Articles Posted in Case Law Update

A couple of months ago, we talked about the Whitfield v. Workers’ Compensation Appeal Board (Tenet Health System Hahnemann LLC) decision by the Commonwealth Court of Pennsylvania.  This was the first time the Court addressed the PA Supreme Court decision in Protz v. Workers’ Compensation Appeal Board (Derry Area School District), which struck the entire Impairment Rating Evaluation (IRE) process from the Pennsylvania Workers’ Compensation Act (Act).

As a brief refresher, the IRE provision of the Act allowed a workers’ compensation insurance carrier to have an injured worker undergo an evaluation, after the injured worker received total disability benefits for two years.  This evaluation, known as an IRE, would change the status of benefits to “partial” from “total” if the injured worker was less than 50% whole-body impaired by the work injury (note that 99.9% of injured workers are less than 50% whole-body impaired; that is a ridiculously high standard).  While this would not impact the amount of benefits an injured worker received, it would start the clock ticking on the 500 week maximum entitlement.

The decision in Protz struck the entire IRE provision from the Act, finding it unconstitutional.  This left attorneys who represent injured workers in PA needing answers to how this would impact the many injured workers already now receiving “partial” disability benefits due to an IRE.

When an injured worker in PA settles a personal injury case against a third party (typically from a work-related car accident, a products liability case or similar), the workers’ compensation insurance carrier has its hand out to get repaid for the wage loss and medical benefits provided to the injured worker.  For past wage loss and medical benefits, that remains the law.  For future medical benefits, however, things have changed dramatically.

Recently, the Supreme Court of Pennsylvania issued a decision in Whitmoyer v. Workers Compensation Appeal Board (Mountain Country Meats).  The Court found that while a workers’ compensation insurance carrier is entitled to a credit against future workers’ compensation wage loss benefits (when a third party settlement is more than the insurance carrier has already paid), the insurance company is NOT entitled to a credit against future medical benefits.  This represents a large change in practice.

When a third party case is settled in the presence of a workers’ comp case in PA, there is a specific form one uses to calculate both the lien (how much the workers’ compensation insurance carrier is getting back for money they have already paid) and the “balance of recovery” (dealing with how the money above the lien amount is treated for future payments).  The balance of recovery is used to calculate the “reimbursement rate” for future payments.  Instead of having to pay the entire amount due for future obligations, the workers’ comp insurer would only have to pay that amount times the reimbursement rate, typically less than half.  This form is called a “Third Party Settlement Agreement” (TPSA).

Facial disfigurement is the only aspect of the Pennsylvania Workers’ Compensation Act under which a Workers’ Compensation Judge (WCJ) has the discretion to award anywhere from zero to 275 weeks of workers’ compensation benefits.  Since such injuries can range from barely noticeable to tremendously disfiguring, these cases vary widely in the amounts awarded.  Note that the scarring can be traumatic, or from a work-related surgery.  After a WCJ views a scar, and renders a decision, either side can appeal the decision to the Workers’ Compensation Appeal Board (WCAB).

What the WCAB can do with this decision was recently addressed by the Commonwealth Court of Pennsylvania in Keister Miller Investments LLC v. Workers’ Compensation Appeal Board (Hoch).  Here, the injured worker (Claimant) was involved in a work-related motor vehicle accident wherein he suffered a broken nose and a laceration to the right side of his head.

A Claim Petition was filed, seeking compensation for the facial scarring.  After viewing the scar, and describing it for the record, the WCJ granted the Claim petition, finding, as required, that the “work-related injury resulted in a serious and permanent disfigurement of Claimant’s face, which is of such a character as to produce an unsightly appearance and not usually incident to the employment.”  In so doing, the WCJ awarded 40 weeks of benefits.

Since the Supreme Court of Pennsylvania set the PA workers’ compensation system abuzz in the Protz case by striking the entire Impairment Rating Evaluation (IRE) section from the Pennsylvania Workers’ Compensation Act (Act), we have waited to see some appellate decision interpreting Protz.  The Commonwealth Court of PA has now weighed in on the issue.

In Whitfield v. Workers’ Compensation Appeal Board (Tenet Health System Hahnemann LLC), the Court reversed the decision of the Workers’ Compensation Judge (WCJ) and the Workers’ Compensation Appeal Board (WCAB), and found that the injured worker was potentially able to reinstate her total disability benefits after an IRE.  The Court remanded for the injured worker to prove she remains totally disabled.

As attorneys for injured workers in PA, we were thrilled with the primary decision rendered by the Court – that being an injured worker whose 500 week maximum of partial disability benefits (which was obtained by IRE) has ended can still seek reinstatement to total disability benefits.  In so finding, the Court rejected arguments by the workers’ compensation insurance carrier that the injured worker could not pursue reinstatement because she had failed to challenge the status of the IRE provisions of the Act initially.

“Notice” of a Pennsylvania work injury is an issue which we have previously addressed in this blog.  Essentially, an injury must be reported to the employer within 21 days to have benefits date back to the first day, and within 120 days of the injury to have an entitlement to PA workers’ compensation benefits at all.  Often, the disputed aspect of a case is whether the notice provided to an employer is sufficient under the Pennsylvania Workers’ Compensation Act.

Importantly, proper notice does not mean that an employee must give a report with specifics or certainty.  What matters is whether the notice provided makes the employer aware that there is a possibility of a work-related injury.  Recently, the Commonwealth Court of Pennsylvania dealt with this very issue in City of Pittsburgh and UPMC Benefit Management Services, Inc. v. Workers’ Compensation Appeal Board (Flaherty).

Here, the injured worker (Claimant) was a firefighter for 16 years.  She was diagnosed with breast cancer in 2004, and was no longer able to continue performing the required duties of the position.  After Act 46 was enacted in 2011, creating a presumption dealing with cancer and firefighters, Claimant received a letter from her union describing the benefit to the new law.  Shortly thereafter, she filed a Claim Petition giving her employer notice that her condition may have been work-related.  She did not receive an opinion from her doctor, that her condition was, in fact, related to work, until a few months later.

Whether an employee hurt during the commute to work is covered by the Pennsylvania Workers’ Compensation Act (Act) is always a difficult analysis, and one we often encounter here.  Each case depends on the specific facts involved. While most employees (those who are “stationary” employees) are not covered for the commute to work, one reaches a point in the commute when the employee is no longer still commuting, but has, for the purposes of the law, arrived at work.  “Parking lot” cases are frequently an aspect of this situation.

Recently, the Commonwealth Court of Pennsylvania made a decision in the matter of  US Airways, Inc. v. Workers’ Compensation Appeal Board (Bockelman).  This was one of those “parking lot” cases.  Here, the employee (Claimant) labored for US Airways as a Philadelphia-based flight attendant.  Employees were not required to drive to work, but, if they did so, there were two designated employee parking lots.  These lots were owned, operated, and maintained by the City of Philadelphia/Division of Aviation (DOA), for the use of all airport employees, not just those of US Airways.  An employee identification badge was required to park in these lots.  A shuttle bus, operated by DOA (and not US Airways) then took the employee from the lots to the airport terminal.  Claimant hurt her left foot when she slipped while riding this shuttle bus after parking her car.

As could be expected, the Employer denied that Claimant was entitled to workers’ compensation benefits, since her injury was sustained while on the commute to work.   A Claim Petition was filed.  After considering the evidence, the Workers’ Compensation Judge (WCJ) found that Claimant was within the scope and course of her employment at the time of the injury, and granted the Claim Petition.  This was affirmed by the Workers’ Compensation Appeal Board (WCAB).

We have lamented the severe and draconian limits on the ability to challenge Utilization Reviews (URs) on this blog before.  We have seen a case where a healthcare provider sent a treatment summary and talked with the reviewer, and a case where records were actually submitted by the provider, but then returned by the reviewer due to a missing verification, both of which were deemed unreachable by appeal (finding that the Workers Compensation Judge (WCJ) lacked jurisdiction due to the failure to supply records).

Considering that UR is the process to limit medical treatment to an injured worker, and that the Supreme Court of Pennsylvania just told us, in Parker v. Workers’ Compensation Appeal Board (County of Allegheny), “we observe that the Workers’ Compensation Act is to be liberally construed in favor of workers in order to effectuate its remedial purpose,” these cases are hard to rationalize.  And, with this latest contribution from the Commonwealth Court of Pennsylvania, even more disappointing.

As noted above, the case law, and regulations, have told us that when a healthcare provider fails to provide records, no report is to be prepared by the Utilization Reviewer, and no challenge can be made from the Utilization Review to a Workers’ Compensation Judge (WCJ).  In fact, the Utilization Review Determination Face Sheet has a specific box to be checked for when no Determination can be issued due to the failure to supply records.

Several years ago, we were excited to tell everyone about the Supreme Court of Pennsylvania decision in Phoenixville Hospital v. Workers’ Compensation Appeal Board (Shoap).  It was this case that made clear workers’ compensation insurance carriers in PA could not simply use a classified “help wanted” ad to reduce every injured worker’s benefits.

If a workers’ compensation insurance carrier in Pennsylvania wants to reduce the benefits of an injured worker, said the Court, the jobs shown must not only be open at the time they are found, the potential jobs in a Labor Market Survey (LMS) or Earning Power Assessment (EPA) should “remain open until such time as the claimant is afforded a reasonable opportunity to apply for them.”  The reasoning behind this, of course, is that an LMS/EPA is not just a tool to cut the benefits of injured workers; it should be a device to assist an injured worker back to gainful employment.

The Commonwealth Court of Pennsylvania recently had to address exactly what a workers’ compensation insurance carrier needs to prove in this regard.  In Smith v. Workers’ Compensation Appeal Board (Supervalu Holdings PA, LLC), the injured worker (Claimant) hurt his neck and back.  At the time he was injured, he was earning an “Average Weekly Wage” (AWW; the calculation we do under the PA Workers’ Compensation Act to see the amount of benefits due to the injured worker) of $992.50.  The injury was accepted by the insurance carrier as a cervical strain and sprain (making eventual fusion surgery required due to the work injury a curious fit to that modest diagnosis).

Among the benefits available under the Pennsylvania Workers’ Compensation Act (Act), are “fatal claim” benefits.  Since these are only relevant for work accidents which involve the death of a worker, these are not things we like to often see.  Unfortunately, sometimes these things do happen, and they are cases which need attention.

In addition to modest “burial expenses,” fatal claim benefits also include benefits for any surviving minor children, and, potentially, a spouse (among other categories of possible recipients beyond this topic).  We say “potentially” since benefits to a spouse are not automatic.

Recently, the Commonwealth Court of Pennsylvania dealt with this issue in Grimm v. Workers’ Compensation Appeal Board (Federal Express Corporation).  Here, the worker who died (Decedent) was employed by Federal Express.  She suffered a fatal heart attack while delivering packages in her normal course of work.

Sometimes odd facts in a Pennsylvania workers’ compensation case make for an odd decision.  Yet, even then, we can often find something of use in that decision.  Seeing how appellate courts approach different situations helps us understand how that may translate to other fact patterns and enable us to better represent injured workers in PA.

Recently, the Commonwealth Court of Pennsylvania issued a decision in Dorvilus v. Workers’ Compensation Appeal Board (Cardone Industries).  Here, the injured worker hurt his low back in 2009.  A Claim Petition was filed, and a Workers’ Compensation Judge (WCJ) granted the Petition, awarding both disability and medical benefits.

On appeal, the Workers’ Compensation Appeal Board (WCAB) reversed the decision of the WCJ as to the award of disability benefits (though the injured worker received disability payments until this reversal in 2013).  Though the injured worker did prove that a work injury took place, said the WCAB, he failed to prove that he was “disabled” as a result of that injury.  This was affirmed by the Commonwealth Court of Pennsylvania (not the decision we are discussing here).  Though requested, an appeal to the Supreme Court of Pennsylvania was not accepted (unlike the WCAB and Commonwealth Court of PA, the Supreme Court of PA has the discretion to accept or decline an appeal).