Articles Posted in Case Law Update

**Update – Appeal accepted by the Supreme Court of Pennsylvania on April 27, 2011 – Stay tuned for more details**

Years ago, before the 1996 amendments to the Pennsylvania Workers’ Compensation Act (Known as Act 57), a workers’ comp insurance company in PA had to prove that work was actually open and available to an injured worker in order to reduce or stop the payment of workers’ compensation benefits. This was known as the “Kachinski” standard, after the Pennsylvania Supreme Court decision in Kachinski v. Workers’ Compensation Appeal Board (Vepco Constr. Co.), decided in 1987. This was discussed in previous blog entries.

One of the more dangerous additions in those changes to the Act in 1996 was the invention of the “Earning Power Assessment” (EPA)[Also known as a “Labor Market Survey” [LMS]]. The EPA, or LMS, was to take the place of actual job referrals. A vocational counselor would be hired by the workers’ comp insurance carrier to go out and find job openings, and prepare the EPA/LMS. This document was to serve as an estimate of the jobs which exist in the geographic area in which the injured worker resides.

In a previous blog posting, we discussed the case of Armstrong v. Workers’ Compensation Appeal Board, decided by the Commonwealth Court of Pennsylvania in 2007. This case first allowed a PA workers’ compensation insurance carrier to use a Notice of Denial (NCD) to “accept” a workers’ comp case. As attorneys for injured workers in PA, we hoped this case would be viewed narrowly, if not reversed, by future Court decisions.

Unfortunately, the Commonwealth Court of Pennsylvania, in the case of Forbes Road CTC v. Workers’ Compensation Appeal Board (Consla), has now expanded this theory. No longer does a PA workers’ comp insurance carrier have to even issue a Temporary Notice of Compensation Payable (TNCP), then revoke the TNCP, to use an NCD to accept a case (as it was done in Armstrong). In Consla, the Court specifically stated that, “we hold an employer may properly issue an NCD to accept a claimed work injury for medical purposes only.”

As we felt after reading the Armstrong decision, we can only wonder why the Pennsylvania Bureau of Workers’ Compensation would have gone to the trouble of developing a specific form called a “Medical Only Notice of Compensation Payable,” which was designed to be issued in this very type of case, if an NCD could simply be used. Oh, and we also wonder how a Court can decide that a Notice of DENIAL can be used to ACCEPT a case. Silly us, we thought the Pennsylvania Legislature was charged with making laws, leaving the Courts to simply interpret them.

As we have discussed in several previous blog entries, an injury at work in PA must happen in the scope and course of employment to be compensable under the Pennsylvania Workers’ Compensation Act. Often, this is the issue in dispute when an employee is injured in a parking lot, either coming to, or leaving, work.

In ICT Group v. Workers’ Compensation Appeal Board (Churchray-Woytunick), recently decided by the Commonwealth Court of Pennsylvania, a worker slipped and fell in a parking lot as she was preparing to leave the premises for lunch. Since the employee was required to take a lunch break, was allowed to leave the premises, the parking lot was used by the employees and the injury took place only about ten feet from the employer’s door, the Court found the injury was within the scope and course of employment and workers’ comp benefits were awarded.

These cases are always very “fact-specific,” and there are many different ways these types of cases go. Yet another reason that injured workers should be sure to select attorneys with extensive experience in PA workers’ compensation matters.

While there is no minimum time a worker must be employed before the worker qualifies for workers’ compensation coverage in Pennsylvania, the worker must actually be “employed” at the time of the injury. This means there must be both an offer and an acceptance of employment, before the work injury takes place.

In Moberg v. Workers’ Compensation Appeal Board (Twining Village), a recent decision of the Commonwealth Court of Pennsylvania, a prospective employee was injured while getting a tuberculin test. Since this test must have been passed before an offer of employment could have been made, the Court found that, at the time of the test, the injured worker was not actually an “employee” yet. As such, PA workers’ compensation benefits were denied.

This case does bring up the fact that an employee is immediately covered under the Pennsylvania Workers’ Compensation Act, as soon as employment begins. We have seen several cases over the years where an employee is hurt on the first day of work. In those cases, there is no doubt the injured worker is entitled to PA workers’ comp benefits. The key, as noted in Moberg, is that the employment relationship must have actually started before the injury takes place.

As we have discussed in a previous blog entry, the PA Workers’ Compensation Act requires that a Notice of Ability to Return to Work be served on an injured worker (and his or her attorney), before the workers’ comp insurance carrier can move to modify or suspend benefits.

Specifically, the Act states, “If the insurer receives medical evidence that the claimant is able to return to work in any capacity, then the insurer must provide prompt written notice, on a form prescribed by the department, to the claimant . . . ” One of the interesting words chosen in this law is “prompt.”

The Commonwealth Court of Pennsylvania, in Melmark Home v. Workers’ Compensation Appeal Board (Rosenberg), decided in 2008, held that a Notice of Ability to Return to Work sent five and a half months after the workers’ comp insurance carrier received the information was “stale,” and was not valid (because it was not “prompt”). That Court also noted that the real key to whether a Notice of Ability to Return to Work is “prompt” enough is the impact on the injured worker.

Generally speaking, when an employee in Pennsylvania is injured while performing the duties of his or her job, the employee is entitled to PA workers’ compensation benefits. One of the exceptions to this rule, however, is when “the injury or death would not have occurred but for the employe’s intoxication.” This is one of the “affirmative defenses” available to a PA workers’ comp insurance carrier. The defendant bears the burden to prove that the intoxication caused the injury.

Recently, the Commonwealth Court of Pennsylvania dealt with whether the defendant’s medical expert had to actually state that the injury would not have occurred “but for” the intoxication. In Thomas Lindstrom Co., Inc. v. Workers’ Compensation Appeal Board (Braun), the employee fell off a steel beam, six to eight inches wide, and suffered very serious injuries, including severe head trauma.

A Notice of Temporary Compensation Payable (TNCP) was issued, and workers’ comp benefits were started. However, when lab results showed that the injured worker had a blood alcohol level of around .28 at the hospital (Far beyond the .08 level which constitutes drunken driving in PA), the claim was then denied by issuance of a Notice of Denial (NCD).

There is a process in PA when a workers’ comp insurance carrier wants to modify or suspend the workers’ compensation benefits of an injured worker. First, there must be evidence of a change in condition. Then, the insurance carrier must serve a form called Notice of Ability to Return to Work on the injured worker (with documentation regarding what type of employment the injured worker can do). Only then can the workers’ comp insurance carrier file a Petition to Modify or Suspend benefits and go before a Workers’ Compensation Judge (WCJ).

But, what if the injured worker is not capable of working at all, due to something other than the work injury? The Supreme Court of Pennsylvania faced this issue in 2000, in Schneider, Inc. v. Workers’ Compensation Appeal Board (Bey). In that case, the worker suffered an injury to his head and neck. While he was receiving workers’ comp benefits, he was stabbed in the head in a bar fight and was rendered paraplegic and brain damaged. The Court held that the workers’ comp insurance carrier did not have to show any job availability, because it would be “fruitless.” In that situation, the injured worker was completely and permanently disabled by the non-work-related injury.

More recently, the Commonwealth Court of Pennsylvania was invited to expand this theory in Wells v. Workers Compensation Appeal Board (Skinner); thankfully, the Court declined. Mr. Skinner injured his back at work, and began to receive PA workers’ compensation benefits. Since Mr. Skinner also suffered with diabetes, cardiac problems and other related health issues, the workers’ comp insurance carrier filed a Petition to Suspend benefits, under the theory of Schneider.

Generally speaking, a Workers’ Compensation Judge (WCJ) is the sole determiner of credibility in PA workers’ comp matters. Testimony of any witness can be accepted, in whole or in part. Determinations of credibility by a WCJ cannot generally be overturned on appeal.

This issue was addressed by the Commonwealth Court of Pennsylvania in Stancell v. Workers Compensation Appeal Board (LKI Group, LLC). In this case, the workers’ comp insurance carrier sent the injured worker for an Independent Medical Examination (IME; more realistically referred to as a “Defense Medical Exam,” as there is usually nothing “independent” about it). That doctor pronounced the injured worker fully recovered.

Based on this opinion, the workers’ comp insurance carrier filed a Petition for Termination. To win such a Petition, the carrier must prove that the injured worker has fully recovered from the entire work injury. In that litigation, the IME doctor admitted he did not examine one of the body parts which were injured (the lower right arm). Regardless, the IME doctor testified that the injured worker had fully recovered from the entire injury (he was asked, hypothetically, if she injured her lower right arm, whether that, too, was recovered). The WCJ found this testimony credible and granted the Petition for Termination.

Under Section 406.1 of the Pennsylvania Workers’ Compensation Act, an employer/insurance carrier has 21 days to investigate a workers’ compensation claim and issue appropriate documentation, either accepting (by Notice of Compensation Payable (NCP) or Agreement for Compensation) or denying (Notice of Denial (NCD)) the claim. If the employer/insurance carrier is unsure whether the claim is compensable, a Notice of Temporary Compensation Payable (TNCP) can be issued. This document can then be revoked, within 90 days, if the employer/insurance carrier wishes to deny the claim.

If an employer/insurance carrier wishes to revoke a TNCP, and deny liability, there are certain procedures which must be followed. If the procedures are not followed exactly, the TNCP can simply convert to an NCP (which cannot be revoked). One of the requirements is that a TNCP can only be revoked if the revocation is made within five days of the last workers’ compensation check.

Using magic powers which would be the envy of Merlin, the Commonwealth Court of Pennsylvania recently made this “requirement” disappear, allowing a TNCP to be revoked despite a clear violation of this provision. In Barrett v. Workers’ Compensation Appeal Board (Vision Quest National), the injured worker suffered a fractured ankle while doing her job. The workers’ comp insurance carrier issued a TNCP, along with the first check for workers’ compensation benefits.

When a PA workers’ compensation insurance carrier wants to “terminate” the workers’ comp benefits of an injured worker, the insurance company must prove that the injured worker has fully recovered from his or her work injury. What constitutes the “work injury” is usually what is described on the Notice of Compensation Payable (NCP)[the document used by the insurance carrier to accept a claim]. While this is the rule, there are always exceptions.

A recent decision rendered by the Commonwealth Court of Pennsylvania, Julio Paz Y Mino v. Workers’ Compensation Appeal Board (Crime Prevention Association), dealt with the exception to the rule. After Mr. Mino was injured, an NCP was issued, describing the injury as lumbar sprain and strain. A Petition to Terminate was filed by the workers’ comp insurance carrier. The Workers’ Compensation Judge (WCJ) denied this Petition, finding the testimony of the injured worker’s doctor more credible than the doctor who performed the Independent Medical Examination (IME) for the insurance company. Though the WCJ did not formally state he was amending the NCP (nor was a Petition to Review, the Petition used to amend an NCP, filed), he noted the diagnosis rendered by the injured worker’s doctor, specifically, an aggravation of pre-existing lumbar stenosis and a lumbar radiculopathy.

The workers’ compensation insurance carrier then filed a second Petition to Terminate (Persistent little devils, eh?). Since the first WCJ did not formally amend the NCP, the second WCJ did not include the entire diagnosis found by the first WCJ. In so doing, the second WCJ found that Claimant had fully recovered and granted the Petition to Terminate.