NWCDN Members regularly post articles and summary judgements in workers’ compensations law in your state.
Select a state from the dropdown menu below to scroll through the state specific archives for updates and opinions on various workers’ compensation laws in your state.
Contact information for NWCDN members is also located on the state specific links in the event you have additional questions or your company is seeking a workers’ compensation lawyer in your state.
New Jersey has a statute of limitations for occupational disease claims. In Rajpaul v. McDonald’s Corporation, A-4681-13T4 (App. Div. August 28, 2015), the proper application of the statute became the issue on appeal.
In this case, the petitioner worked as a maintenance person from August 1995 until November 2005 at McDonald’s. He began to have pain in his shoulders, wrists, and elbows in 1999. He sought medical treatment at Somerset Family Practice and was referred to Somerset Orthpedic Associates where he was diagnosed with bilateral bicipital tendonitis in 2001.
For the next four years petitioner continued to work at McDonald’s. In June 2005, he returned to Somerset Family Practice for treatment of his left shoulder. In November he left McDonald’s to work elsewhere. In June 2006, petitioner was diagnosed with a left shoulder rotator cuff tear and underwent surgery to repair the tear.
On December 14, 2006 petitioner filed a claim petition against McDonald’s alleging that occupational duties over 10 years caused his rotator cuff tear. McDonald’s moved to dismiss and argued that petitioner had failed to file within two years from when he knew the nature of his condition and thought that it was due to work. The Judge of Compensation granted the motion, and petitioner appealed.
On appeal, petitioner argued that the two-year statute of limitations should not have run in his case because he did not know he had a rotator cuff tear until 2006. While he did know he had shoulder problems as far back as 2001, he was never told he had a rotator cuff tear. Respondent argued that his condition was simply a progressive one due to tendonitis.
The Appellate Division sided with petitioner. “We agree with the compensation judge that petitioner knew of his prior diagnosis of tendonitis as early as 2001. Even so, we disagree with the compensation judge’s determination that petitioner had sufficient knowledge of a torn rotator cuff, based on previous treatment for tendonitis, to trigger the statute of limitations under N.J.S.A. 34:15-34.”
The Court in this case felt that the statute cannot run on a rotator cuff tear condition via a prior diagnosis of tendonitis because these are two completely different medical conditions. The case is helpful for practitioners in deciding when there is a valid statute of limitations defense. At a minimum, the medical condition at issue must have been diagnosed sometime in the past, and it must be the same medical condition that is presently at issue for the employer to win a statute of limitations defense.
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John H. Geaney, Esq., is an Executive Committee Member and a Shareholder in Capehart Scatchard's Workers’ Compensation Group. Mr. Geaney concentrates his practice in the representation of employers, self-insured companies, third-party administrators, and insurance carriers in workers’ compensation, the Americans with Disabilities Act and Family and Medical Leave Act. Should you have any questions or would like more information, please contact Mr. Geaney at 856.914.2063 or by e‑mail at jgeaney@capehart.com.
Our new Commissioner made some personnel changes at DWC. Barbara Salyers is the new Chief
Deputy. Her stated job duties are management and oversight of DWC operations and liaison with
TDI-Hobby administration and operations. Amy Lee and the Research and Evaluation Group now
report directly to Ms. Salyers. Patricia Gilbert, former Executive Deputy Commissioner for
Operations retired and Joe McElrath is now the Deputy Commissioner for Business Process, a
position similar to that previously held by Ms. Gilbert. Kathy McMaster will serve in a new position
called Deputy Commission of Claims and Customer Services (previously Field Operations). Kristen
Harmon is the new Director of External Relations. It remains to be seen what the impact of all of
these changes will be, but we will continue to keep an eye on things over at the Division.
We think it bears repeating that effective October 1, 2015, the Division is making the transition from
ICD-9 to ICD-10. The Division has a video to help participants with this transition at:
www.tdi.texas.gov/wc/hcprovider/icd10.html. As we mentioned in July, the Division has not
provided guidance on how carriers should process bills submitted with ICD-9 codes for dates of
service after 10-1-15 and has not provided any guidance to stakeholders regarding many issues that
are expected to arise. Hopefully we can update you in September. It could be quite a mess.
The Division education conferences will be held in Austin and Dallas this again this fall. The Austin
conference will be September 18 at the Renaissance Austin Hotel and the Dallas conference will be
October 9 at the Renaissance Dallas-Richardson Hotel. The Division offers continuing education
credit for adjusters. For more see: www.tdi.texas.gov/wc/events/edconference.html.
The short answer? It depends....The California Labor Commission ruled that an Uber driver who
filed a claim against the company was an employee. That ruling was limited to the facts of the
specific case in question, but could have ramifications for Uber drivers nationwide. On the opposite
coast, a New Jersey workers’ compensation judge ruled that a limousine driver in a business not
unlike Uber was an independent contractor. As the nature of the workforce continues to change in
the “gig” economy, many question whether worker protections fashioned for traditional full-time
workers provide adequate protection for the less traditional employment relationships. In Texas,
the real question is whether the company has the right to control the work performed by the
individual in question. There are currently no pending Uber-related cases in Texas. Stay
tuned..........
Charlesetta Jennings worked as a Support Services Assistant (SSA) at Womble Carlyle, a 500 lawyer firm based in North Carolina. Her job required performing a wide variety of tasks, including managing supplies, delivering or picking up packages, copying and scanning documents, setting up conference rooms, filing for receptionists, operating copy and scanning machines, and binding documents.
Jennings took FMLA leave in 2008 when she was diagnosed with breast cancer and intermittent leave during periods of chemotherapy. In November 2009, she noticed tenderness and swelling in her left arm, a condition diagnosed as lymphedema related to the breast cancer treatment. Jennings continued to work but devised ways to avoid doing heavy lifting such as lifting packages or boxes of paper.
In June 2010, Jennings suffered a work injury occasioned by heavy lifting. She was working alone at the Liberty Plaza location of the office and had to tape up and move about 14 boxes weighing 32 to 38 pounds in addition to moving some paper boxes weighing 50 pounds. Her doctor then restricted her to lifting no more than 10 pounds.
The law firm met with Jennings and broke down the duties which Jennings could no longer perform. There were two or three times more duties that she could not perform than the ones she could perform within the 10 pound restriction. She could still copy and scan documents and deliver light weight envelopes as well as fill in for receptionists on breaks. The law firm continued to accommodate her for six months on light duty because it had a large scanning project going on. After the scanning project ended, the law firm could only keep Jennings busy 20% of the time.
On February 1, 2011 Jennings provided an updated doctor’s note allowing her to lift permanently no more than 20 pounds. However, there were still many tasks which Jennings could not perform with a 20 pound restriction. The law firm therefore placed her on a medical leave of absence effective February 9, 2011 and when the leave ran out, the firm terminated her employment in August 2011.
Jennings sued under the ADA and contended that Womble Carlyle failed to make reasonable accommodation. The EEOC brought the suit on behalf of Jennings. The District Court dismissed the law suit, holding that even with reasonable accommodation, Jennings could not lift more than 20 pounds. The Court of Appeals for the Fourth Circuit affirmed.
The Court of Appeals rejected the EEOC’s argument that Womble Carlyle could not consider job tasks that Jennings had not performed for quite some time. It said, “That an employee may typically be assigned to only certain tasks of a multifaceted job ‘does not necessarily mean that those tasks to which she was not assigned are not essential.’” (citations omitted). The Court pointed out that many of the tasks of an SSA required lifting substantially more than 20 pounds. When Jennings had tried to life more than 20 pounds, she had in fact injured herself in 2010.
To be sure, Jennings was able to devise ways to do some tasks, but she remained unable to do many more. She could not work alone at Liberty Plaza or Winston Tower or on Saturdays, assist with office moves, deliver or pick up packages from offsite or among any of the three Womble Carlyle buildings, set up conference rooms, or any of a number of tasks. Thus, even though Jennings’ work-around methods enabled her to perform a small subset of the job’s responsibilities, the ability to lift over 20 pounds was inextricably tied to the vast majority of them.
The Court concluded that Jennings was not a qualified individual under the ADA because she could not perform the essential job functions, even with accommodations. The Court also said it would be unreasonable to require the law firm to reallocate essential functions and noted that the ADA does not require such reallocation. See 29 C.F.R. pt. 1630 app. 1630.2.(o).
This case is helpful for practitioners because it focuses on a fairly common situation where an employer temporarily accommodates an employee for a period of time until permanent restrictions are issued. The mere fact that the employer temporarily made accommodations does not require the employer to permanently make those accommodations if the employee cannot perform the essential functions of the job with or without reasonable accommodation. Nor must the employer ignore other essential functions of the job that the employee has not performed in quite some time. The case may be found atEEOC v. Womble Carlyle Sandridge & Rice, LLP, 31AD Cases 1349 (4th Cir. 2015).
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John H. Geaney, Esq., is an Executive Committee Member and a Shareholder in Capehart Scatchard's Workers’ Compensation Group. Mr. Geaney concentrates his practice in the representation of employers, self-insured companies, third-party administrators, and insurance carriers in workers’ compensation, the Americans with Disabilities Act and Family and Medical Leave Act. Should you have any questions or would like more information, please contact Mr. Geaney at 856.914.2063 or by e‑mail at jgeaney@capehart.com.
On 8/26/15, the Division closed the informal comment period on possible amendments death and
burial benefits rules. The proposed amendments allow eligible spouses of first responders to remain
eligible for death benefits after remarriage and to increase the maximum amount of reimbursement
for burial benefits payable in all workers’ compensation death cases from $6,000 to $10,000. The
changes would apply to injuries occurring on or after 9/1/15. Formal comments will be requested
once the rules are proposed and published in the Texas Register.
The number of doctors on the Division’s Designated Doctor List dropped in the past year from 1008
in July of 2014 to only 699 in July of 2015. Of the 699 still on the list, 250 of those doctors are
medical doctors, 37 are osteopaths and 332 are chiropractors. The number of medical doctors on
the list has dropped by half and the number of chiropractors is down by 129.
One explanation for the drop may be the “new” examination to test designated doctors’ competency
to evaluate MMI and impairment rating, which was implemented on 5/1/13. As that test would not
have been required of doctors on the list on 5/1/13 until the date there credentials expired (every 2
years) many of the doctors on the list were not required to take the test until 5/1/15.
According to many of the doctors, increased regulation and certification requirements without a
corresponding increase in the reimbursement rate paid for designated doctor examinations are
largely responsible for the drop in the number of doctors willing to perform designated doctor
evaluations.
Hopefully the new requirements will result in a smaller number of more qualified doctors. The down side continues to be a drop in the number of qualified doctors willing to travel west of I-35
to perform those examinations.
There is no limit on how much an air ambulance provider (or any other health care provider, for that
matter) can charge for its services or how often it can raise its charges. For example, one of the
largest air ambulance providers in Texas, PHI Air Medical, increased its base rate from $11,492.00
in 2010 to $26,177.00 in 2014, a 128% increase. At the same time, it increased its mileage rate from
$150.00 per mile to $290.00 per mile, an increase of 93%.
However, the lack of any restrictions on a provider’s billed charges is only a problem when it is held
that the provider is entitled to reimbursement of its billed charges. Since January 2014, the Division
has been doing just that, issuing medical fee dispute decisions holding that its medical fee guideline
does not cover air ambulance services and ordering payment of the air ambulance providers’ billed
charges on the grounds that they are “fair and reasonable.”
Many of the Division’s decisions have been appealed to the State Office of Administrative Hearings
(SOAH) where they have been assigned to Administrative Law Judge Craig Bennett. Judge Bennett
consolidated a group of early cases between PHI Air Medical and eight insurance carriers. These
lead cases will determine the legal issues for the remainder of the air ambulance cases pending at
SOAH. James Loughlin with the Firm represents seven of the eight carriers.
Judge Bennett issued a preliminary order on August 5, 2015 announcing his decision that “the
proper reimbursement rate for the air ambulance services in issue is 149% of Medicare.” This is a
great victory for the carriers because Judge Bennett has rejected the Division’s position that PHI’s
billed charges are fair and reasonable, he has concluded that reimbursement should be Medicarebased,
i.e., a percentage of the Medicare rate, and he has picked a percentage which is not much
higher in dollar terms than 125% of Medicare.
The carriers paid PHI at 125% of the Medicare rate based on their understanding that the Division's
fee guideline applies to ambulance services. The difference between the 125% paid by the carriers
and the 149% determined by Judge Bennett to be fair and reasonable is less than 13% of the amount
sought by PHI which was based on its claim that it is entitled to reimbursement of its billed charges.
Judge Bennett's decision and order which will explain his reasoning in detail is expected by the
second week of September. PHI's counsel has already indicated that PHI intends to appeal Judge
Bennett's decision to district court. Judge Bennett previously rejected PHI's argument that the
federal Airline Deregulation Act preempts Texas' workers' compensation laws governing
reimbursement to health care providers from being applied to it. This issue has national implications
for PHI.
The carriers will likely cross-appeal Judge Bennett's decision on the grounds that the fee guideline
applies and 125% is more than fair and reasonable. The carriers presented compelling, unrebutted
evidence at hearing that 125% is more than fair and reasonable. The sticking point on appeal may
boil down to the legal issue of whether the statutory standards for fair and reasonable
reimbursement, if properly interpreted, guarantee health care providers a profit.
Judge Bennett's decision will hopefully encourage the Division to move quickly to adopt a fee
guideline for ambulance services. Air ambulance fee disputes will continue to pile up at the
Division until it does so. Judge Bennett's decision will hopefully also cause the Division to
reconsider its approach to these disputes of ordering payment of the air ambulance providers’ billed
charges.
Florida Appellate Court Overturns Circuit Court’s
Prior Declaration that the Exclusive Remedy Provision of the Workers
Compensation Act Is Unconstitutional
In our report from June, 2015 we discussed the order of a trial judge declaring Florida’s workers’ compensation law in its entirety (Chapter 440, Florida Statutes) to be unconstitutional so long as §440.11, Florida’s exclusive remedy provision, remained a constituent part of the law as a whole. We are pleased to report that our Third District Court of Appeal reversed the final summary judgment declaring the unconstitutionality on two bases. First, the appellate court found that procedurally the original case was moot secondary to the employer/carrier’s dismissal of its own affirmative defense of workers’ compensation immunity. Second, the appellate court found substantively that “the trial court lacked a justiciable case or controversy within which to determine, and the [various groups seeking the decimation of exclusive remedy] lacked standing to assert, that the challenged provisions of the Florida Workers’ Compensation Law are unconstitutional.”
Subsequent to the Third District’s opinion, which can be found on Westlaw at 2015 WL 3875442, the advocates in favor of unconstitutionality filed a notice of discretionary jurisdiction with the Florida Supreme Court on July 7, 2015 and the same was acknowledged by the Court on July 10, 2015. A motion by the advocates to stay the Third District’s opinion pending further review was denied by the Florida Supreme Court on July 22, 2015. As of this update, there has been no indication from the Court whether it will accept discretionary jurisdiction.
Florida’s Attorney’s Fee
Structure Ruled to be Non-Cumulative
The well-known battles over the changes to Florida’s workers’ compensation attorney fee statute that began in 2003 have spawned a seemingly endless array of strategic challenges. One such challenge was unique in that it was not the result of efforts by the claimants’ bar like those we have previously reported. Rather, it was a judge of compensation claims’ interpretation of our fee provision. Distilled to its essence, Florida allows claimant attorneys to be paid a fee equal to 20% of the first $5,000 in benefits secured, 15% of the second $5,000 in benefits, and then 10% of all benefits afterward. The judge of compensation claims ruled that the 20% and 15% fee payments could only be secured by a claimant attorney once, and not each time a claim was filed. InCortes-Martinez v. Palmetto Vegetable Co., LLC, 159 So.3d 934 (Fla. 1st DCA 2015), the First District Court of Appeal reversed the judge of compensation claims, essentially finding that there were constitutional implications flowing from such a determination and thus declaring that the avoidance of a constitutional issue was paramount. Accordingly, the 20/15/10 structure applies to each distinct set of claims. See alsoUrguelles v. El Oasis Café, 162 So.3d 1057 (Fla. 1st DCA 2015).
Medical Care After Maximum Medical
Improvement Still Requires Proof of Medical Necessity
That palliative care remains available to a claimant after reaching maximum medical improvement is well established in Florida. See, e.g.,Homler v. Family Auto Mart, 914 So.2d 1071 (Fla. 1st DCA 2005). However, in the recent case ofEchevarrria v. Luxor Investments, LLC, 159 So.3d 991 (Fla. 1st DCA 2015), the First District Court of Appeal ruled that the claimant must still establish by evidence that the palliative treatment is medically necessary, i.e. “medical service or medical supply which is used to... or treat an illness or injury, is appropriate to the patient’s diagnosis and status of recovery, and is consistent with the location of service, the level of care provided, and applicable practice parameters. The service should be widely accepted among practicing health care providers, based on scientific criteria, and determined to be reasonably safe. The service must not be of an experimental, investigative, or research nature.”The confirmation that medical necessity remains a required element for post-maximum medical improvement care is important in light of the fact that a zero impairment rating seems fundamentally at odds with any further need for medical treatment.
First District Court of Appeal Takes On Gamesmanship
Florida workers’ compensation law allows a claimant to secure a single one-time change of physicians pursuant to Florida Statute §440.13(2)(f). Provided that the employer/carrier responds to that request within 5 days after receipt of the request, the employer/carrier gets to choose the physician for claimant’s one-time change. If they do not timely respond, claimant gets to choose who the new physician will be. InGonzalez v. Quinco Electrical, Inc., 2015 WL 4256794 (Fla. 1st DCA 2015) (presently not released for publication in permanent law reports), the First District Court of Appeal addressed the issue of gamesmanship involving a one-time change request. According to the appellate opinion, claimant’s counsel first officially appeared of record via a petition for benefits. Three weeks later he filed a “Notice of Appearance.” The petition for benefits did not mention anything about wanting a one-time change. The Notice of Appearance, however, was described by the court as having, on the second page of the notice, “a request for a one-time change of treating physician pursuant to section 440.13(2)(f).” The court also noted that [c]ounsel admitted before the [judge of compensation claims] that he “took advantage of” his belief that adjusters do not always read in full every document they receive. Counsel for the employer/carrier did not catch the one-time change request until the sixth day after the Notice of Appearance was received. The judge of compensation claims rejected the assertion that the employer/carrier was late in responding given the circumstances. The First District noted that such gamesmanship is contrary to the legislative mandate of a self-executing system and rather firmly addressed the conduct in question.
Castellanos & Westphal
No decision from the Florida Supreme Court on either case. In Castellanos claimant’s appellate counsel continues to file Notices of Supplemental Authority in what is most likely an effort to push their agenda. InWestphal a single Notice of Supplemental Authority has been filed in 2015. Otherwise, there is no discernible activity.