Articles Posted in Case Law Update

There are several types of benefits which can be received by an injured worker in Pennsylvania.  A comprehensive review of these benefits can be seen here on our website.  One of those benefits is called “specific loss,” which contains things like loss of use of a body part and disfigurement of the head, face or neck (though House Bill 930 could expand disfigurement beyond the head, face or neck).

Importantly, specific loss benefits cannot be received while the injured worker is still receiving “temporary total disability” benefits (essentially, what we call total wage loss benefits).  Again, at least as far as disfigurement, this could change with House Bill 930.

What if the injured worker dies before the temporary total disability benefits stop?  Surely, the specific loss benefits, since already “awarded” would be paid to the estate, right?  Nope, wrong.  The full answer is that it depends what caused the death of the injured worker.

When an employee in Pennsylvania gets injured, the PA Workers’ Compensation Act allots the workers’ compensation insurance carrier 21 days to investigate and accept or deny the claim.  If 21 days is not sufficient, the insurance carrier can opt to issue a Notice of Temporary Compensation Payable (NTCP or TNCP), and continue the investigation for up to 90 days more.  If the TNCP is not properly revoked within those 90 days, according to the Act, the TNCP becomes a regular Notice of Compensation Payable (NCP), and the injury can no longer be denied.  Simple, right?

Not so fast.  When a TNCP has been issued (for both wage loss and medical benefits), an insurance carrier can simply file a Medical-Only NCP, accepting liability solely for the medical aspect of the case (thus, denying liability for wage loss), without ever revoking that TNCP or issuing a Notice of Denial (NCD) for wage loss.  While this seems contrary to the words, if not the spirit, of the Act, the Commonwealth Court of Pennsylvania says this is perfectly fine.

This happened recently in an unreported case, Moretti v. County of Bucks (Workers’ Compensation Appeal Board), though prior reported decisions of the Commonwealth Court, supporting such a situation, were cited by the Court.

What if an injured worker in Pennsylvanian is employed by a company who (in direct violation of PA law) fails to carry workers’ compensation insurance?  Back in the old days, the injured worker, through no fault of his or her own, would be stuck with whatever assets the employer had.  However, in recognizing the pure unfairness of such a situation, several years ago, the Pennsylvania legislature created the Uninsured Employers’ Guaranty Fund (UEGF), essentially functioning as an insurer for the uninsured employers.

While the UEGF is wonderful in theory, it is less so in practice.  Funding for the UEGF comes from other insurance carriers, and it is seemingly consistently underfunded.  The law holds that the UEGF is NOT an insurance carrier, so it cannot be penalized for violations of the Pennsylvania Workers’ Compensation Act (Act), including the failure to pay an award as ordered by a Workers’ Compensation Judge (WCJ).  This makes collecting an award from the UEGF a delicate and diplomatic process.

In the past several years, to protect the limited funds of the UEGF, the PA legislature has tightened the requirements to obtain an award against the UEGF, and made such litigation much more difficult.  Timeframes have been drastically shortened and requirements of proof have been significantly increased.

Over the past several years, PA has legalized the use of medical marijuana.  Given the current difficulties in dealing with the opioid epidemic, this would seem to be a reasonable tool to help injured workers (and anyone else suffering from chronic pain) deal with their conditions without the use of narcotic medications.  The controversial status of marijuana, and both PA and Federal law, however, gave us great uncertainty as to whether use of medical marijuana would be covered under the Pennsylvania Workers’ Compensation Act.  Two recent decisions by the Commonwealth Court of Pennsylvania answer this question quite clearly in the affirmative.

Notably, the Medical Marijuana Act [MMA] specifically states that “Nothing in [the MMA] shall be construed to require an insurer or a health plan, whether paid for by Commonwealth funds or private funds, to provide coverage for medical marijuana.”  Additionally, marijuana remains illegal under Federal law.  These two factors have made payment for medical marijuana under the PA Workers’ Compensation Act (Act) nearly impossible.  Until now.

The two companion cases on this issue of first impression are Appel v. GWC Warranty Corporation (Workers’ Compensation Appeal Board) and Teresa L. Fegley, as Executrix of the Estate of Paul Sheetz v. Firestone Tire & Rubber (Workers’ Compensation Appeal Board).  Both of these injured workers suffered from severe pain, one from multiple back surgeries and the other from several conditions, including “herniated disc at L5-S1, cervical sprain, disc herniation at L4-L5, lumbar radiculopathy, cervical strain with cervical myofascial spasm, major depression, and aggravation of cervical degenerative spondylosis of degenerative disc disease.”

Under the Pennsylvania Workers’ Compensation Act, once an injured worker establishes that he or she has suffered a work-related injury, benefits continue until something happens.  That “something” may be the injured worker returning to gainful employment, a doctor finding the injured worker fully recovered, or another change in situation.  But, a doctor could not possibly find the injured worker fully recovered before the date a workers’ compensation insurance carrier accepts a claim, right?  According to the Commonwealth Court of PA, that suspicion would be wrong.

In Danielle Wolfe v. Martellas Pharmacy (Workers’ Compensation Appeal Board), the injured worker was employed as a cashier, when on June 10, 2017, a metal gate came down on top of her head.  The workers’ comp insurance company issued a Notice of Temporary Compensation Payable (NTCP, also referred to as TNCP)) on June 28, 2017, accepting a “skull contusion.”  Rather than revoking the NTCP, the insurance carrier issued a Medical-Only Notice of Compensation Payable (MO-NCP) on September 8, 2017.  This stopped wage loss benefits (the Court also dealt with whether the insurer can dispense with the statutorily-required Notice Stopping Temporary Compensation (NSTC), finding that they can).

On August 10, 2017, the injured worker underwent a Defense Medical Examination (DME; humorously referred to by the Court as an Independent Medical Examination (IME) – nothing “independent” about these).  When the DME physician opined that the injured worker had fully recovered, the insurance company filed a Petition for Termination.

One of the pitfalls in the Pennsylvania workers’ compensation system is the concept of “withdrawal from the labor market.” Without intending to do anything but receive additional income, an injured worker in PA can easily cause his or her workers’ compensation benefits to stop accidentally. This is one of the many reasons we urge every injured worker to have the representation of an attorney Certified as a Specialist in Workers’ Compensation law (as are both of the attorneys at Brilliant & Neiman LLC).

A recent decision from the Commonwealth Court of Pennsylvania, Hi-Tech Flooring, Inc. v. Workers’ Compensation Appeal Board (Santucci), reminds us of the perils of an alleged “withdrawal from the labor market.” Here, the injured worker suffered what was initially accepted as a “right knee contusion.” Later litigation expanded the injury to a more accurate injury description of “ongoing progressive degenerative changes of the right knee as a result of the August 18, 2014 work incident.”

A few years after the injury, seeking to have additional income, the injured worker filed for pension benefits from his union and filed for Social Security Disability (SSD) benefits. Each application was accepted. The decision approving the SSD application noted that Claimant had the following ailments or conditions, “lumbar and cervical disc disease, status post C5-6 cervical discectomy and fusion; bilateral knee degenerative osteoarthritis, status post bilateral arthroscopic procedures; right hip degenerative joint disease; and status post total hip replacement.” According to the Court, the determination granting the SSD benefits did also mention “resulting synovitis in Claimant’s right knee and ongoing right knee pain.”

A topic often litigated in the Pennsylvania Workers’ Compensation system is whether an injured worker was within the scope and course of his or her employment at the time of the incident.  Accordingly, this is a topic that is no stranger to this blog.  Though this area continues to depend drastically on the facts within each case, a recent decision by the Commonwealth Court of Pennsylvania does shed some additional guidance on such cases.

In Henderson v. WP Ventures, Inc. (Workers’ Compensation Appeal Board), a custodian was waiting to be able to perform his usual tasks.  He was being prevented from doing so by the facility being cleaned and ventilated after a roof leak.  Taking advantage of his down time, the injured worker stepped out for a cigarette and to grab a sandwich from a nearby shop.  While outside of the facility, the injured worker fell and hurt his head.

A Claim Petition was filed, and litigated, before a Workers’ Compensation Judge (WCJ).  The injured worker testified that if his supervisor was not around (as was the case that day), he was permitted to take limited breaks without express permission when there was idle time.  This was not disputed by the employer.  After hearing the evidence, the WCJ granted the Claim Petition.  Specifically, the WCJ found, “Claimant was taking a cigarette break when he slipped and fell on the walkway outside of the building in which he was working, and this was a minor deviation from employment that would fall under the personal comfort doctrine.”

A recent case in the Commonwealth Court of Pennsylvania touched on two interesting aspects of the PA workers’ compensation system.  First, the Court dealt with the offset for Social Security Old Age benefits (personally, I find “Social Security Retirement” benefits a bit less offensive), under Section 204(a) of the Pennsylvania Workers’ Compensation Act.  Second, the role and importance of a post-injury conviction, in the context of the vocational process, was considered.

The case we are discussing is Sadler v. Philadelphia Coca-Cola (Workers’ Compensation Appeal Board).  Obviously a serious injury, the workers’ comp insurance carrier accepted “’a right pinky finger amputation,’ ‘distal radioulnar joint subluxation, ECU tendinopathy, pisotriquetral joint arthritis resulting in pisiform excision, right wrist DRUJ resection’ and ‘right transverse process fractures of L2-3 and L4, contusion to the right gluteal region/right hip, fracture of the right 6th rib and right leg radiculitis, . . . and low back sprain.’” After the injury, while receiving temporary total disability (TTD) benefits, the injured worker applied for Social Security Retirement (SSR) benefits (and, in turn, the insurance company filed a Notice of Offset, reducing the TTD payments based on 50% of the SSR benefits).  Also subsequent to the work injury, the injured worker was convicted of a Class II Felony and incarcerated for some period of time.

As frequently happens, the workers’ compensation insurance carrier had the injured worker evaluated for an “Independent Medical Examination” (IME; the word “independent” being dubious, since it is the carrier who unilaterally selects the physician).  After the IME doctor releases the injured worker to gainful employment, the insurance company retains a vocational counselor to prepare a Labor Market Survey (LMS), also known as an Earning Power Assessment (EPA).  The insurer then files a Petition for Modification, based on the jobs found in the LMS/EPA (in addition to a Petition for Termination, which is not relevant to our discussion).  Among other petitions not directly relevant, the injured worker filed a Petition to Review Benefit Offset.

One of the most unfair aspects of Pennsylvania Workers’ Compensation has always been how injured workers must defend petitions which address only medical benefits.   While injured workers receiving total disability benefits can easily retain an attorney (paying a portion, usually 20%, of such benefits as the fee), injured workers who continue to work, and lose no wages, must decide whether to pay an attorney from their pocket or risk losing access to medical benefits for the work injury.  However, this situation has now changed, thanks to a decision by the Supreme Court of Pennsylvania.

The PA Workers’ Compensation Act (“Act”) has typically been interpreted to allow attorney fees to only be assessed against the workers’ comp insurance carrier if there is a showing that the petition at issue was “unreasonable.”  Thus, the award of attorney fees, chargeable to the insurance company, was the exception to the rule.  This despite the fact that Section 440 of the Act says:

“In any contested case where the insurer has contested liability in whole or in part, including contested cases involving petitions to terminate, reinstate, increase, reduce or otherwise modify compensation awards, agreements or other payment arrangements or to set aside final receipts, the employe or his dependent, as the case may be, in whose favor the matter at issue has been finally determined in whole or in part shall be awarded, in addition to the award for compensation, a reasonable sum for costs incurred for attorney’s fee, witnesses, necessary medical examination, and the value of unreimbursed lost time to attend the proceedings: Provided, That cost for attorney fees may be excluded when a reasonable basis for the contest has been established by the employer or the insurer.” [Emphasis added]

Back in July, 2019, we blogged, unhappily, about the Commonwealth Court of Pennsylvania decision in Peters v. Workers’ Compensation Appeal Board (Cintas Corporation).  This decision found a traveling employee to not be in the scope and course of his employment when he was injured in a motor vehicle accident after leaving a work-sponsored event.  Today, it is our pleasure to report that the Supreme Court of Pennsylvania has issued a decision vacating the decision of Commonwealth Court.  Essentially, the Supreme Court agreed (as did we) with the two dissenting judges on the Commonwealth Court.

Just to give a quick recap, the injured worker (“Claimant”) was a salesman, who went to various sites in his day.  There was no dispute that he was a “travelling” employee for the purposes of the PA Workers’ Compensation Act (Critical, since commuting to work is not generally covered with a stationary employee, absent some other factor, such as “a special mission”).

One day, after completing his work, Claimant drove to a bar, where his employer was sponsoring an event, typical of an after-sales blitz.  The employer paid for the food and drink.  To get to this bar, Claimant had to actually pass the exit for his home.  After the event, Claimant was injured in a car accident.

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