Articles Posted in Case Law Update

The Pennsylvania Workers’ Compensation Act sets forth that medical treatment related to a work injury is to be paid for by the workers’ comp insurance carrier (provided the treatment is reasonable and necessary).  If there is a dispute as to whether treatment is related to a work injury, a petition must be filed.  If, on the other hand, the dispute is whether treatment is reasonable and necessary, then the Utilization Review process is to be used.  Whether treatment is related to a work injury is not a factor in a Utilization Review.  A recent decision from the Commonwealth Court of Pennsylvania dealt with this distinction.

In Haslam v. Workers’ Compensation Appeal Board (London Grove Communication), the injured worker (“Claimant”), fell from a building.  He suffered fractures to his right ankle, tibia, and fibula, a left calcaneus fracture, and injuries to his neck and low back.  After some time, the indemnity aspect (wage loss part) of the work injury was settled by Compromise & Release Agreement.  The settlement documents described the work injury as “R and L Foot Fracture.”

After the settlement, the workers’ compensation insurance company filed for Utilization Review against the treating doctor, seeking a ruling of whether ongoing medical treatments, including compound creams, were reasonable and necessary.  The Utilization Review Determination found all treatment to be reasonable and necessary.

Complicated fact patterns tend to make for complicated blog entries.  A recent decision by the Commonwealth Court of Pennsylvania in McNeil v. Workers’ Compensation Appeal Board (Department of Corrections, SCI-Graterford) is one of these situations, but is valuable for the lessons contained within.

In that case the injured worker (“Claimant”) tripped and fell on January 26, 2011, injuring her low back and left shoulder.  A Claim Petition was filed.  In the interim, a Notice of Compensation Payable (NCP) was issued accepting first left ankle sprain and left shoulder sprain, then later amended to add low back sprain.  Eventually, the Claim Petition was granted, so that the accepted work injury included, “left ankle sprain, acute cervical strain, acute back pain, musculoskeletal injury of the left shoulder, mild edema of the left ankle, left shoulder sprain, and tenderness of the Claimant’s left shoulder and upper and lower back.”  There was no appeal of this decision.

After the decision was rendered in the Claim Petition, the workers’ compensation insurance carrier filed a Petition for Termination, alleging that Claimant had fully recovered from the work-related injuries. The Petition for Termination was based on a May 21, 2014 “Independent” Medical Examination (IME, though a more realistic term is Defense Medical Examination, or DME).  Claimant filed Petitions for Review (to amend the description of injury) and Penalties (for the failure to pay for medical treatment related to the work injury); these Petitions were consolidated with the Petition for Termination.

Of course, no injured worker is trying to lose his or her Pennsylvania workers’ compensation benefits.  But, not being properly advised by an attorney who is certified as a specialist in PA workers’ compensation law can lead to that very result.  Take the cautionary tale of Mr. Torijano, a plumber’s helper who suffered a lumbar strain while working.

As addressed by the Commonwealth Court of Pennsylvania in Torijano v. Workers’ Compensation Appeal Board (In A Flash Plumbing), Mr. Torijano (“Claimant”) was released to go back to light duty work following his injury.  Initially, he did go back to work.  But, he felt the work was too heavy for him.  He also was unhappy that his employer reprimanded him (for failing to call in before each job, as the employer required).  Rather than bring the physical problems to the attention of his employer, or his doctors, he simply stopped reporting for work.

After hearing testimony from four representatives of the employer, and reviewing a letter the employer sent Claimant, making clear light duty work was available, the Workers’ Compensation Judge (WCJ) granted the Petition for Suspension, stopping the wage loss replacement benefits.  The testimony of Claimant’s own medical expert confirmed that he remained capable of light duty work.  Also not helpful was the admission from Claimant that he told the adjuster the only reason he stopped going to the light duty job was the reprimand.  The WCJ found that Claimant voluntarily quit the job, which was within his light duty capabilities.  This decision was affirmed by the Workers’ Compensation Appeal Board (WCAB).

On our website, we have discussed the various types of benefits available under the Pennsylvania Workers’ Compensation Act (Act).  One of these types of benefits is known as “specific loss.”  This is the type of benefit available when a worker loses the use of a body part for “all practice intents and purposes.”  Recently, the Commonwealth Court of Pennsylvania dealt with the requirements of proving a “specific loss.”

In Morocho v. Workers’ Compensation Appeal Board (Home Equity Renovations, Inc.), the worker injured his thumb, index and middle fingers while using a table saw.  A Claim Petition was filed seeking, among other things, a specific loss of the index finger.

While litigating the case before the Workers’ Compensation Judge, the injured worker presented testimony from himself, and hospital records, showing that there was a significant injury to the index finger.  Specifically, in the post-operative note, the diagnosis was listed as “P1, P2 open fracture, partial tendon laceration, flexor digitorum profundus greater than 50% of the tendon width.”  Two pins were placed in the finger, then later removed, though significant damage to the finger, greatly limiting its use, remained.  A report from the treating physician observed that the injured worker “has effectively lost function of the index finger at this time for all intents and purposes.”  The insurance carrier doctor felt there was no loss of use.

We have discussed Section 204(a) of the Pennsylvania Workers’ Compensation Act (Act) on this blog in the past.  This is the provision of the Act that provides a credit to the workers’ comp insurance carrier for certain other benefits an injured worker might receive, such as pension, social security retirement, unemployment compensation or severance.  While the Act may be specific on the credit due, the interpretation by the courts is puzzling.

In relevant part, Section 204(a) reads, “the benefits from a pension plan to the extent funded by the employer directly liable for the payment of which are received by an employee shall also be credited against the amount of the award made under [the Act].”  Given its ability to do so, the Pennsylvania Bureau of Workers’ Compensation then promulgated regulations on this offset, stating in pertinent part, “If the employe receives the pension benefit on a monthly basis, the net amount contributed by the employer and received by the employe shall be divided by 4.34.”  While not exciting, at least the language sounds clear.

In Harrison v. Workers’ Compensation Appeal Board (Commonwealth of Pennsylvania), the Commonwealth Court of Pennsylvania dealt with this Section directly.  The injured worker had the option of two pensions to take, either the maximum amount of money (which would have created a monthly offset of $1,885.03) or a lesser amount of money which included a survivor benefit for his wife (which would leave a monthly offset of  $1,537.79).

One of the more disputed areas of workers’ compensation in PA, and therefore the source of many appellate decisions, is whether an employee is injured in the scope and course of his or her employment.  We have addressed scope and course of employment many times on this blog.  Recently, another of these cases came before the Commonwealth Court of Pennsylvania.

In Wilgro Services, Inc. v. Workers’ Compensation Appeal Board (Mentusky), the employee (Claimant) was an HVAC mechanic, working on the roof of a building.  To get to the roof, and back down, he had been using a ladder roofers had been using.  Unfortunately, one day he was the last one on the job, and the roofers had taken away the ladder.  After considering his options, Claimant elected to jump from the lowest part of the roof, perhaps 16 to 20 feet from the ground.  In so doing, Claimant suffered bilateral calcaneus fractures, left medial malleolus fracture, and lumbar spinal fractures at L-4 and L-5.

The workers’ compensation insurance carrier denied the claim, feeling this case was very similar to that of Pennsylvania State University v. Workers’ Compensation Appeal Board (Smith), which was previously discussed on this blog.  In that case, the employee decided to jump a flight of stairs on a whim and ended up with multiple fractures in both legs.

We have discussed the Notice of Temporary Compensation Payable (NTCP or TNCP) on this blog in the past.  This is a tool a Pennsylvania workers’ compensation insurance carrier can use if it is still investigating and unsure whether to formally accept liability for a work injury in PA (instead of issuing a Notice of Compensation Payable (NCP) or Agreement for Compensation).  Of course, as with many tools, it is most often misused and abused by insurance carriers, but that is a different blog for a different day.

The beauty of the NTCP for insurance carriers is that, within 90 days, the NTCP can be revoked, and the claim still denied.  A recent case in the Commonwealth Court of Pennsylvania dealt with the timing of this type of revocation.

In Jones v. Workers’ Compensation Appeal Board (Villanova University), the injured worker (Claimant) allegedly suffered an injury to her knees at work.  The workers’ comp insurance company issued an NTCP on June 6, 2012.  Pursuant to the NTCP, a check for temporary total disability was issued by the carrier and received by Claimant on June 14, 2012.  This check was for the period of May 15, 2012 to June 6, 2012.  The day after the check was received by Claimant, June 15, 2012, the workers’ compensation insurance carrier issued a Notice Stopping Temporary Compensation (NSTC) and a Notice of Compensation Denial (NCD).

We have written volumes about the Impairment Rating Evaluation (IRE) process.  It would now appear all of those words just became moot with the decision rendered by the Supreme Court of Pennsylvania, which ruled the entire IRE provision to be unconstitutional.

Back in September of 2015, we talked about the decision rendered by the Commonwealth Court of PA in Protz v. Workers’ Compensation Appeal Board (Derry Area School District).  In that decision, the Court found that the IRE provision within the Pennsylvania Workers’ Compensation Act (Act) was unconstitutional in that the impairment rating was to be determined by the latest version of the American Medical Association (AMA) Guide to Disability.  The Court believed this to be an impermissible delegation of power.  While this delegation of power was struck down by the Court, the case was remanded (sent back) to the Workers’ Compensation Judge (WCJ), to perform the IRE using the 4^th edition (this was the edition which existed when the IRE provision was added to the Act).

The Supreme Court of Pennsylvania has now ruled that the Commonwealth Court was only correct in part.  Yes, said the highest court in the State, the delegation of power was indeed unconstitutional.  But, the Act does not contain any mention of using the 4^th Edition of the AMA Guides.  A Court cannot rewrite a law.  Therefore, without a version of the AMA Guides to use, to measure an impairment rating, the entire IRE provision must be struck from the Act.

On this blog we often discuss the beginning and ending of a workers’ compensation case in Pennsylvania.  This is a natural, and obvious, area of litigation.  However, there is also potential for dispute, and thus, litigation, when an injured worker goes back to work.  This is especially true where the injured worker remains under limitations, and there may or may not be partial disability benefits due.  Recently, the Commonwealth Court of Pennsylvania issued a decision is this area.

In Holy Redeemer Health System v. Workers’ Compensation Appeal Board (Lux), a nurse (Claimant) suffered a back injury in the nature of lumbar sprain, facet arthropathy, and radiculitis while bending to care for a patient.  She was disabled from her pre-injury position (as a telemetry nurse) by this injury.  Since her employer had modified-duty work available within that department, the Claimant continued to work (with restrictions) and suffered no loss in wages.  The workers’ compensation insurance carrier accepted the claim on a medical-only basis.

While the injured worker continued to perform the modified-duty work, at no loss in wages, her employer created a permanent, available position in a different department and offered it to Claimant.  The employer did not force or require Claimant to leave her original modified-duty position.  This new position actually led to Claimant earning less money than in her modified-duty job in the other department.

Since the Pennsylvania Workers’ Compensation Act covers “employees,” but not “independent contractors,” the relationship between these two terms is something we have previously discussed on our blog.  A recent case from the Commonwealth Court of Pennsylvania on this topic featured an added twist of a late answer.

In Hawbaker v. Workers’ Compensation Appeal Board (Kriner’s Quality Roofing Services and Uninsured Employer Guaranty Fund), the injured worker was employed as a roofer, when he fell.  The injury was denied by the workers’ compensation insurance carrier, who alleged the injured worker (the “Claimant”) was actually an independent contractor, and not entitled to benefits under the Pennsylvania Workers’ Compensation Act.

Claimant filed a Claim Petition, and the insurance carrier did not file a timely Answer.  Under the law, all factual allegations made by the Claimant are deemed admitted if there is no timely Answer denying the allegations (Known as a “Yellow Freight” situation, for the case which first addressed it).  Claimant included in the allegations that he was an employee of the employer.  After hearing the evidence, the Workers’ Compensation Judge (WCJ) found the Claimant to have been an independent contractor, and denied the Claim Petition.  This was affirmed on appeal to the Workers’ Compensation Appeal Board (WCAB).