the respondent then told her not to return to work until she could work full-time.  Petitioner was paid $339.43 in temporary disability benefits for the period she worked part-time. 

            Respondent claimed that petitioner was authorized to return to work with restrictions on October 14, 2011.  It tried to accommodate the restrictions which actually increased over the next two months, but petitioner either did not arrive at work, arrived late or did not perform her job even with accommodations.  Respondent further claimed that petitioner stopped coming to work entirely without producing any medical note.  She resigned from the company on February 9, 2012 because she was moving. It was undisputed that petitioner returned to work on February 10, 2012.

            On January 13, 2012 petitioner filed a motion for medical and temporary disability benefits.  She argued that her wage was miscalculated and that she was entitled to temporary disability benefits from October 25, 2011 to November 14, 2011.  She maintained that her temporary disability benefits should have continued until February 3, 2012.   She also argued that when she filed the motion in January, 2012, she was not working at that time and was, in her view, entitled to temporary disability benefits.  Therefore, in her view, it did not matter that she later returned to work on February 10, 2012. She argued that she was entitled to a decision on her motion at that time.

            The Judge of Compensation, Honorable Philip A. Tornetta, denied the motion because the claim concerned past periods of temporary disability and was contested by respondent.  The Judge relied onN.J.A.C. 12:235-3.2(a):

Motions for temporary disability and/or medical benefits shall evidence that petitioner is currently temporarily totally disabled and/or in need of current medical treatment.  Where only past periods of temporary total disability and/or medical expenses are claimed by petitioner, such issues should be presented at pretrial for resolution or trial and not by motion under this section. 

The Appellate Division reviewed the appeal and affirmed Judge Tornetta’s decision.  It said, “in this matter an incorrect determination of past temporary benefits can be remedied by a retroactive award of benefits.  Thus, this appeal is interlocutory.”   It relied on Della Rosa v. Van-Rad Contracting Co. Inc., 267 N.J. Super. 290, 294 (App. Div. 1993).  “A serious injustice might occur if a respondent were required to pay an award for temporary disability and medical services and then be unable to obtain the return of its monies in the event of reversal.  It would also be a matter of concern to petitioner to receive such payments with the prospect of possible repayment being required.”

            The case can be found at Wilson v. Studio I, Inc., d/b/a/ Venture Photography, A-0117-12T4 (App. Div. August 8, 2013).  It is useful case for practitioners in clarifying whether a motion for medical and temporary disability benefits should be heard early in the case or held to the end of the case when all issues will be decided.

On August 16, 2013, The Alabama Court of Civil Appeals released its opinion in the matter ofDuBose Construction Company, LLC v. James Simmon. This was the third time this case had come before the Court. The subject injury was to the employee’s right knee which occurred as the result of a fall at work. At trial, the judge found the matter compensable and assessed a 15 percent permanent partial loss of the employee’s ability to earn. The employer appealed on the grounds that the judge should not have considered evidence of vocational loss or assessed a whole body impairment where the injury was to a scheduled member. The Court of Civil Appeals agreed and reversed the judgment. Four months later, the trial court dismissed the case in its entirety. After a failed attempt at mediation, the employee filed a petition for writ of mandamus asking the Court to order the trial court to vacate its dismissal. The Court granted the petition. The employer then filed a petition for a writ of mandamus to the Alabama Supreme Court in an effort to have the Court of Civil Appeals’ mandamus order vacated. That petition was denied.

The evidence at trial revealed that the employee had a torn medial meniscus in his right knee. While performing an arthroscopy, the treating physician discovered that the employee also had chondromalacia which was described as a wear and tear, arthritic issue. Upon reaching maximum medical improvement, the employee was released to return to work at full duty with zero restrictions and no medical impairment. In his trial deposition, the treating physician testified that any complaints of pain would be due to the arthritic issue.

At trial, the employee testified that his knee injury caused him to walk with a limp and that his back was off balance. On remand, the trial judge relied on this testimony to remove the knee injury from the schedule and consider evidence of vocational disability. The employer then appealed on the grounds that the employee’s testimony failed to prove that his knee injury had any effect on other parts of his body.

The Court of Civil Appeals agreed with the employer. In reversing and remanding the matter, the Court relied on theDrummond test. In Ex parte Drummond, the Court adopted the following test: If the effects of the loss of the member extend to other parts of the body and interfere with their efficiency, the schedule allowance for the lost member is not exclusive. In applying this test, the Court noted that the employee never actually testified that he was having lower back problems. The evidence further revealed that the employee never received any medical treatment for any other body parts. In fact, his treating physician testified that the employee never complained about any body part other than his knee.

In reversing and remanding the matter, the Court instructed the trial court to determine what, if any, disability the employee had to his right leg.

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About the Author

This article was written by Michael I. Fish, Esq. of Fish Nelson LLC, a law firm dedicated to representing employers, self-insured employers and insurance carriers in workers’ compensation matters. Fish Nelson is a member of The National Workers’ Compensation Network (NWCDN). If you have any questions about this article or Alabama workers’ compensation issues in general, please feel free to contact the author atmfish@fishnelson.com or any firm member at 205-332-3430.

On August 9, 2013, the Alabama Court of Civil Appeals released its decision inDevero v. North American Bus Industries, in which it upheld summary judgment in favor of North American Bus Industries (NABI) for various tort claims Devero alleged arose out of his employment with NABI.

In February of 2005, Devero and seven other employees of NABI filed a lawsuit in the Circuit Court of Calhoun County, Alabama against NABI and two other defendants, PPG Industries and E.I. DuPont de Nemours, asserting claims of fraud, negligence, wantonness, failure to warn, civil conspiracy, and infliction of emotional distress stemming from alleged exposure to hazardous chemicals in the workplace at NABI. In January of 2006, the trial court entered an Order stating that all of the plaintiff’s claims against NABI were governed by the exclusivity provisions of the Alabama Workers’ Compensation Act. The trial court ordered Devero to restructure his Complaint to state claims under the Act. Devero then filed a new Complaint for workers’ compensation benefits, asserting that he had been exposed to toxic chemicals, deadly solvents, and spray paint particles that had damaged his internal organs and caused him to develop peneumoconiosis. NABI filed an Answer denying all of Devero’s allegations and then moved for summary judgment, asserting that there was no evidence that Devero had been exposed to any toxic substances at work, and that there was no evidence to indicate that Devero suffered from any illness or occupational disease related to his employment. In support of its Motion for Summary Judgment, NABI submitted Devero’s deposition testimony, the medical records of Devero’s personal physician, and hospital records pertaining to Devero’s treatment for his alleged peneumoconiosis.

After consideration of all the evidence, the trial Court granted NABI’s Motion for Summary Judgment, finding that Devero had not presented any evidence of legal or medical causation for his alleged injuries and/or occupational disease. However, the trial Court’s Order did not contain specific findings of fact and conclusions of law addressing whether Devero was suffering from an injury or disease that occurred in and arose out of his employment with NABI.

Devero appealed. On appeal, the Court of Civil Appeals held that an Order granting a Motion for Summary Judgment in a workers’ compensation case need not contain findings of fact and conclusions of law, thus overturning a prior case ofFarris v. St. Vincent’s Hospital, 624 So. 2d 183 (Ala. Civ. App. 1993). Devero also continued that the trial Court erred in failing to allow him to proceed with his tort claims, which he alleged were outside the scope of the Alabama Workers’ Compensation Act. However, the Court of Appeals held that although Devero’s claims against NABI involved allegations of intentional or reckless conduct, those claims dealt with workplace conditions "within the bounds of an employer’s proper role", and therefore, those claims were precluded by the exclusivity provisions of the Alabama Workers’ Compensation Act.

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ABOUT THE AUTHOR

The article was written by Charley M. Drummond, Esq. of Fish Nelson, LLC. Fish Nelson is a law firm located in Birmingham, Alabama dedicated to representing employers, self-insured employers, and insurance carriers in workers’ compensation cases and related liability matters. Drummond and his firm are members of The National Workers’ Compensation Defense Network (NWCDN). The NWCDN is a national and Canadian network of reputable law firms organized to provide employers and insurers access to the highest quality representation in workers’ compensation and related employer liability fields.

If you have questions about this article or Alabama workers’ compensation issues in general, please feel free to contact the author atcdrummond@fishnelson.com or (205) 332-3414.

The case of Young v. Wackenhut Corporation, 2013 U.S. Dist. LEXIS 14414 (D. N.J. Feb. 1, 2013) demonstrates the importance of providing required FMLA notice to eligible employees.

            Jacqueline Young, a Payroll Specialist, advised her employer, The Wackenhut Corporation (hereinafter “TWC”), of her interest in maternity and FMLA leave in November 2008 when she first found out that she was pregnant.  On April 30, 2009, she sent the HR Director an email regarding her “maternity and FMLA leave.”  She supplied the HR Director with leave of absence forms and a doctor’s note putting her out of work.  She went out on maternity leave on June 12, 2009. 

            TWC did not provide any notices as required under the FMLA.  This turned out to be the key fact in the case.  Specifically, the company did not provide the FMLA Eligibility Notice, the Rights and Responsibility Notice, and the Designation Notice.  Instead after months of leave, company representatives called Young on November 30, 2009 and told her that her leave had expired and that she needed to return to work.  This was the first time that TWC reached Young, although Young had called and emailed the company before this date.  The company also told Young that it would need a return-to-work note from her doctor.  On December 1, 2009, the company terminated Young’s employment for failing to provide a return-to-work note and for exhausting her FMLA leave.

            Young sued under the FMLA and argued that the company violated her rights under the FMLA because she was never informed that she had to return to work by November 19, 2009, nor provide a doctor’s note.  The District Court first noted that the company failed to provide Young with “individualized notice” as required by the FMLA. It rejected the company’s argument that an employer’s inclusion of a summary of an employee’s rights in an employee manual constitutes “sufficient notice.” Even though all employees had access to an employee handbook both online and at the HR office, the court held 29 C.F.R. 825.300 specifically requires compliance with the Eligibility Notice, Rights and Responsibility Notice and Designation Notice. The employer is also required to advise on designation whether it will require a return-to-work note.

            TWC argued that even if it had not complied with FMLA notices, plaintiff could not prove any real prejudice to her.  The company maintained that Young took more than her allowed 12 weeks of leave and should not be able to advance an FMLA claim.  Young countered that had she gotten the appropriate notices up front, she would have known her expected return-to-work date and she could have avoided termination.  The court said, “TWC’s argument ignores the fact that the November 30, 2009 telephone call between Plaintiff and Winter Lemon and Doris Wallace was the first time Plaintiff was formally told by TWC that her FMLA leave time had been exhausted.” 

            The Court relied on prior New Jersey case law, particularly Conoshenti v. Public Serv. Elec. & Gas Co., 365F.3d 135, 143 (3d Cir. 2004) for the proposition that an employee has a right to make an informed decision about structuring leave time and planning recovery so as to preserve job protection. 

            This case is consistent with recent FMLA amendments which allow employers to retroactively designate FMLA time, but only where such designation does not prejudice the rights of the employee.  In this case, the employer’s failure to provide individualized notice created the initial problem; the subsequent attempt by the employer to retroactively designate time off on maternity leave failed since the employee had a strong argument that had she received notice promptly, she could have structured her leave so as to return to work by November 19, 2009.  Most importantly, the case underscores why it is so crucial for employers to utilize appropriate FMLA notice forms.  Having an FMLA policy in an employee manual and online is wise but it cannot substitute for specific notice requirements.

A number of carriers were fined recently for failing to accurately submit medical bill and payment data. One carrier was fined $15,000 for this violation.  The submission of medical bill and payment data is governed by a complex set of regulations which includes the Labor Code, Division rules 134.800 - 134.808, the IAIABC EDI Implementation Guide, the Texas EDI Medical Data Element Requirement Table, the Texas EDI Medical Data Element Edits Table, and the Texas EDI Medical Difference Table. 

James Madison could have been describing the laws governing the submission of medical bill and payment data when he wrote the following:

It will be of little avail to the people that the laws are made by men of their own choice, if the laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood; if they be repealed or revised before they are promulgated, or undergo such incessant changes that no man who knows what the law is today can guess what is will be tomorrow.

James Madison, Federalist no. 62, February 27, 1788.

Given the complicated reporting standards and the lack of harm to any system participants from these alleged violations, the Division should consider taking a more collaborative approach with carriers rather than treating potential violations as an opportunity to collect a fine.

SB1322 takes effect September 1, 2013 allowing informal networks for durable medical equipment and home health care. The Act was previously amended in 2011 to allow informal networks for pharmaceutical services. Within 30 days after an informal network is established, it must report certain information to the Division including the name and contact information for the network and a list of the carriers and entities with whom it contracts. At least quarterly, notice must also be given to each contracted health care provider of all carriers given access by the network to the provider’s discounted rates. The notice can be provided in an electronic format or through an Internet website link if certain requirements are met.

Effective September 3, 2013, Kerry Sullivan will join the Division as Deputy Commissioner for Hearings, replacing Dan Barry, Acting Deputy Commissioner for Hearings, who will return to his role as head of the Appeals Panel. Some of you may know Mr. Sullivan from his many years as an administrative law judge at the State Office of Administrative Hearings (SOAH). SOAH proceedings tend to be more formal than DWC proceedings. The rules of evidence apply at SOAH and there are also detailed procedural rules which tend to be consistently and uniformly applied, resulting in fewer surprises for the parties. Mr. Sullivan was well respected as a judge by those who appeared before him and will hopefully be a positive influence on the Division.