July 2, 2009

Injured Worker Not in Scope and Course of Employment When on Break

To obtain workers’ compensation benefits in PA, the worker must be injured while in the scope and course of his or her employment. Fortunately, PA law does not require that a worker be chained to his or her desk, or work area, the entire day. Pennsylvania law recognizes that “small temporary departures” from work do not remove an employee from being in the scope and course of his or her employment. The degree of latitude given also varies depending on whether one is a “stationary” as opposed to a “traveling” employee.

Recently, the Commonwealth Court of Pennsylvania decided Department of Labor & Industry v. Workers’ Compensation Appeal Board (Savani), finding a stationary employee not in the scope and course of her employment when she fell and suffered a fractured arm while off the employer’s property on a paid break. The Court found that being off the employer’s property for personal reasons, even though on a paid break, was not “a small temporary departure from work” or an “inconsequential or innocent departure from work.”

These types of cases vary greatly, depending on the facts in each situation. This is why it is important to have your case reviewed by an experienced PA workers’ comp attorney.

June 12, 2009

Notice of Work Injury Found Not Sufficient Under PA Workers’ Comp Act

When a worker gets hurt at work in PA, the Pennsylvania Workers’ Compensation Act requires that the employer be notified of the injury with 120 days. If the injury is one of repetitive, or cumulative, nature, such as carpal tunnel syndrome or hearing loss, the 120-day period does not begin until the date the condition, and its relation to work, is known (called “the discovery rule”). This notice does not need to contain the exact diagnosis of the work injury, but merely “a reasonably precise description of the injury.”

In Gentex Corp. v. Workers’ Compensation Appeal Board (Morack), decided by the Commonwealth Court of Pennsylvania on June 4, 2009, the Court addressed what “sufficient” notice of an injury must contain.

Ms. Morack began having pain in her hands at work. At first, she was not aware it had anything to do with her job. She applied for short-term disability benefits on February 2, 2005, putting on the application that her disability was not work-related, and the condition was swelling in arms, hands, knees and ankles from fibromyalgia and high blood pressure.

Later in February, 2005, her doctor advised her that she had carpal tunnel syndrome, and it was related to her duties at work. Ms. Morack called her employer and left a message on voicemail that she had “work-related problems.” The next notice came to the employer in September, 2006, when they received a copy of the Claim Petition.

The Workers’ Compensation Judge (WCJ) found Ms. Morack credible and granted the Claim Petition. The WCJ found that Ms. Morack called the employer and gave notice within 120 days. The Workers’ Compensation Appeal Board (WCAB) affirmed.

On appeal to the Commonwealth Court, the employer had two arguments. First, the employer said Ms. Morack failed to prove the voicemail was left within 120 days (no time was stated for when the voicemail was left). Second, the employer alleged the notice given was not sufficient.

The Court disagreed on the first point, finding that, since Ms. Morack was found credible, and won before the WCJ, she is entitled to all reasonable inferences. Based on the evidence, there was no reason to believe the voicemail was left more than 120 days from the injury date.

On the second argument, however, the Court agreed with employer and reversed the decision of the WCJ. The Court found that simply telling the employer that she had “work-related problems” was not sufficient. While, in some situations, the short-term disability application may provide the missing detail, here, the application cited body parts and conditions not even alleged to be work-related, so it was of no help. In the end, Ms. Morack failed to provide any description at all of her alleged work injury. As such, the granting of the Claim Petition was reversed by the Court.

June 5, 2009

Review of Utilization Review Barred Even When Doctor Sends Medical Records

In PA, when a workers’ compensation insurance carrier wants to challenge whether medical treatment is reasonable or necessary, the insurance carrier can request Utilization Review (UR). In such a case, the PA Bureau of Workers’ Compensation assigns the UR Request to a Utilization Review Organization (URO). The URO then obtains records from the provider under review, and a personal statement from the injured worker if he or she wishes, and a Utilization Review Determination is issued. This Determination can then be appealed by either party by filing a Petition to Review Utilization Review Determination.

However, if the healthcare provider under review fails to submit records, the regulations to the Pennsylvania Workers’ Compensation Act require the URO simply find treatment unreasonable and/or unnecessary, because records were not submitted. In this situation, no report is prepared by the URO, and no findings on the merits are made. Importantly, this type of Determination cannot be appealed under the County of Allegheny v. Workers’ Compensation Appeal Board case, decided by Commonwealth Court of Pennsylvania in 2005.

Recently, the Commonwealth Court of Pennsylvania has made things even worse for injured workers, by extending County of Allegheny. The case of Sexton v. Workers’ Compensation Appeal Board (WCAB) was decided by the Court on May 22, 2009. In Sexton, the provider submitted records to the URO, but forgot to submit a verification with the records. The URO returned the records to the provider, so the provider could resubmit the records with the required verification. Unfortunately, the provider never resubmitted the records or the verification.

The Workers’ Compensation Judge (WCJ) ordered a new UR be performed. The WCAB, though, reversed. This was affirmed by the Commonwealth Court of PA. The Court found that the verification was required to be submitted, to assure the records were true and correct. Since the verification (and the records) were never resubmitted, the URO could not generate a report and reach a Determination on the merits. As such, under County of Allegheny, the Determination could not be appealed by the injured worker.

I find County of Allegheny inconsistent with the terms, and the spirit, of the Pennsylvania Workers’ Compensation Act, which was intended to be humanitarian legislation, beneficial to the injured worker. Sexton then extends the harm even further. Records were actually submitted in Sexton. As the dissent by Judge Johnny J. Butler (former Secretary of the PA Department of Labor & Industry) observed, there was no authority in the Act for the URO to send the medical records back to the provider. Worse, even if medical records could not be used on appeal, what is the basis for precluding the injured worker from testifying as to the reasonableness and/or necessity of the treatment at issue? Under the Act, if the testimony of the injured worker was found credible, this could be the basis to grant a Petition to Review Utilization Review Determination. Under current law, however, the injured worker cannot even file the Petition to Review Utilization Review Determination when the provider fails to submit records.

June 1, 2009

PA Workers’ Compensation Appeal Board Reversed – Testimony of Claimant’s Doctor Unequivocal

When a work injury is denied by the workers’ compensation insurance carrier in PA, the injured worker must file a Claim Petition with the Pennsylvania Bureau of Workers’ Compensation. The Claim Petition is then litigated before a Workers’ Compensation Judge (WCJ). To win a Claim Petition, usually the injured worker needs the WCJ to find both the injured worker, and his or her doctor, credible.

The testimony of the medical expert must be “unequivocal,” that the injured worker suffered a work-related injury, and has been disabled from work as a result of this injury. “Unequivocal” does not require 100% certainty (since nothing in life is 100% certain), but simply requires the doctor to believe that is the case.

A recent decision by the Commonwealth Court of Pennsylvania, Moyer v. Workers’ Compensation Appeal Board (WCAB), addressed this issue. The WCJ in this case found Claimant and his doctor credible and granted the Claim Petition. However, the WCAB reversed the WCJ, finding the testimony of Claimant’s doctor to be equivocal.

The Claimant had a past medical history of low back problems, before the work injury, and the WCAB felt the testimony of Claimant’s doctor was based only on the fact there was an increase in pain just after Claimant lifted a bucket at work. The opinion of a doctor is equivocal if it assumes an injury is work-related just because it happens right after an event at work. Similarly, an opinion is equivocal if the doctor can only say the work event “could have” caused the disability.

The Commonwealth Court of Pennsylvania reversed the WCAB, and granted the Claim Petition. The Court noted that one cannot take a single statement of a witness out of context; instead, one must examine the testimony as a whole. When looked at in this way, the Court found the testimony of Claimant’s doctor was based on the history given by Claimant (found credible by the WCJ), and observed a difference in Claimant’s condition before and after the event at work. The doctor did not merely say the event “could have” caused the aggravation of his low back condition, the doctor testified the event “was” the cause of the aggravation. Considering all of this, the opinion of Claimant’s doctor was unequivocal.

Cases like this highlight the importance of getting the right testimony from medical witnesses. If the attorney is not familiar with PA workers’ comp law, the testimony obtained may not be sufficient to win a Claim Petition.

May 18, 2009

Retirement Effect in PA Workers’ Comp, Update on Recent Cases, Topics of Seminar

As noted in a previous blog entry, Glenn Neiman, a partner at Brilliant & Neiman LLC, was invited to join the prestigious faculty of Lawline.com. Being a nationally recognized leader in continuing legal education programs, Lawline.com’s faculty includes some of the most well-known attorneys in the Country.

On May 14, 2009, Mr. Neiman recorded his first PA workers’ compensation seminar for Lawline.com. The seminar dealt with the effect of retirement on the receipt of workers’ compensation benefits in Pennsylvania, as well as an update on recent cases in PA workers’ comp. After the piece is edited by Lawline.com, it will be added to their course catalogue and made available to attorneys across the Country.

May 15, 2009

Workers’ Comp Benefits in PA Suspended When Injured Worker Has Earnings

Typically, under the Pennsylvania Workers’ Compensation Act, the benefits of an injured worker are reduced based on any earnings the injured worker has after his or her injury. Specifically, the injured worker receives two-thirds of the difference between the pre-injury earnings and the post-injury earnings (up to a statutory maximum).

In a somewhat troubling decision issued by the Commonwealth Court of PA, Alessandro v. Workers’ Compensation Appeal Board, an injured workers’ benefits were ordered to be suspended, despite the workers’ comp insurance carrier having no evidence that post-injury earnings equaled pre-injury earnings. The Court, noting that the Workers’ Compensation Judge found the injured worker not credible, believed the burden to show earnings (and subsequent wage loss) rests with the injured worker, not the workers’ comp insurance carrier.

As an attorney who represents injured workers in Pennsylvania, I find this decision problematic. Mr. Alessandro testified that he worked some, but had a large wage loss. Since it appears he was paid in cash (meaning there are no written wage records), and Mr. Alessandro was found not credible, as a practical matter, it seems almost impossible for Mr. Alessandro to prove he has a wage loss. How can one prove an absence of earnings?

May 5, 2009

Social Security Retirement Offset Against Workers’ Compensation Benefits Unconstitutional Says Utah Supreme Court

Under Section 204(a) of the Pennsylvania Workers’ Compensation Act, a workers’ comp insurance company in PA is entitled to an offset when an injured worker receives Social Security Retirement Benefits (SSR). This is one of the provisions in the Act that seems most unfair to us attorneys who represent injured workers in PA.

The Supreme Court of Utah recently declared a similar provision in that State’s workers’ compensation laws to be unconstitutional, as it discriminated against injured workers on the basis of their age. Only injured workers old enough to qualify for SSR would have their workers’ comp benefits reduced.

Since workers’ compensation laws vary widely from State to State, there is no direct impact of this decision on the laws in Pennsylvania. However, this law does give us hope that a similar result can eventually be accomplished in the Supreme Court of Pennsylvania.

May 4, 2009

Healthcare Workers' Exposure to Infectious Diseases

With the dangers of Swine Flu on the minds of everyone, but perhaps especially the minds of those workers in the healthcare industry, this article from the Centers for Disease Control (CDC) may be of interest. Ironically, this article was posted on March 31, 2008, long before the current Swine Flu pandemic.

Raising this issue also brings to light that a healthcare worker in Pennsylvania who is stricken with an infectious disease as a result of his or her job is entitled to PA workers’ compensation benefits. We often see this type of case with Clostridium Difficile Colitis (C-Dif), Methicillin-resistant Staphylococcus Aureus (MRSA), and other infectious diseases which are known to exist in hospitals, nursing homes and other healthcare facilities.

If you suspect you have caught an infectious disease as a result of performing your job duties in PA, it is critical that you contact an experienced Pennsylvania workers’ compensation attorney.

May 1, 2009

Workers’ Comp Benefits Modified in PA With No Job Availability Shown

As discussed in previous blog entries, the case of Diehl v. Workers’ Compensation Appeal Board is of great importance in determining whether it matters when a workers’ compensation insurance carrier in Pennsylvania requests an Impairment Rating Evaluation (IRE) within 60 days of the expiration of 104 weeks of total disability.

In a decision rendered on April 28, 2008, the Commonwealth Court of Pennsylvania held that a PA workers’ compensation insurance carrier must show job availability if the IRE request is not made within that 60 day period. This decision was then vacated by the Court, to be addressed again by the entire Court (rather than a panel, as this decision was). Finally, on April 22, 2009, the Court issued a final decision in this matter, achieving a different result.

As feared by attorneys who represent injured workers in PA, the Court held that a workers’ compensation insurance carrier need not prove job availability whether or not the IRE request is made within that 60 day period. Instead, if that time period is missed, the workers’ comp insurance company merely has to prove the Impairment Rating Evaluation resulted in an impairment rating of less than 50%.

Unfortunately for injured workers in Pennsylvania, this means there is very little difference whether the workers’ comp insurance carrier requests the IRE within the 60 day period or not.

April 7, 2009

Modification of Benefits After Impairment Rating Evaluation Takes Effect on Date of Evaluation, Not on Date of Subsequent Decision Granting Modification

One of the major changes in the Pennsylvania Workers’ Compensation Act, which was enacted in the 1996 amendments, is the creation of the Impairment Rating Evaluation (IRE). Under this concept, once an injured worker receives 104 weeks of temporary total disability benefits, the workers’ comp insurance company has the right to send the injured worker for an IRE. If the IRE results in a whole body impairment rating of less than 50% (which covers more than 98% of injured workers; this is an impossibly high standard), the status of workers’ compensation benefits can be changed from total to partial. This change in the status of benefits does not effect the rate of the weekly compensation, but how long such benefits can be received by an inured worker.

In PA, an injured worker can only receive a maximum of 500 weeks of partial disability benefits (there is no limit to the receipt of total disability benefits). Therefore, once the status of benefits is changed from total to partial, the receipt of benefits may be capped at 500 weeks.

If the IRE is requested within 60 days of the expiration of 104 weeks of total disability benefits, the change in status is automatic (the PA workers’ comp insurance carrier only has to file a Notice of Change of Status). On the other hand, if the request is not made within this window, the PA workers’ comp insurance carrier must file, and litigate, a Petition for Modification to have the status changed. In this situation, attorneys representing injured workers in PA have wondered whether the change in status takes effect on the date of the IRE or the date a Workers’ Compensation Judge (WCJ) decides the Modification Petition.

The Commonwealth Court of Pennsylvania recently answered this question in Ford Motor/Visteon Systems v. Workers Compensation Appeal Board (Gerlach). Unfortunately, the Court stated that the change in status is effective on the date the condition changed (the date of the IRE), rather than the later date the WCJ decides the Modification Petition. Given that litigation of a Modification Petition often lasts over a year, the injured worker is then left with far less than 500 weeks of benefits when the dust settles.

April 3, 2009

PA Workers’ Comp Benefits Can Only be Stopped After Conviction – Incarceration Alone Insufficient

Under the Pennsylvania Workers’ Compensation Act, an insurance carrier can stop paying benefits to an injured worker who is “incarcerated after a conviction.” The Commonwealth Court of Pennsylvania recently emphasized that there must be a conviction before workers’ compensation benefits can be suspended.

In Rogele Inc.v. Workers’ Compensation Appeal Board (Mattson), which the Court decided on April 2, 2009, the Workers’ Compensation Judge (WCJ) assessed penalties against the workers’ comp insurance carrier, after the carrier stopped paying benefits to the injured worker. In that case, the injured worker was in jail, in the process of pleading guilty to a felony which was to entail significant jail time. At the time benefits were stopped, however, there had been no conviction.

The Court affirmed the decision of the WCJ, finding that in PA, as anywhere in the United States, one is innocent until proven guilty. Whether one later pleads guilty is irrelevant. The plain language in the Pennsylvania Workers’ Compensation Act requires the claimant be “incarcerated after a conviction.”

The Court rejected the workers’ comp insurance carrier’s argument that the incarceration caused the injured worker to intentionally, or voluntarily, remove himself from the work force. Again, until there is a conviction, even if it results from a guilty plea, everyone is innocent.

April 2, 2009

Trust in Workers' Compensation Insurance Company Doctors Misplaced?

An article in the New York Times, talking about how insurance company’s “Independent Medical Examiners” (IME) may not be acting truthfully, hit home to me. Though the article deals specifically with New York workers’ comp, their system is close enough to Pennsylvania’s that comparisons are valid.

While I urge folks to read the entire article, the part that was my absolute favorite was the insurance company doctor who said, “If you did a truly pure report, you’d be out on your ears and the insurers wouldn’t pay for it. You have to give them what they want, or you’re in Florida. That’s the game, baby.”