Archive for September, 2011

What Constitutes a “Lawful” Personnel Action?

September 16th, 2011 2 comments

Applicant, a psychiatric nurse, filed a psyche claim after repeatedly being told by a supervisor (a psychiatric technician) to administer a drug at a more frequent rate than that prescribed by the treating physician.  The disagreement had to do with the meaning of “24 hour period.”  The technician incorrectly believed that a 24-hour period ran from midnight to midnight, rather than an actual 24 hour cycle beginning with the first administration of a drug.

The Workers’ Compensation Judge interpreted applicant’s claim as hurt feelings based on resentment at being under the supervision of a technician, and found applicant had suffered no actual injury.  Applicant filed a petition for reconsideration.

The Workers’ Compensation Appeals Board denied applicant’s petition, adopting the WCJ’s opinion and concluding that defendant’s conduct was a lawful, good-faith personnel action and regarded applicant’s claim as a means of confronting the defendant hospital over the issue of its chain of command.

The Court of Appeals took a different approach to this matter.  In its opinion, the Court annulled the decision of the WCAB and remanded the case to determine if the action of defendant, through its supervising technician, was, indeed, lawful.

Labor Code § 3208.3 governs psyche claims, and subsection (h) provides a defense against those psychiatric injuries substantially caused by “a lawful, nondiscriminatory, good faith personnel action.”

At least in this case, the good faith personnel action defense to a psyche claim turns on the meaning of the word “lawful.”  The psyche technician’s interpretation of “24 hours” seems at odds with the definition used in the practice of medicine, and likely the common sense meaning of the term (imagine a patient, in following the prescription of 1 pill every 24 hours, taking one pill ten minutes before midnight and another twenty minutes later.).

That being said, does such a mistake and deviation from generally accepted practice somehow make the supervisor’s actions anything other than lawful?  At most, this seems like an act of negligence.

Hopefully, lawful and correct will remain two distinct terms and the good-faith personnel defense will be one less chip worse for the wear.  Let’s all keep our eyes open for how this case turns out.

Categories: 3208.3, Defenses, Develop the Record Tags:

AB 375 DOA

September 15th, 2011 2 comments

Although your humble author is an admitted cynic, as a compensable consequence of  California Workers’ Compensation Defense practice, he is always happy to report a victory for employers (read: California’s survival).

Assembly Bill 375, introduced by Assemblywoman Nancy Skinner (D – 14th District), was voted down in the senate last Friday (September 9, 2011).

AB 375 would have created yet another presumption, this time for hospital workers.  If enacted, infection of certain bloodborne diseases would have been presumed compensable, even if the injury arises 180 days after the last day of work.

Admittedly, this is a limited victory.  It lightens no load for employers while merely checking one of the many encroachments against the employer survival rate.  However, a victory is a victory and even a cynic can be happy about that.

Categories: Legislation, News Tags:

132a When Employee Says He Can’t Do the Job? Not in My Workers’ Comp!

September 14th, 2011 No comments

In California’s Workers’ Compensation world, how much consideration can a defendant give an applicant’s own concerns about performing his or her job duties after an industrial injury?

In the relatively recent case of Moreno v. Workers’ Compensation Appeals Board, applicant energy technician injured his lumbar spine and right hand.  He then filed a claim for additional benefits under Labor Code § 132a.  Labor Code 132a provides additional benefits if the applicant can show discrimination against him or herself in retaliation for filing a workers’ compensation claim.  By law, an employer cannot insure against a 132a claim.

The skinny:  Applicant can not prevail on his 132a claim when he fails to show that he was treated differently than a non-industrially injured worker would have been; defendant successfully asserted the “business necessity” defense by showing a reasonable concern for undue risk of harm to the applicant in his pre-injury job.

Applicant had complained of pain in performing his job duties within the work restrictions set out by the Agreed Medical Evaluator.  The employer then put him on the priority list for the next available job, but took the original work away.

If the worker himself says he can’t do the job because of industrial-injury related pain, shouldn’t that be enough?  Apparently so!

The Workers’ Compensation Judge ordered the applicant to take nothing on the 132a claim, finding that applicant did not meet the burden of proof.  That burden could have been met by showing that non-industrially injured workers were treated better than applicant had been.

Furthermore, defendant had met the burden of showing its actions were motivated by a business necessity.  The business necessity defense was met by showing that, at the time applicant wanted re-instatement to his old job, the employer reasonably believed applicant was unable to perform the duties without undue risk of harm to himself, based on the conflict between the AME’s restrictions and the job duties.

After defendant sought clarification from the AME on the imposed work restrictions, the AME rescinded some, and applicant returned to work.

The Workers’ Compensation Appeals Board denied applicant’s petition for reconsideration, and the Court of Appeals denied applicant’s petition for a writ of review.

Categories: 132a, Defenses Tags:

Congress to the Rescue on Medicare

September 13th, 2011 No comments

Roberto Ceniceros, of Business Insurance has an interesting article on an issue that quickly became one of the more frustrating parts of California Workers’ Compensation practice.  The conflicts between employees and insurance companies, or the employee’s self-insured employers, can be heated and difficult, but that’s the nature of the game.  The frustration comes in when the parties have agreed and want to settle, but Medicare tells them they can’t.

This was the subject of an earlier post, but the efforts to change this system are the subject of Mr. Cenicero’s articleH.R. 1063 sponsored by (former) Congressman Tim Murphy, the bill is now referred to the House Subcommittee on Health, and would limit the amount of time CMS could respond to a request for Medicare Set-Aside approval.

Presently CMS will not respond to a request for approval of a settlement amount $25,000 or less if the applicant is a current Medicare beneficiary or will enroll in Medicare within the next 30 months and the settlement amount is over $250,000.  The CMS explanation may be read here.

As the saying goes, if wishes were fishes, we’d all be full (except, of course, those of us who do not eat fish).  That being said, both sides of the ongoing struggle of California Workers’ Compensation can wish for H.R. 1063 to eventually see the President’s signature.  For those who need a brush-up on how this process works:

Categories: Legislation, News Tags:

From China With Love

September 12th, 2011 No comments

A recent writ-denied case (Interwoven, Inc. v. Workers’ Compensation Appeals Board (2011) 13 WCAB Rptr. 13,252) explored, or rather declined to further explore, the extent to which a lien claimant must prove industrial causation in California’s Workers’ Compensation system.

The skinny:  A lien claimant has the burden of proving industrial causation by a reasonable probability standard, and not to a medical certainty standard.

Applicant traveled to China on business, and worked there for his employer, starting in April of 2000.  He fell ill in May of 2000, and his health quickly deteriorated until he expired in September 2001.

Prior to his death, he had been treated at Beijing Union Hospital, Stanford University Hospital, and UC Davis Hospital.  After the case in chief was settled by compromise and release in 2010, a lien-claimant, Healthcare Recoveries, Inc., came forward with a lien in excess of $2,000,000.

The facts present a murky issue at best – 29-year-old applicant is in China for a few months and some unknown event or substance causes him to fall ill and tragically die.

Though expert testimony entered into the record during the case in chief, the lien claimant met a standard of reasonable probability, but not medical certainty.

The standard, as articulated by the Workers’ Compensation Appeals Board panel (and which the Court of Appeals declined to review) was “more convincing force and greater probability of truth.  Thus, the preponderance of the evidence establishes that the decedent’s illness and death arose out of and occurred in the course of employment.”

Categories: Liens Tags:

Free Medical Care for Non-Industrial Injuries

September 9th, 2011 No comments

Labor Code § 4600, as part of California’s Workers’ Compensation system, imposes on employers, through self-insuring or through workers’ compensation insurance, to provide injured workers with medical treatment “reasonably required to cure or relieve the injured worker from the effects of” the injury.

But a person can be injured in more ways than one: an industrial shoulder injury and a non-industrial knee injury or an industrially injured respiratory system but non-industrial impairment of the circulatory system.  Does section 4600 turn an industrial injury into a ticket for medical buffet?  All indications point to section 4600 being ripe for abuse in this regard.

A recent panel decision denying reconsideration in the case of Hammerly v. Carrows Restaurant, in which applicant hurt her back.  The injury was accepted, and the agreed medical evaluator recommended psychological treatment to address persistent pain problems following a surgery performed on the injured area.  Applicant testified during her deposition that she had not filed a claim for injury to the psyche, nor did she intend to.

Defendant then argued that psyche treatment is unwarranted without applicant’s meeting the predominant cause standard of Labor Code § 3208.3.  Section 3208.3(b)(1) states that “in order to establish that a psychiatric injury is compensable, an employee shall demonstrate by a preponderance of the evidence that actual events of employment were predominant as to all causes combined of the psychiatric injury.”

Until applicant had met her burden of proof, argued Defendant, she was not entitled to any psychiatric treatment.

The Workers’ Compensation Judge and the Workers’ Compensation Appeals Board were not persuaded by this argument and instead held that section 3208.3 does not limit the application of section 4600.  Because treatment of a non-industrial impairment is necessary to relieve the effects of an industrial injury, the employer must pay for this treatment.

In other words, if an applicant’s non-industrial obesity makes surgery for an industrial injury less safe, applicant is suddenly entitled to a “free” gym membership, or perhaps even an at-home gym.

If applicant’s non-industrial depression makes physical therapy ineffective, applicant becomes entitled to psyche treatment.  Perhaps applicant is even entitled to a ramp on his vacation home.

So long as an applicant’s attorney can persuade a panel qualified medical evaluator or an AME to link the symptoms of a non-industrial injury with an industrial one, applicant becomes entitled to free medical care (not free to the employer, of course, just free to the applicant).

This, of course, translates to more leverage for the applicant to demand a higher settlement by compromise and release, forcing defendants to choose between paying the Danegeld or enduring a scorched Earth campaign.  Neither is appealing, especially when faced with a sympathetic evaluator.

The best way out of this trap is solid advocacy – the attorneys in the Hammerly case put forth a good argument, but sadly it did not work, despite its obvious merit.  The key battles appear to be in the initial selection of a QME and the persuasive depositions that follow.

Categories: Uncategorized Tags:

Regulating the Economy Towards Prosperity

September 8th, 2011 7 comments

The refreshing winds of September are filling the air, and as they sweep in, they bring with them that rosy scent of fresh legislation: as always, fiery, thick, and perfectly half-baked.  Two pieces of would-be/will-be law have come under the popular spotlight recently.  The first is that of Assembly Bill 889 put forward by Assemblyman Tom Ammiano (D – San Francisco).

The bill would require rest-breaks, over-time pay, and (you guessed it) workers’ compensation insurance for domestic workers such as care persons, nannies, babysitters and cleaners.

While exempting babysitters under the age of 18, I expect this bill, if made law, to send presently free-lance domestic workers into the arms of organized companies.  No matter how much I want to see a perfectly good classic movie ruined by a modern-recreation in a theater, I have no intention of hiring a human resources staff to help me comply with this law while hiring a babysitter for the evening.  I imagine the typical parent in California will likely feel the same way.

So free-lancing, self-employment for babysitters and other domestic workers might decrease, insurance profits may go up, and Sacramento will press harder on small employers with its left hand while continuing to squeeze larger businesses with its right.

The second piece of legislation is Senate Bill 684, which makes it more difficult for insurance companies to have and to enforce arbitration clauses in their workers’ compensation insurance contracts, by requiring a separate disclosure of the existence of the arbitration clauses, the venue and choice of law of the arbitration, and the fact that they are negotiable.

Authored by State Senator Ellen M. Corbett (D – San Leandro), the legislation was greeted with enthusiasm by Insurance Commissioner Dave Jones in a Department of Insurance Press Release.

Many insurance companies are regional or national, and so would normally be subject to the contract laws of several states (wherever their policy holders entered into the contract).  Arbitration clauses allow all disputes to be resolved in one state, and the insurance company’s legal department needs to know only one state’s laws.

Now, insurers will have to either face increased costs in negotiating, quoting, and preparing insurance contracts, or retain different legal departments for every state in which they offer their services.  But while the costs of operation go up, workers’ compensation insurance rates are set by law and cannot be increased.

SB 684 has passed both the Assembly and the Senate and now awaits Governor Brown’s signature.  Perhaps, if the legislation is signed into law, an update will be necessary on the benefits of self-insurance.

Categories: Insurance, Legislation Tags:

A Rejected Theory of Causation

September 7th, 2011 No comments

California Workers’ Compensation law allows the injured worker to recover not only for the actual injury sustained, but also many of the consequences that follow from the impetus of the injury.  An injured right knee turns into a bilateral knee claim, injured elbows can lead to psyche claims, and injured backs develop into compensable sleep disorders.  But, despite all evidence to the contrary, it appears that the “compensable consequences” is not a panacea for all of an applicant’s injuries, industrial or otherwise.

A recent writ-denied case rejected an applicant’s theory of causation of injury to his previously non-injured arm.

The case is that of Jantz v. Workers’ Compensation Appeals Board (2011 Cal. Wrk. Comp. Lexis 119).  Jantz injured his legs, elbows, back, left arm and left shoulder.  Some time afterward, he fell at his granddaughter’s softball game because of uneven cement, injuring his right shoulder.

His theory of causation for the right shoulder as a compensable consequence?  If his left arm had not been in a sling, he would have been able to use his left arm to stop his fall.  The theory was squarely rejected as speculative.

Jantz will hopefully lend itself easily to other cases to defend against other compensable consequence claims.

Categories: Defenses Tags:

Another Extra-MPN Case

September 6th, 2011 No comments

As you might recall, the Valdez case, which is presently awaiting a new decision from the en banc Workers’ Compensation Appeals Board, was discussed here and here.

The original Valdez decision held that medical reports from doctors outside of defendant’s Medical Provider Network are inadmissible, and the defendant is not required to pay the bills for these reports.

Recently, the Court of Appeals issued a writ denied opinion for a WCAB decision with a similar holding – non-MPN doctors’ reports are inadmissible.  (Scudder v. Verizon California (2011Cal. Wrk. Comp. P.D. Lexis 138)).

The order denying applicant’s petition for writ of review can be found under the citation 2011 Cal. Wrk. Comp Lexis 126.

Had the Court of Appeal granted the petition for writ of review (and, ideally, affirmed the Scudder WCAB panel opinion) the Valdez case may have very well been moot.

Two of the commissioners on the Scudder panel are on the Valdez en banc panel as well.  Hopefully that is grounds for some optimism as to how the en banc decision in Valdez will ultimately empower or cripple Medical Provider Networks in California Workers’ Compensation practice.

As always, brave readers, when I know more, so will you.

Categories: Medical Provider Network Tags:

Happy Labor Day!

September 5th, 2011 No comments

Happy Labor/Labour day!  Just to make you crack a smile:

Categories: Uncategorized Tags: