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NWCDN is a network of law firms dedicated to protecting employers in workers’ compensation claims.


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.


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Michael Savio was injured on a job site on June 1, 2006.  He stated that he worked for Matthew Giambri for four weeks on two job sites, pouring concrete on one site, and doing plumbing work on the other site.  Giambri paid him $150 per day to pour concrete; otherwise, he paid him $100 to $125 per day.

On the day of the accident, Giambri picked up Savio from his home and drove him to a job site.  His job that day was to tear off siding on a home.  Savio testified that Giambri pointed out what he had to do and then left.  He said he had his own tools but there was no evidence that he used them on the job site.  He brought no materials with him as everything he needed was there.

After Savio removed the siding, he descended from a ladder which broke, causing Savio to fall two-and-a-half stories and injure his spine.  He treated for four years for the injury and was never able to resume construction work.  Petitioner filed a petition asserting that he was employed by Giambri, and his employer asserted that he was an independent contractor or a casual employee and therefore not protected by workers’ compensation laws.

The Judge of Compensation and the Appellate Division found that petitioner was an employee.  The opinion of the Appellate Division is interesting because the court reviewed 12 factors outlined in the case of Estate of Kotsovska, ex rel. Kotsovska v. Liebman, 221 N.J. 568 (2015).

§  The first factor is the employer’s right to control the means and manner of work performance. The court found that there was evidence that Giambri provided instruction in what to do and how to remove the siding, as well as materials to do the job. The court felt it insignificant that Giambri left the work site while the siding was removed. The court also said that the “control” factor carries less weight than other factors;

§  The court felt that the second and third factors had minimal significance in this case. They involve supervision necessary over the job and skills to perform the job.  The court agreed with the Judge of Compensation that Savio had the skills and required little direction;

§  The fourth factor pertains to who furnishes equipment, and this was clearly in Savio’s favor;

§  The fifth factor involves the length of time a worker performs duties for the alleged employer. In this case the court felt that four weeks was sufficient.

§  The sixth factor relates to the method used to pay the alleged employee. Here Savio was paid by cash or personal check, and Gambri gave him a W-2 form at the end of the year.  This also favored employment;

§  The seventh factor focuses on the manner in which the work relationship terminated. In this case the petitioner could not return to work because of his injury.

§  The eighth, tenth, and eleventh factors pertain to benefits: annual leave, retirement benefits, and payment of Social Security taxes.  There was no evidence in this case regarding these factors.

§  The ninth factor focuses on whether the alleged employee’s work is an integral part of the employer’s business. “Here, the judge found Giambri was a contractor who employed laborers to perform services on his behalf and, thus, the work Savio performed was an integral part of Giambri’s business.”

§  Lastly, the twelfth factor examines the intentions of the parties. The Appellate Division believed that there was a relationship consistent with an employer and employee, even if there was no documentation expressing intention.

The Appellate Division felt that the vast majority of these factors favored employment status and affirmed the decision of the Judge of Compensation.  The case is very helpful in resolving disputes of this nature by providing a framework to analyze similar situations.   It can be found at Savio v. GiambriA-0701-15T1 (App. Div. July 12, 2017).


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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.

 

The Minnesota Supreme Court reversed a decision by the WCCA, and held that the WCCA erred when it found that an expert opinion lacked adequate foundation.

In this case, Debra Mattick (“Employee”) sustained a non-work-related injury to her right ankle in 2000. She underwent two surgeries, and eventually was able to engage in recreational activities including sand volleyball and biking. She was diagnosed with post-traumatic arthritis, and had periodic pain. She returned to work as a cake decorator at Hy-Vee in 2001, working 40-45 hours per week. In 2004, the Employee tripped over a pallet while working at Hy-Vee and twisted her right ankle. She filed a workers’ compensation claim seeking reimbursement for an ankle-fusion surgery. At the Hearing, the compensation judge denied the Employee’s claim for surgery and found that the injury was temporary and had fully resolved. The judge relied on the expert opinion of Dr. Fey and concluded that neither the Employee’s medical records nor the opinions of her treating physicians supported her claim.

The case was appealed to the WCCA, which reversed the compensation judge’s decision and concluded that Dr. Fey’s report lacked adequate factual foundation. The WCCA found that Dr. Fey’s report was suspect, including his discussion of the Employee’s arthritis condition and ankle sprain, and well as his failure to note a 10-year gap in the Employee’s symptoms. Due to this, they found the report to be lacking in adequate foundation.

The Minnesota Supreme Court reversed the WCCA’s decision and reinstated the findings of the compensation judge. The Supreme Court noted that an expert opinion lacks foundation when (1) the opinion does not include the facts and/or data upon which the expert relied in forming the opinion, (2) it does not explain the basis for the opinion, or (3) the facts assumed by the expert in rendering an opinion are not supported by the evidence. Hudson v. Trillium Staffing, 2017 WL 2458132 (Minn. June 7, 2017). The Supreme Court, however, analyzed Dr. Fey’s report based on these factors and found that the report clearly recounted and analyzed the specifics of the Employee’s injuries before opining on the potential aggravation of her arthritis in her ankle, and it was adequately supported by factual foundation. A few statements in the report taken out of context is not enough to discredit the entire report. In conclusion, the Supreme Court found that the WCCA erred, and that the compensation judge properly relied on Dr. Fey’s report.

As the takeaway, the Minnesota Supreme Court reiterated the WCCA’s appellate standard of review under Hengemuhle for the past three decades: the WCCA exceeds its scope of review when it rejects a Compensation Judge’s findings that are supported by substantial evidence and substitutes its own findings.

The case Mattick v. Hy-Vee Foods Stores, A16-1802 and can be found here: http://www.mncourts.gov/mncourtsgov/media/Appellate/Supreme%20Court/Standard%20Opinions/OPA161802-071217.pdf

The issue of independent contractor versus employer has been litigated in South Dakota. There is a presumption that the worker was an employee and it is the employer’s burden to establish the worker is an independent contractor. The Department of Labor and the South Dakota Supreme Court have provided a set of factors to consider when determining whether a worker is an independent contractor or an employee.

The following factors have been used by the Department of Labor as considerations when determining whether a worker is an independent contractor or employee:

1. The extent of control which, by the agreement, the master may exercise over the details of the work;

1. One must look at whether the employer has the ability to hire, fire, and lay off the worker. It is also important how much control the master has over the workers’ functions.

2. Whether the one employee is engaged in a distinct occupation or business.

1. Here it is important to see whether the worker operated a separate business or under a separate trade name. It is also important whether the worker worked solely for this master, on a full time basis.

3. The kind of occupation with reference to, in the locality, the work is usually done under the direction of the employer or by a specialist without supervision.

4. The skill required for that particular occupation.

5. Whether the employer or the workman supplies the instrumentalities, tools, and the place of work for the person doing the work;

1. Here, “when the employer furnishes valuable equipment, the relationship is almost invariably that of employment.” SeeLarson on Worker’s Compensation §44.43(a).

6. The length of time for which the person is employed.

7. The method of payment, whether by the job or by the hour.

8. Whether the work is part of the regular business of the employer.

9. Whether the parties believe they are creating the relationship of master and servant.

The South Dakota Supreme Court has essentially adopted these factors although it has grouped certain factors into a two-part test. InEgemo v. Flores, 470 NW2d 817 (SD 1991) the employer argued the servant was an independent contractor. The court noted there was an important distinction as an independent contractor is not covered by workers’ compensation. The court stated there is a two factor test: (1) whether the individual has been and will continue to be free from control or direction over the performance of the services, both under contract or service and fact, and (2) whether the individual is customarily engaged in an independently established trade, occupation, profession or business.

In evaluating the “right of control test” the important considerations include direct evidence of the right of control, the method of payment, furnishing major items of equipment, and the right to terminate the employment relationship at will and without liability. In Egemo, the court noted the employer did not exercise control or supervision over the method or manner in which the servant completed his task. Furthermore, the master did not direct the hours of work, breaks, or even the days off. The court also noted the servant did not withhold any amounts for income tax, social security, or unemployment insurance. The employer also filed a Form 1099 as a non-employee compensation form. The court noted the servant was required to supply all of his own tools, and his own maintenance and transportation to the work sites. Furthermore, the employment relationship could not be terminated without liability.

The significant considerations in the test of “independently established trade” are that:

The requirement that the employee’s occupation be independently established and that he be customarily engaged and it calls for an enterprise created and existing separate and apart from the relationship with the particular employer; an enterprise that will survive the determination of that relationship. The individual must have a proprietary interest in the enterprise to the extent that he can operate without hindrance from any other individual.

However, it is not skill alone which determines whether an individual is established in a trade or business, but whether that individual by reason of such skill engages himself in an economic enterprise such that he bears the risk of his own unemployment. Whether or not he is unemployed is solely a function of market forces and a demand for skills, not the response of his master to similar economic realities.

The South Dakota legislature has also addressed this issue and stated the difference between an employer and an independent contractor in SDCL 61-1-11. That statute states “service performed by an individual for wages is employment subject to this title unless and until it is shown to the satisfaction of the Department of Labor that: (1) the individual has and will continue to be free from control or direction over the performance of the service, both under his contract of service and in fact; and (2) the individual is customarily engaged in an independently established trade, occupation, profession, or business. The South Dakota legislature defined employee in SDCL 62-1-3 for the purposes of worker’s compensation. The definition is roughly the same as that set forth above.

Roy Hendrickson worked for thirty years at UPS.  His first 19 years were as a package car driver making over 100 stops per day to deliver or pick up packages.  He injured his back in 1992 but did not file a workers’ compensation claim.   In 2002 he injured his back lifting a heavy package, losing two months of work time.  He was diagnosed with sprains, degenerative disc disease and stenosis.  He received an award of 15% permanent partial disability.   He reopened that claim in 2004, settling for 17.5% credit 15% for the prior award.

In 2006 Hendrickson began working as a feeder driver for UPS, driving tractor-trailers to New York City, the Meadowlands, Secaucus, Cranbury and locations in New England.  He drove trucks without air ride suspensions, testifying that he felt shocks and vibrations over pot-hole ridden roads.  He said this activity caused additional pain in his low back, requiring acupuncture treatment.

In 2008 Hendrickson also began working as a shifter driver, which required backing the truck into a trailer and “hitting the pin” to connect the two.   He testified that every time he made the connection, around 75 times per day, there was an impact such that he felt as though he were being punched in the back.

In 2012 Hendrickson was at a mall and collapsed due to pain and numbness radiating down his legs from his low back.  His chiropractor sent him for an MRI in August 2013, which showed herniated discs at L3-4 and L4-5 along with severe stenosis.  His chiropractor refused to treat him after the MRI study, so Hendrickson saw a surgeon who recommended bilateral nerve blocks.  When that failed to relieve his pain, Hendrickson opted for surgery in March 2014 to decompress the disc at L4-5.  The surgery provided three months’ relief, but a repeat MRI showed persistent disc herniation at L4-5 with impingement on the L5 nerve root.  Hendrickson said he continued to work in pain but avoided any non-work activities that might increase his pain.

Hendrickson filed a Claim Petition and a Motion for Medical and Temporary Disability Benefits, asserting that UPS should pay for his back surgery and lost wages based on occupational injuries over the years.  UPS opposed the motion and argued that the claim was time barred because the back problems stemmed from the 2002 trauma.  That claim had not been reopened but once, concluding many years ago.

Petitioner produced testimony from Dr. Michael Cohen, who contended that petitioner’s back problems were not the result of trauma suffered in 2002 but rather repetitive occupational stress over the years.   Dr. Nirav Shah on behalf of UPS testified that petitioner suffered an injury to his back on April 16, 2014 from lifting packages.  However, the record did not support Dr. Shah’s assertion that there was a work accident on April 16, 2014.   Dr. Shah testified that petitioner’s back revealed multiple herniations that were the result of chronic degenerative changes in the spine.  He said these changes progressed naturally, not from repetitive occupational exposures.

The Judge of Compensation found Dr. Cohen to be more persuasive than Dr. Shah.  The judge credited petitioner’s testimony that the 2006 transfer to feeder and shifter work worsened his spine condition.  The judge noted that petitioner frequently bounced around in his truck when driving over potholes or bumps in the road.   The judge further noted that the action of hitting the pin in connecting vehicles created a sensation of petitioner being hit in the low back.  He found Dr. Cohen credible in explaining how driving a tractor trailer objectively worsened petitioner’s low back.   The Judge found Dr. Shah less than credible because in part Dr. Shah mistakenly believed there was a 2014 traumatic accident.  The judge found that there was aggravation and acceleration of petitioner’s spine from 2006 to 2013 caused by work.

UPS appealed and argued again that petitioner’s claim petition was barred by the statute of limitations because everything went back to 2002 accident.  The legal argument was interesting, pitting two major case precedents against each other.  UPS argued that this was like the case of Peterson v. Hermann Forwarding Co., 267 N.J. Super. 493 (App. Div. 1993), certif. denied, 135 N.J. 304 (1994).  In that case a trauma occurred to a truck driver, whose back got progressively worse after the next five brief trucking jobs he worked, eventually leading to total disability.  The Appellate Division placed responsibility in that case on the first employer with the traumatic event, stating that there was no objective proof of worsening over the next five employments.  All of the occupational claims were dismissed.

Petitioner relied on the case of Singletary v. WAWA, 406 N.J. Super. 558 (App. Div. 2009).   The rule in that case was that “Very short periods of employment . . . may allow no reasonable inference of material contribution to disability. In contrast, long periods of physically taxing employment, such as the five years Singletary worked at WAWA after her December 2001 accident, may reasonably support a finding of material contribution of disability.”  The Appellate Division disagreed with UPS and concluded that petitioner’s occupational exposure was largely responsible for causing petitioner’s medical issues.  Counsel for Hendrickson, Mr. Richard Schibell, Esq., contended that petitioner’s back pain progressively worsened over the years due to ongoing stressors at work, and that there was no statute of limitations issue since petitioner was still being exposed to occupational injuries when he filed the claim petition.

The case can be found at Hendrickson v. UPS, A-3627-15T2 (App. Div. July 11, 2017).  The case shows how an occupational orthopedic disease claim must be proved in order to prevail in workers’ compensation.  There must be detailed testimony by the employee or co-employees of credible physical stressors, and then credible medical testimony linking those physical stressors to the medical condition afflicting the claimant.

 

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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. 


The moment all of you have been waiting for….
The fifth prong of the five-part test provides: The employee must actually pursue the reasonable program of rehabilitation.
This part likely seems pretty self-explanatory, and, frankly, it is. If the Claimant can satisfy all of the other elements of the retraining benefits test, then he/she needs to actually pursue the reasonable program of rehabilitation in order to receive the benefits. How the retraining benefits work is that the Claimant is given their workers’ compensation indemnity benefit payment during the period of time that they are in the rehabilitation program. Accordingly, it seems quite clear that they need to actually pursue that program. SDCL 62–4–5.1 specifically allows rehabilitation benefits while a claimant is “engaged in a program of rehabilitation which is reasonably necessary to restore the employee to suitable, substantial and gainful employment.” This statute allows rehabilitation benefits while the claimant is engaged in a “program” of rehabilitation, not simply a “period” of rehabilitation. Chiolis v. Lage Development Co., 512 N.W.2d 158, 160 (SD 1994).
The rehabilitation program may be a two-year program or a four-year program, depending on what is determined to be a “reasonable means of rehabilitation” and a four-year program although more rare, can be reasonable in certain situations. See A. Larson, The Law of Worker’s Compensation § 61.22 (1992). The fifth part of the rehabilitation test is not complicated, but it is necessary in order for the Claimant to be entitled to the benefits. A Claimant cannot simply find a suitable rehabilitation program and receive the rehabilitation benefits without actually pursuing the program.
I imagine that all of you will undergo a brief grieving process now that this 5-part series is over, but rest assured that we will continue to provide everyone with up-to-date information on the changes you need to know about in South Dakota workers’ compensation and employment law. Until next time.

In a surprising but unreported decision, the Appellate Division affirmed an award to a police officer who fell in the municipal parking lot on December 9, 2011 on a day when he was not supposed to be at work.  The officer said he came to work to collect his paycheck and also to check his court schedule while he was there.  The case is Grawehr v. Township of East Hanover, A-1686-15T3 (App. Div. June 29, 2017).

The accident involved a slip and fall on ice which led to shoulder surgery.  The Township denied the claim since petitioner was not working that day, and no one asked him to come to work.  The petitioner admitted that he was coming to work to get his paycheck, but he said that he also wanted to check his personal folder for any new subpoenas for scheduled court dates.  There had been problems with police officers missing scheduled appearances due to a recent merger with the Township of Hanover. A township Lieutenant testified that it was not uncommon for the more diligent officers to come in on their days off to check on their court files.

Even though Officer Grawehr never failed to appear for court and had not been disciplined (unlike others) for failing to come to court, and even though the next court date was not until December 22, the Judge of Compensation found for petitioner and awarded petitioner 27.5% or $41,187 for permanency and medical expenses. The Appellate Division affirmed. The theory of compensability in this case was the existence of a mutual benefit to the Township and the employee by these impromptu visits to the police department on days off.  The Township denied that there was any benefit to it at all.

The “mutual benefit” theory has been questioned as recently as May 1, 2017 in Liu v. 4D Security Solutions, Inc.A-3591-15T1 (App. Div. May 1, 2017).  In that similarly unpublished case a different appellate panel found that the mutual benefit doctrine did not survive the 1980 amendments.  That appellate panel rejected the doctrine completely just one month before this decision.  The decision in Grawehr makes no mention of the Liu decision.

In Grawehr, the Appellate Division struggled mightily to find case law supporting the existence of a mutual benefit doctrine.  The only case it cited was a pre-1980 case called Salierno v. Micro Stamping Co., 136 N.J. Super. 172 (App. Div. 1975), where a heart attack experienced by a worker during contract negotiations on behalf of his union was found to be compensable.   That case is not really a mutual benefit decision, and it would likely not meet the current law dealing with the requirements for compensability of heart attacks.  In essence, the panel in Grawehr assumed the existence of the mutual benefit doctrine even though the issue was whether it exists at all.

It is clear that an injury that occurs when an employee comes into work simply to pick up a paycheck is not compensable.  Miller v. Saker Shoprite, A-3746-13T2 (App. Div. November 13, 2015).  In this practitioner’s opinion, the Grawehr decision is open to criticism because the appellate panel never really found a case that supported the existence post 1980 of the mutual benefit doctrine in New Jersey.  Interestingly, neither could the appellate panel in Liu cited above.  This practitioner is aware of only two reported post-1980 decisions where the court based its decision on the existence of the mutual benefit doctrine.  One case was Daus v. Marble, 270 N.J. Super. 241 (App. Div. 1994) and the other was Mahon v. Reilly’s Radio Cabs, Inc., 211 N.J. Super. 28 (App. Div. 1986).  These cases were not mentioned in this matter or in Liu.  We will need clarification from a future reported appellate division panel or the Supreme Court on whether the mutual benefit doctrine, as applied to trips to and from work, still exists – or exists in any other context.

This case illustrates the problem inherent in the mutual benefit doctrine when it is applied to cases involving trips to work on non-work days.  The doctrine can be interpreted so broadly that it can create a massive end-around to the requirement that all accidents must meet the test of “in the course of employment.”  Anyone who comes into work to retrieve something and falls at work after hours or on days off can argue that there was a mutual benefit conferred on the employer by coming to work.  Do both parties have to agree that there was a benefit?  The township said there was no benefit in this case.  It is an extremely subjective test.  The obvious reason the claimant was coming to work in this case was to pick up his paycheck.  But that activity alone is not compensable.  Further, the next court date was 13 days away, so the decision in favor of compensability makes very little sense under any analysis.

                                                     

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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. 

Beginning July 1, 2017, the maximum workers’ compensation payable in Alabama was raised to $843.00 per week and the minimum was raised to $232.00 per week.

By: Brad Inman

Although overshadowed by the Wilkes v. City of Greenville opinion issued the same day, the N.C. Supreme Court came to a decision on another workers’ compensation matter last month.  While not as significant as Wilkes in terms of future claim handling (at least until subsequent legislation takes effect), the decision in Harrison v. Gemma Power Sys., LLC did provide some insight on how the courts look at issues such as statute of limitations and permanent impairment.   Harrison is also a good reminder of how litigation can often take years to wind its way through the system, an often overlooked factor in the early decision-making and settlement process.

The plaintiff in Harrison suffered a compensable neck injury and was quickly released without restrictions in 2001 after the treating doctor found no permanent impairment.   Defendants continued to authorize treatment over the ensuing years, including two independent medical examinations.  By 2009, defendants determined that the effects of the accident had subsided, and they refused to provide additional medical treatment after an MRI referral.

The case turned into a procedural quagmire, replete with technical arguments and what the courts determined to be deficient findings of fact.  After remands and new decisions, the case ended up at the Court of Appeals twice before the N.C. Supreme Court heard the matter.  From a risk handling perspective, the key takeaways are as follows:

  1. Even if an employee continues authorized treatment and later obtains work restrictions, when two years goes by from the last payment of medical compensation in a medical-only claim, the employee is then time barred from receiving indemnity benefits.
  2. Plaintiffs are eligible for permanent impairment compensation regardless of whether they suffered a loss of wage-earning capacity.
  3. If a plaintiff receives an early determination that no permanent impairment is found, this opinion is not conclusive as subsequent treatment could indicate that impairment is indeed warranted.
  4. However, work restrictions placed on an employee many years after an accident do not necessarily indicate a compensable impairment unless the restrictions are deemed to relate back to the accident.

After reviewing and attempting to reconcile the previous findings of fact and conclusions of law, the N.C. Supreme Court remanded the Harrison case so that the Industrial Commission could more adequately address whether plaintiff retains any compensable permanent impairment.  Closure is thus still forthcoming.  Even though no ground-breaking law has been established, the case does highlight that the time it takes for a party to obtain relief is often out of their control once a case moves into litigation mode.

Part four of the five-part test states that an employee must file a claim with his employer requesting the benefits in order to be entitled to the same. The South Dakota Supreme Court, in Chiolis v. Lage Dev. Co., 512 N.W.2d 158, 161-162 (S.D. 1994), stated:

“Even recognizing that the primary purpose of rehabilitation benefits is to restore the injured employee to substantial and gainful employment, the worker may not unilaterally decide what training he or she may want to pursue and proceed to do so at the employer’s expense. To approve such an independent approach to rehabilitation training by a claimant would result in untold administrative and economic chaos and a total breakdown of the legislatively intended benefits to the injured worker of rehabilitation training. While such self-improvement is highly laudable, particularly in view of the claimant’s independent quest for it, unaided by the employer or carrier, it is outside the range of benefits provided by South Dakota law. To approve a procedure which allows an injured employee to select a rehabilitation program before petitioning Department or reaching an agreement with the employer would be putting the cart before the horse.”

The Court in Chilois denied retraining benefits, in part, due to the claimant’s unilateral decision to enter into a rehabilitation program.

The Department addressed a similar factual scenario in Shellie Holvig v. Rent-a-Center and Specialty Risk Services, HF No. 130, 2004/05, when the claimant therein moved to Phoenix and began her retraining program without alerting her employer and insurer of the same. The Department held that the acts of the claimant deprived her employer and insurer or a reasonable opportunity to evaluate her vocational situation properly and demonstrate the necessity of element four of the retraining test. Id. at 6. The Department also noted that the claimant had decided long before the denial to assume financial responsibility for her bachelor’s degree, and that there was no evidence that employer and insurer therein led the claimant to believe she would receive benefits for the program and she took no actions to her detriment based on any actions of the employer and insurer. Id.

All seemed pretty clear on this issue until Koval v. City of Aberdeen and SDML Workers’ Compensation Fund, HF No. 142, 2014/15. In Koval, the claimant had completed his claimed retraining program before petitioning or otherwise requesting retraining benefits from the Employer/Provider. On a motion for summary judgment, the Department stated:

“However, there is nothing in SDCL 62-4-5.1 or the five part test established by the Supreme Court which dictates when such a claim must be made. It is merely required that a claim be made. That such a claim could later be denied is merely a risk the Claimant makes by not getting preapproval. “A claimant may enroll in a rehabilitation program without the consent of employer, but he does so at his own risk; that is, rehabilitation benefits will not be guaranteed for a particular program simply because the program is one the claimant wishes to pursue.” Kurtenbach v. Frito-Lay, 1997 S.D. 66, ¶ 23, 563 N.W. 2d 869, 875. “It is [claimant’s] right to seek a college education, but [employer] cannot be compelled to pay for such a program if it is not necessary.” Chiolis v. Large Dev. Co., 512 N.W.2d 158, 161 (S.D. 1994) (emphasis added) (quoting Cozine v. Midwest Coast Transport Inc., 454 N.W.2d 548, 554 (S.D. 1990)).

Pursuing a rehabilitation program without first filing a claim and receiving approval does not guarantee the receipt of benefits. However, not seeking preapproval does not preclude the application of the rest of the test to establish if claimant is entitled to the rehabilitation benefits. Therefore, since Claimant’s claim satisfactorily fulfills step four of the test, and Claimant and Employer disagree on his fulfillment of the rest of the five-part test requirements, issues of material fact remain regarding Claimant’s petition for retraining benefits.”

The Koval decision was settled before hearing and consequently there have been no appeals from this curious decision that clearly allows a claimant, contrary to Chiolis, to “…put the cart before the horse”.

 

Board Rules that Medical Treatment Guidelines Apply to Out-of-State Treatment

 

In Hospice, Inc. (WCB Case No. 5951 3410, 5/24/17), a Board Panel ruled that the New York State Medical Treatment Guidelines (“MTGs”) apply to treatment rendered to a claimant residing out-of-state by an out-of-state provider. This represents a significant departure by the Board from its prior decisions on this issue.

The claimant in Hospice lived in Nevada and sought treatment from a Nevada provider. The carrier filed a C-8.1B to the bill for this treatment, arguing that the treatment provided was not based upon a correct application of the MTGs because the provider billed for medications not approved under the MTGs. The WCLJ found the C-8.1B in favor of the provider and the carrier filed an Application for Board Review.

The Board reversed and ruled in the carrier’s favor, noting that even though it previously held that a nonresident claimant seeking treatment out-of-state was not bound by the MTGs, it was now disavowing and departing from such prior Board Panel decisions and ruling that the MTGs apply regardless of where or by whom the treatment is rendered. The Board’s decision was based on its reading of the Court of Appeals decision inKigin v. State of New York Worker’s Compensation Board, 24 N.Y.3d 459 (2014).

The Board also held that the variance process applies to out-of-state providers but that out-of-state providers are not required to use the Board’s forms (i.e, MG-1, MG-2 and C-4AUTH). Use of the forms is preferred but not a basis to deny treatment.

 

Board Issues New C-240: Employer’s Statement of Wage Earnings Form

 

On 6/19/17, the Board issued Subject Number 046-949, which introduced a substantially revisedC-240 form (Employer’s Statement of Wage Earnings) to the workers’ compensation community. The Subject Number provided additional guidance regarding the phrase “a substantial part of the year” in determining whether a similar worker payroll should be used. Significantly, the Subject Number and new C-240 form suggest that it is now permissible for an employer to attach payroll information in lieu of completing the payroll tables on the second page of the form.

 

Appellate Division Clarifies Calculation of End Date of Carrier’s “Holiday” Credit in Third-Party Action Cases

 

On 6/1/17, the Appellate Division, Third Department, decided Lala v. Site Works Contracting Corp. At issue was how the end date for a carrier’s third-party action holiday should be calculated for cases involvingBurns payments for the carrier’s equitably apportioned share of the third-party action litigation expenses.

The claimant inLala settled his third-party action for $100,000.00 on 3/11/11.  He received a net recovery of $64,541.51.  The Board awarded him $500.00 per week for indemnity.  Of that amount, 35.46% ($177.30 per week) constituted the carrier’sBurns payment, with the remaining $322.70 directly credited to the third-party action holiday.

The Board held that the credit expired on 8/20/13. In calculating this date, the WCLJ used the $322.70 portion of the carrier’ credit and also the $177.30 Burns payment, meaning the full $500.00 per week was deducted from the $64,541.51 credit. On appeal to the Appellate Division, the carrier argued that only its $322.70 per week share should be deducted from the credit and that the $177.30 per week Burns payment should not be deducted from the credit. If this method were used, its credit would not expire until 1/6/15. The claimant and the Board argued that the full $500.00 per week should be deducted from the credit when calculating the exhaustion date.

Citing Kelly v. State Insurance Fund, Burns v. Varriale, and Stenson v. New York State Department of Transportation, the Appellate Division held that in the absence of a specific provision to the contrary in the carrier’s settlement consent letter, the appropriate manner for calculating the credit exhaustion is to include both the amount ofBurns payment and the carrier’s share of the awards in the weekly deductions from the net third-party action recovery when indemnity awards are payable to the claimant. In other words, the appropriate deduction from the carrier’s credit was $500.00 per week, not $322.70 per week. The Court explained that under the Court of Appeals precedent governing equitable apportionment of third-party action litigation expenses, the carrier’s share of litigation expenses is based on the total benefit derived from the third-party action recovery. Because Burns payments are a pay-as-you-go method of repaying the claimant’s third-party action litigation expenses, allowing the carrier to deduct only its weekly share of the net recovery from the amount of the third-party action credit would create a double recovery to the carrier because the Burns payments are supposed to reimburse the claimant for the costs incurred in obtaining the third-party action recovery.

The Appellate Division’s use of the phrase “in the absence of a specific provision to the contrary” should serve as a reminder to all parties of the importance of careful drafting of consent letters to third-party settlements due to the scrutiny given to them by the Board and the Courts.

 

Appellate Division Allows Claimant to Receive Two 100% SLU Awards for the Same Injury

 

On 5/25/17, the Appellate Division, Third Department decided Deck v. Dorr, holding that a claimant can receive a 100% schedule loss of use award for the thumb and a separate 100% schedule loss of use award for the same hand at the same time as long as there are distinct separate injuries to the thumb and the rest of claimant’s fingers.

Claimant lost all four fingers when his hand became stuck in a meat grinder.  The grinder also amputated his thumb, but doctors were able to reattach a portion of the thumb to his hand.  The thumb was half the size of claimant’s thumb on the opposite hand and had no pinching ability.  The parties stipulated to a 100% schedule loss of use award for the hand based on claimant’s loss of all four fingers, and litigated claimant’s eligibility for a separate 100% schedule loss of use award for the thumb.  Uncontradicted medical testimony stated that the Disability Guidelines allow for more than 100% loss of use for a hand under certain circumstances.  The Board awarded claimant the 100% loss of use for his hand and a separate 100% loss of use for the thumb, stating that claimant sustained distinct injuries to his four fingers and his thumb, and that the separate injuries had differing impacts on the functionality of his hand.  Based on this, the Board concluded that distinct loss of use awards for the four fingers (which translates into a 100% loss of use of the hand), and the thumb was appropriate.

On appeal, the carrier argued that the injuries to the fingers and thumb should be subsumed into a 100% schedule loss of use for the hand with no additional award. The Court disagreed, citing precedent from the New York State Court of Appeals, New York’s highest appellate court, and Appellate Division precedent holding that when a claimant has multiple injuries to different parts of the hand, the schedule loss of use award is not limited to 100% of the hand. The Court highlighted the fact that the Disability Guidelines treat the fingers and thumbs separately for schedule loss of use award analysis. The Court also highlighted the uncontradicted medical testimony that the Guidelines contemplate a greater than 100% loss of use for the hand under certain circumstances.

The take-away from the case is that when a claimant has multiple injuries to different parts of a hand, separate schedule loss of use awards can be awarded for those distinct injuries.

 

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