Category Archives: QMEs

Compensability Presumption Defeated by Lying Applicant

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Apparently, the Home Depot can be a stressful place to work.  William Wong worked at Home Depot as an assistant store manager, but was fired shortly after sending his supervisor a letter by facsimile indicating that he intended to file a workers’ compensation psyche claim.  (William Wong v. The Home Depot)

Then, it was all quiet on the comp front for more than seven years, after which applicant resurfaced to file an application for his psyche injury.

Naturally, the defense invoked the statute of limitations and lawful good-faith personnel action under Labor Code section 3708 defenses.  The workers’ compensation Judge ruled that applicant had documented that the employer had notice of the claimed injury, but he had not been provided with a claim form, and the injury had not been denied within 90 days, so it was presumed compensable under Labor Code section 5402.

If anyone other than applicant’s evaluating physician asked what applicant had been up to in those seven years between the “injury” and the filing of the application, applicant could have told them about his arrest for possession of a controlled substance and resisting arrest.  But that information wasn’t given to the evaluating physician.  He also told the evaluating physician that there was no history of psychosis in the family, even though his uncle had committed suicide.

Needless to say, the workers’ compensation Judge was not impressed.

Although the WCJ held that the presumption of compensability under Labor Code 5402 applied, that presumption was rebutted because applicant proved to be an unreliable historian, meaning that the medical reports based on his statements were not substantial evidence.

Also, the WCJ reasoned, the history of criminal activity and drug use could have been causative factors in his psychotic break.   In other words, as your humble blogger likes to say, No Soup For You!

Bear in mind, my dear readers, the defense in this case got very lucky.  Applicant had a bad history, and lied to the evaluating physician.  If applicant had not lied about his arrest history and the psychosis history of his family, he would have probably recovered and only suffered a bit of apportionment.  In any case, let this be a lesson to us all – hand out claim forms early and often!

Different Strokes for Different Folks

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In as much as you adore your humble blogger, one can only hope that you will forgive the pun in today’s blog post title.

Applicant suffered a stroke while working as a journeyman screen printer in the case of Francisco Amaya v. California Printed.  Mr. Amaya was given the job of printing thirty six flags and a deadline of 1:00p.m.  The trial evidence differed on whether he was assigned this task at 8:00 a.m., allowing for five hours, or at 9:30 a.m., allowing for three and a half hours.  In any case, because of the “stressful working condition” of having to make so many flags to print in so little time, applicant suffered a stroke.  Also contributing to the stroke was the fact that he had stepped on a spray can, causing him to fall to the ground.  Sounds pretty bad, no?

Well, some facts might clear this up.  Applicant suffered his stroke a little before 11:00 a.m., and at that time had completed six of his assigned thirty six flags.  So, that means that he had between 1.5 and three hours to print the six flags, leaving another 30 to be completed by 1:00 in the afternoon.  How many flags could YOU print in that short a time period? 10? 20?  Well, if you’re one of applicant’s co-workers, it would probably take you thirty minutes, which is what it took another employee who was assigned the remainder of Mr. Amaya’s workload.  Not so much of a “high pressure” situation any more, is it?

Also, what may have contributed to the stroke was the non-industrial and untreated “hypertension, hypercholesterolemia, and diabetes” which applicant had at the time of the stroke.

So, here is what the panel QME did with this case:

1)      He ordered a CT scan of applicant’s head, because head trauma “could have been a precipitating or enhancing factor.”  Without having seen the CT scan results, eh concluded that applicant’s stroke was caused by 25% industrial factors and 75% non-industrial factors.  When he later saw that the CT scan showed no head trauma, he declined to change his opinion.

2)      He also found that his stroke could have been a reaction to stepping on a spray can, but if he did not step on the spray can, the PQME would not change his opinion.

Here is how your skeptical blogger reads these facts: “well, I’m not going to let these facts let this guy walk away from this thing empty-handed.”

The defense argued that the PQME’s opinions do not constitute substantial medical evidence – this lunacy of a medical opinion does not justify its findings and seems unmoved by any shifting facts.  So, what do you think the Workers’ Compensation Judge did with this?

The WCJ threw it out of her courtroom!  She found that the PQME “did not explain the bases for his opinion that Applicant’s work activities … constituted 20-25% of the causation of the stroke, irrespective of the pace at which Mr. Amaya was required to work.”  The injury was ruled non-compensable, and applicant’s request to take a second bite at the apple further develop the record was denied as the PQME “has been given ample opportunity, through the deposition process, to provide support for his opinions… [he] has not provided the necessary support, and … further discovery such as another deposition is not likely to yield a properly supported opinion.”

The Workers’ Compensation Appeals Board denied applicant’s petition for reconsideration and incorporated the WCJ’s report.

Curious about this Northern California PQME who hands out causation like it’s candy?  Please shoot me an e-mail for the panel opinion: gregory@grinberglawoffice.com

An Evaluator Turning Down the Almaraz/Guzman Dance

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This blog has covered some tactics that good defense lawyers can use to push back against the impairment inflation of Almaraz/Guzman. Sometimes, we even see A/G used to actually cut down the total impairment.  In the recent case of Malhotra v. State of California, Department of Developmental Services, the panel Qualified Medical Evaluator was not inclined to jump on the A/G bandwagon… and the Workers’ Compensation Judge would have none of it.

Applicant sustained an injury consisting of a laceration to the small finger of his hand, resulting in decreased range of motion and loss of sensation.  The panel QME found this to reflect a 2% whole person impairment.   The applicant’s attorney tried, unsuccessfully, to play the A/G tune for the PQME and get him to rate grip loss with or instead of the decreased ROM and loss of sensation.

But he wouldn’t budge – the PQME in this case manifested some strange and completely irrationally dedication to the truth and the honest evaluation of applicants.  The AMA Guides clearly state that, in the presence of reduced range of motion, grip loss cannot be rated.

In crafting the instructions to the DEU rater, the WCJ noted that the PQME “does not appear to be aware of the latitude he has,” and proceeded to instruct the DEU to rate grip loss.  The result, of course, was a 20% permanent disability rating.  On cross-examination, the DEU rater testified that he would not have rated grip loss, but would have instead rated applicant with 1% permanent disability, but the Judge’s instructions are the Judge’s instructions.

After the WCJ awarded applicant 20% permanent disability, defendant promptly and zealously petitioned the Workers’ Compensation Appeals Board for reconsideration.  On what possible grounds could an objection to the course of events be made?  Well, in the en banc case of Blackledge v. Bank of America (2010), the WCAB held that the physicians assess the injured employee’s whole person impairment, and the WCJ frames rating instructions.

According to the WCAB, the WCJ, in this case, was “again usurping the role of the physician in determining that applicant’s impairment should be based upon grip loss, rather than the factors he identified that comport with the AMA Guides.”   (To my dear WCJs out there, please recall, your humble blogger but reports these opinions, he does not draft them.  If he were free to draft binding opinions, there probably would be considerable cause to be very angry with what he had to say…)

The end result was a victory for the defense and for anyone interested in having a workers’ compensation system build on consistency and predictability – a scratch on your pinky does not render you only 4/5th of the worker you were.

When the PQME Goes Ex Parte, Who Gets to Order a New Panel?

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WCDefenseCA does not often agree with panel opinions which hand victory to an applicant at a defendant’s expense.  Grudgingly, however, your humble blogger is forced to agree with the panel decision in Darlene Berke v. Bloomingdales.

We all remember how Alvarez threw the workers’ compensation world, applicants’ attorneys and defense lawyers alike, upside down, keeping us guessing as to how trivial or administrative a communication could incur the punishment of an ex-parte sanction.  Subsequent decisions have since clarified this issue, but only a little.

Well, the Berke case did not reach that point.  Instead, it addressed the issue of who holds the right to demand a new panel under Labor Code section 4062.3(f).  Basically, the panel Qualified Medical Evaluator called the defendant’s office demanding payment of a deposition fee two weeks in advance of the deposition, complaining of a history of insurance companies not paying him.

The defense moved to have the panel stricken for ex parte communication – the PQME contacted them in an inappropriate manner (not in writing and not copied to both sides).  The workers’ compensation Judge and the Workers’ Compensation Appeals Board both ruled that the party not involved in the ex parte communication holds the right to request a new panel.

This makes sense, after all – imagine if any time the applicant was unhappy with the panel QME, he need only pick up the phone and talk about the weather for 10 minutes before he could demand a new panel.

However, that being said, if your ever-ambitious and power-hungry blogger should ever get his hands on a black robe and gavel, he could be persuaded that defendant’s position is the correct one under a particular theory.

What is this brilliant theory that your sharp-witted blogger hatched to bring glory to the defense community?  I’m so glad you asked!

In Berke, it was the PQME who initiated the contact and engaged in ex parte communication with a party.  In such a case, it is fair to assume that the PQME, either through ignorance of the law or through reckless disregard of it, has a habit or propensity of engaging in such behavior.  Therefore, if the defense knows that the PQME has engaged in ex parte communication with it, the defense can safely assume that the PQME has or will engage in ex parte communication with the applicant’s attorney.  Sometimes, such communications may go unreported by the other side.

Also, ex parte communication should come with a sanction of some sort.  In cases such as these, the parties are blameless, but the PQME is in the wrong.  Perhaps a loss of fees and probationary QME status is an appropriate punishment.

 

What Happens When the Defense Goes Along with an Improper Panel Request?

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A recent panel opinion discussed the issue of waiver in the context of workers’ compensation.  Your gadfly blogger will quickly run through the facts so he can begin yet another angry rant against the workers’ compensation system.  (The case is Israel Granados v. Barrett Business Services).

Applicant saw a number of treating physicians within defendant’s MPN for a variety of alleged injuries, including injury to the hand, arm, wrist, upper extremity, psyche, and in the forms of a sleep disorder and headaches.  So what’s the problem with humpty-dumpty?  He decided the treating physicians weren’t giving him a high enough rating and he elected to go outside the Medical Provider Network.

When the workers’ compensation Judge ruled that the extra-MPN reports were not admissible (see Valdez).  At that point, applicant demanded panels in various specialties, psyche amongst them, citing objections to the MPN treating physician reports.  This was a puzzling development, given that none of the MPN physicians had yet issued an opinion with respect to applicant’s psyche claim.

Defendant went along with the dance, striking one psyche qualified medical evaluator from the panel, requesting the remaining PQME address certain issues.  But, after reviewing the report, objected to the psyche QME as improperly obtained.  The WCJ and the Workers’ Compensation Appeals Board both found that defendant had waived his objection to an improperly requested panel (“we will deny reconsideration because by failing to object to the section 4062 and 4062.2 process until it was complete, the defendant invited any error and waived any objection.”)

The same treatment, however, does not often extend to applicants and their attorneys.  If you are reading this blog post somewhere with privacy, go ahead and raise your hand if you’ve had a Judge allow an applicant to get a second panel because he or she became represented after the first panel QME didn’t award total permanent disability for a paper cut, even after there was an evaluation and report.

This policy of waiver applies more evenly or fairly the higher one goes in the chain of appeal, but on the ground level, far too often there is leniency afforded to applicants and their attorneys that would get a defense attorney sanctioned.

In any case, the defense bar will just have to look at this as a training tool – under these conditions, we are always at our very finest in order to get the job done.

New Record for Faintest “Injury” Resulting in Death Benefits Award

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So let me get this straight… applicant-nurse is “attacked” by a teen-aged patient and sustains a scratch and a bruise.  She shrugs it off and goes about her day.  Six days later she has a stroke (arguably caused by her pre-existing, non-industrial hypertension) and then dies more than a year later.  The panel Qualified Medical Evaluator finds her stroke and death to be non-industrial… and somehow the workers’ compensation Judge still comes down on the side of the applicant?

In the case of Amelia Mendoza (Dec’d) v. Workers’ Compensation Appeals Board, applicant nurse was evaluated for her scratch and bruise while she was suffering from non-industrial hypertension and high blood pressure.

The workers’ compensation Judge went so far as to say that the panel QME was a doctor “hired by defendant” and disregarded his opinions as influenced by a “bias in favor of a hospital where he may wish to practice and a defendant who he may wish to do QME work for.”  Still no word on whether chiropractor QMEs can be disqualified for “bias” because they may want to later serve as treating physicians for the applicants they evaluate.

After the trial, the WCJ awarded death benefits when no claim for death benefits had been made and the only issues at trial were Arising out of Employment/in the Course of Employment (AOE/COE) and applicant’s attorney’s fees.

So what did the WCJ base his conclusion on, if not the opinions of the “hired” and “biased” panel QME?  The treating physician – the one who:

(1) relied on the widower-husband’s accounts of the “attacks” who was not present during the time of the attacks;

(2) relied on a report of a head injury (which were not mentioned in any contemporaneous medical reports); and

(3) somehow found a causal link between applicant’s high blood pressure and the scratches she sustained during the “attack” simply because both were observed at the same time.

The Workers’ Compensation Appeals Board, in granting defendant’s petition for reconsideration, held that the WCJ appeared to imply that “when an employee with pre-existing nonindusrial hypertension seeks treatment for a minor industrial abrasion and exhibits concurrent elevated blood pressure, the employer thereafter becomes liable for all treatment and consequences of the employee’s elevated blood pressure.  That is not an accurate interpretation of workers’ compensation law.”

Not easily discouraged, applicant filed a petition for writ of review … which the Court of Appeal denied.

Appeals are expensive and time-consuming, but they are often worth it, especially in cases like these.  The defense stuck to its proverbial guns and didn’t allow its case to get steamrolled.  WCDefenseCA sends its salute to the Huntington Hospital. 

Audiologists to Become QMEs

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Let’s say you want to get a qualified medical evaluator to take a look at the applicant’s hearing and determine if there is any basis for apportionment or to argue AOE/COE.  It’s simple, you would just request a panel in with the specialty of audiology, right?  What’s that you say?  There’s no such specialty… not even at the QME database on the Medical Unit’s website?

Well, it looks like there may be a change to that soon enough.  Assembly Bill 1454, introduced by Assembly Member Solorio (D-69th District), unanimously passed through the Committee on Insurance on March 28, 2012 and is on its way back to the Committee on Appropriations.

Some of my readers may recall that Assemblyman Solorio has been mentioned on this blog before, having exerted his influenced in an effort to see the temporary disability cap raised to 240 weeks.

We’ll have to keep our collective eyes on this one – before we know it, we may be fighting off prescriptions for blue-tooth devices and trying to figure out if the new crop of audiologists has an applicant bias.

Is 15 Miles Too Long to Drive for an Evaluation?

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The panel Qualified Medical Evaluator system certainly has its advantages – less doctor-shopping, less doctor and deposition fees, etc.  On the other hand, it has the ridiculous effect of sticking parties with a list of three (effectively two, once the other side uses its strike) choices in who the panel QME will be.  After all, the physician may not be actually qualified or may have an applicant’s bias (“What do you mean it’s NOT industrial? There is no such thing!”).

Parties will try every trick in the proverbial book to get out from under a bad panel.  The recent case of Sharon Frink v. Shasta-Tehama-Trinity Joint Community College is no exception.  The basic point of this case was that applicant was evaluated by a PQME in Anderson, California.  The PQME then moved his office to Redding, California.  The two offices were 15 miles apart.

Naturally this warrants a new panel, because the doctor was obviously “unavailable” under California Code of Regulations section 34(b).  Applicant’s attorney moved for a new panel and the defense filed a petition to compel attendance at the PQME’s new office in Redding.  Reading the plain language of the rule, the workers’ compensation Judge ordered the Medical Director to issue a new panel.  It may be just your beloved cynical blogger’s observations, but it seems that asking a WCJ to apply the plain language of a rule or statute is usually a fruitless effort when done by defendants.

Defendant promptly petitioned the Workers’ Compensation Appeals Board for removal.  Dear readers, if you are wondering why this issue was not the subject of a petition for reconsideration instead, might I suggest you glance at the “Reconsideration or Removal?” posts.  In granting the defendant’s petition for removal, the WCAB held that “the Legislature intended to prevent the AME/QME selection process from restarting where there is a reasonable possibility that the injured worker return to the same medical evaluator.”  This policy “both minimizes medical-legal costs and thwarts attempts to doctor-shop.”

In other words, a 15-mile-drive is not an unreasonable burden for the applicant to undertake.

The MPN is Back! (For Now)

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The post made on Wednesday had some scary implications.  Fortunately, it appears there may be a light at the end of the tunnel, and this time it has a 50-50 chance of not being a train.

In the case of Michael Thomas v. Safeway Stores Inc., the Workers’ Compensation Appeals Board had previously ruled that the self-insured employer must pay for surgery to be performed by a surgeon in Washington, even though there were eleven surgeons in Safeway’s medical provider network which could do the surgery and were close to applicant’s residence in the San Francisco Bay Area.

Panic ensued among the defense community as the California Applicant’s Attorneys Association toasted to the death of the MPN over flutes of champagne.  But it appears that Safeway stood firm and in filing a petition for reconsideration was rewarded with the sight of the WCAB blinking.

Standing firm against the waves is a sensation every workers’ compensation defense attorney wants to feel – staying standing when the wave crashes against you is one rarely felt.

A new order issued granting reconsideration, giving the parties ten days to settle this dispute or to return to the workers’ compensation judge to give the defense a chance to cross-examine the panel qualified medical evaluator and offer rebuttal evidence.  After all, defendant’s due process rights were summarily brushed off thus far.

Defendant’s offer to settle the matter was fairly reasonable:  Safeway would pay for the surgery under the California fee schedule and applicant would pay for travel and lodging.  There is no word yet on whether the applicant, let alone the surgeon in Washington, would agree to these terms.

In short, it appears that sanity might return to the world of workers’ compensation, even if for a short while.  Workers’ compensation lawyers and adjusters can rejoice in that, at least for now.  Despite rockets red glare and bombs bursting in air, the MPN flag is still there!

In what is quickly developing into an MPN trifecta here at WCDefenseCA, drop by on Monday to see another pro-MPN opinion recently released into the wild.

A Few Acceptable Ex Parte Communication Types

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Every once in a while, the storm of insanity that is California’s workers’ compensation system breaks, and a gust of rational air soothes and refreshes us all.

As my well-read and well-informed readers no-doubt remember, the panel QME system was turned into a grade-school dance by the decision in Alvarez v. Workers’ Compensation Appeals Board.

The panel qualified medical evaluators lined up on one side of the gym, the workers’ compensation attorneys on the other, each afraid to move lest they be accused of cooties ex parte communication.

You see, the Alvarez decision didn’t tell the world of workers’ compensation exactly what is, and what is no, ex parte communication of the sort that would trigger a Labor Code section 4062.3, but instead said that “an [ex parte] communication may be so insignificant and inconsequential that any resulting repercussion would be unreasonable.”

For a while after the Alvarez decision, defense firms (and possibly applicant’s offices) were walking on egg-shells.  If sending a letter by facsimile to the panel QME, make sure to fax it to the applicant’s attorney first, and keep a confirmation receipt of both!  It’s silly – an immaterial communication having nothing to do with the substance of the case, often times enough conducted by support staff on both ends.

Who wants to be the first to ask one of the girls to dance?

A recent panel opinion (Lewis Cunningham v. County of San Bernardino (2011) 14 WCAB Rptr. 14, 012) concluded that at least three forms of communication between a panel QME and an applicant’s attorney did not trigger a right to a new panel:

1) a communication to obtain a copy of an echocardiogram report;

2) a communication to facilitate scheduling a deposition; and

3) a communication to facilitate re-scheduling a deposition.

No doubt the limits of “insignificant and inconsequential” will be explored further in the future, perhaps with some binding authority providing a list.  In any case, so long as the matter remains uncertain, more litigation and more expense will follow.