tag:blogger.com,1999:blog-65715366664114849322024-02-08T14:56:19.625-05:00PA Work Comp DefenseA Review of Pennsylvania Workers' Compensation Law for the Employer and Insurerpawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.comBlogger160125tag:blogger.com,1999:blog-6571536666411484932.post-66224523650017948302023-04-14T15:45:00.001-04:002023-04-14T15:45:19.876-04:00A Review of "Reasonable Travel" in the identification of "Open & Available" employment positions for the Pennsylvania injured worker. <p> </p><p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">REASONABLE TRAVEL AND THE “AVAILABLE” JOB OFFER <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">What constitutes an “open and available” offer of an
employment position in terms of the travel time/distance required </span><span style="font-family: "Times New Roman", serif; font-size: 16px;">by the injured worker </span><span style="font-family: "Times New Roman", serif; font-size: 12pt;">to reach the work site ?</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The Employer has a remedy in the Pennsylvania Workers Compensation
Act for Modification or Suspension of indemnity wage loss compensation benefits,
which maybe be based upon the establishment of an injured worker’s post-injury
earning capacity. That earning capacity may be established via an offer of a
position by the employer or via vocational expert evidence in an Labor Market
Survey and Earning Power Assessment report.<span style="mso-spacerun: yes;">
</span>An Employer must produce evidence in support of a modification or
suspension of an offer of an open position that fits the occupational category
for which the injured worker has been provided medical clearance. See
Generally: <u>Kachinski v. WCAB (Vepco Construction Co.) 532 A.2d 374 (pa.
1987). </u><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">There are a number of factors to consider in
establishing that an employment position is “open and available” to an injured
worker – medical restrictions, vocational or education requirements,<span style="mso-spacerun: yes;"> union status, </span>specialized skills, to name just a few. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The travel required to an available employment
position is another criteria to be considered when preparing the job offer .
Appellate decisions have established certain parameters regarding availability
of transportation, travel time, travel distance with an assessment of a
“totality of the circumstances” when making a determination of the availability
of an employment position. <o:p></o:p></span><span style="font-family: "Times New Roman", serif; font-size: 16px;">The analysis of these factors is identical for the Employer job offer and the Vocational Expert Earning Power Assessment.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">One appellate decision referred to a 25 mile radius as the <span style="mso-spacerun: yes;"> </span>“industry standard” in vocational placement. A
modification of compensation benefits was granted based upon LMS/EPA evidence of
positions offered within the this travel range. This travel was found to be in claimant’s
geographic area. <u>Bentley v. WCAB (Pgh. Bd. of Educ.) 987 A.2d 1223 (Pa.
Cmwlth. 2009).</u> The “industry standard” terminology seems to have been surpassed by
the use of the “totality of the circumstances” standard.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Travel to an employment site (distance or time) can be
a significant criteria is assessing the “availability” of an employment
position, as a position can be found to be <u>unavailable</u> where the worker
can perform the physical requirements of the position – but he/she cannot
tolerate the work commute. Where the work commute was 120 miles in addition to
the 8 hour work day, it was determined that the work position was not “available” to modify workers
compensation benefits. See: <u>Roadway Express Inc. V. WCAB (Palmer) 659.A.2 12
(Pa. Cmwlth. 1995). <o:p></o:p></u></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">An employment position as a dispatcher was found to <u>not
be available</u> to a former interstate truck driver where the position
required the injured worker: (1) to leave his residence; (2) establish
residence at a motel; (3) purchase all meals; (4) at a location 116 miles from
the residence.<span style="mso-spacerun: yes;"> </span>See: <u>Litzinger v. WCAB
(Builders Transport) 731 A.2d 258 (Pa. Cmwlth. 1999). <o:p></o:p></u></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">One parameter has emerged regarding work site location
and the assessment of the “availability” of an employment position. The
employment position location may be assessed on the basis that –<span style="mso-spacerun: yes;"> </span><b>the travel required to the work site is
within the geographic area that others in the same community would travel.</b> Where
jobs offered were 39 and 42 miles from claimant’s residence, benefit
modification was denied, as there was no evidence that other workers in claimant’s
community would travel this distance for work. <span style="mso-spacerun: yes;"> </span><u>Peljae v. WCAB (Mrs. Smith’s Frozen Foods)
667 A.2d 763 (Pa. Cmwlth. 1995).</u> <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Similarly, a work position was found to be <u>not available</u> where
the one way commute was 150 miles and the total commute was 6 hours per day. Note:
Although this travel distance seems significant, in context, this Claimant had
previously worked at a site 100 miles from their residence. However, a determining factor was that there was
no evidence that other community members would work in this distant area. <u>Trout v.
WCAB (Trans Continental Refrig.) 836 A.2d 178 (Pa. Cmwlth. 2004).</u><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Contrast - where an employment position was <u>found
to be available</u> where it required a commute of 47 miles one way
(roundtrip 94 miles). Although the wage was in a lower range, this position was available
on a full-time basis, 8 hours per day, 5 days per week. This employee had adequate personal
transportation available and <b>the vocational expert testified that it was
common for individuals in the same community to accept employment at that
location.</b> The WCJ rejected claimant’s evidence that he could not tolerate
the driving. <b>A two (2) hour commute with an 8 hour work day was found to be not
unreasonable.</b> <u><span style="mso-spacerun: yes;"> </span>Dilkus v. WCAB
(John F. Martin & Sons)<span style="mso-spacerun: yes;"> </span>671 A.2d
1135 (Pa. 1996). <o:p></o:p></u></span></p>
<p class="MsoNormal"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Likewise, a public transportation commute of less
than one hour each way was reasonable</span></b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;"> and the position was <u>available</u>
to the claimant. This was a city commute from NE Philadelphia to Center City Philadelphia, which
was described as a “extremely common commute”. <u>Sinnott v. WCAB (2014 Pa.
Commw. Unpub. LEXIS 359 Cmwlth. 2014. </u><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">A position was found to be <u>available</u> based upon a “totality
of the circumstances” presented, where the employee travel would increase from
60 miles to <b>68 miles.</b> This mileage increase was described as a negligible difference. The
position was full-time, with a greater wage. It was found to be employment within claimant’s geographic
area. <u>Newhouse v. WCAB (P.J. Dick Corp.) 803
A.2d 2002).</u><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">A position was <u>available</u> where the travel was
25-30 miles one way, a total commute of 50 miles per day for a full-time
position. Claimant presented evidence and his testimony regarding his allegations of limitations of his driving, alleged as a result of his work-related physical
symptoms. This evidence was found to be not credible. <u>Shultz v. WCAB 2011 Pa. Commw. Unpub. LEXIS 593 Pa.
Cmwlth 2011.</u> <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">In the legal anaylsis and assessment of the "availability" of an employment position, one may reasonably assume that a person’s personal preference is irrelevant – if the
position is located in the same community that others would accept employment. Jobs
offered to this claimant were 8, 10 and 37 miles away. These jobs were found to
be within the claimant’s geographic area. Testimony that Claimant preferred to
not “drive out of town” due to possible snow and ice was not relevant to the assessment
of job availability. <u>Scheib v WCAB (Ames Dept. Stores) 598 A.2d 1032 (Pa.
Cmwlth. 1991).</u> <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Caution must be noted – as there have been occasions when a claimant may successfully
argue that a job is not “available” as they do not have <b>a reliable vehicle
available</b> or they do not have access to reasonable public transportation. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">See <u>DME Company v. WCAB (Peters) 639 A.2 869 (Pa. Cmwlth.
1994)</u> where a light duty position that was <u>20 miles</u> from claimant’s
residence was found “not available” as claimant had a vehicle, but it was
unreliable. Also there was no evidence that: (1) public transportation was
available and (2) that claimant community members would travel to work in this
area.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">One may appropriately observe that – that the commute time and travel distance
are not absolute “standards”. As Appellate decisions have evolved over time, there has been an
emphasis upon the “totality of the circumstances” standard. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">For example, a part-time 20 hour per week light duty job was <u>not
available</u> to a claimant, where the job site was 30 miles from the residence
– but not private transportation was available and the public transportation
commute would total 3 hours with 4 bus transfers. The Court noted that this job
offer would require a three (3) hour commute for a employment during a four (4) hour per day job. See: <u>Goodwill
Industries v. WCAB (Friend) 631 A.2d 79 (Pa. Cmwlth. 1993). </u><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">In Conclusion, where the injured worker has reliable
private or<span style="mso-spacerun: yes;"> </span>public transportation
available, an employment position may be considered to be “available” if the
travel time/distance/location is <span style="mso-spacerun: yes;"> </span>typical
for individuals in the same community to accept employment at that location.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Assessments of job availability based upon the travel
distance/time requirements have varied. A position 25 miles from the claimant’s
residence has been found to be “available” … and so has a position which is 68
miles from the claimant’s residence.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">When assessing the "availability" of an employment opportunity to the injured worker , we believe that an employment position which requires
a Claimant’s travel time of approximately one (1) hour, would be a position within
the parameters of appellate decisions which have found similar positions to be “available”.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;"><o:p> </o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-63126292746743198202023-03-20T15:38:00.005-04:002023-03-20T17:38:43.366-04:00<p> </p><p class="Default" style="text-align: center;"><b><span><span style="font-family: arial;">Pennsylvania Commonwealth
Court orders Work Comp insurer to reimburse an injured worker for out-of-pocket
expense for medical marijuana</span></span></b></p>
<p class="Default"><span><span style="font-family: arial;">In two recent decisions, the
Pennsylvania Commonwealth Court reversed the Workers Compensation Judge
decision and ordered the workers compensation insurer to reimburse
out-of-pocket expenses, incurred by an injured worker, as reasonable and
necessary medical expenses. See:</span></span></p>
<p class="Default"><span style="font-family: arial;"><b><u><span>Teresa L. Fegley, as
Executrix : of the Estate of Paul Sheetz v. Firestone Tire & Rubber (WCAB),</span></u></b><b><span> No. 680 C.D. 2021 opinion filed March 17, 2023</span></b></span></p>
<p class="Default"><span><span style="font-family: arial;">And</span></span></p>
<p class="Default"><span style="font-family: arial;"><b><u><span>Edward Appel v. GWC
Warranty Corporation (WCAB),</span></u></b><b><span>
No. 824 C.D. 2021 </span></b><b><span>opinion filed March 17, 2023</span></b></span></p>
<p class="Default"><b><u><span><span style="font-family: arial;">Issues Presented in
Appeal to the Commonwealth Court</span></span></u></b></p>
<p class="Default"><span><span style="font-family: arial;">The<b> Appel</b> <b>appeal </b>argued
one issue, that the WCAB erred:</span></span></p><p class="Default" style="text-indent: 0px;"><span style="text-indent: -0.25in;"><span style="font-family: arial;">1. by concluding
that a workers compensation insurer or employer cannot be required to pay for
the lawful use of medical marijuana based on the plain language of the Medical
Marijuana Act (MMA) section 2102.</span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The <b>Fegley appeal</b> argued several issues, that
the WCAB erred:</span></span></p><p class="MsoNormal"><span style="font-family: arial;"><span style="line-height: 107%;">1. </span><span style="text-indent: -0.5in;">as Employer did not raise and therefore waived,
Section 2102 of the Medical Marijuana Act as a defense;</span></span></p><p class="MsoNormal"><span style="font-family: arial;"><span style="text-indent: -0.5in;">2. </span><span style="text-indent: -0.25in;">by concluding Section 2102 of the MMA applies
to WC carriers and overrides the WC Act requirements that insurers pay for
reasonable, necessary medical treatment that is related to an accepted work
injury;</span></span></p><p class="MsoNormal"><span style="font-family: arial;"><span style="text-indent: -0.25in;">3.</span><span style="text-indent: -0.25in;">by
concluding that Section 2102 of the MMA precludes reimbursement for medical
marijuana to a claimant such treatment was determined to be reasonable,
necessary and related to an accepted work injury;</span></span></p><p class="MsoNormal"><span style="font-family: arial;"><span style="text-indent: -0.25in;">4. </span><span style="text-indent: -0.25in;">by
failing to address and reverse the WCJ’s sole basis for denying the Penalty
Petition – that reimbursement of Claimant’s medical marijuana treatment would
cause the WC carrier to violate federal law.</span></span></p>
<p class="Default"><span style="font-family: arial;"><b><span>NOTE:</span></b><span> As the <b><i>Fegley</i></b> opinion and reasoning is
cited and relied upon in the <b>Appel </b>decision, we will utilize the <b><i>Fegley</i></b>
opinion as the starting point for analysis of these Medical Marijuana issues.</span></span></p>
<p class="Default"><b><u><span><span style="font-family: arial;">Fegley Opinion <span style="mso-spacerun: yes;"> </span>- Commonwealth Court Conclusions<span style="mso-spacerun: yes;"> </span></span></span></u></b></p>
<p class="Default"><span><span style="font-family: arial;">Employer did preserve the
defense that Section 2102 of the MMA prevented the WCAB from compelling
Employer to reimburse Claimant for his lawful use of medical marijuana.</span></span></p>
<p class="Default"><span><span style="font-family: arial;">Section 2102 of the MMA applies
to WC carriers. The plain language of Section 2102 is limited to not requiring
insurers to provide <i>coverage </i>for medical marijuana. The Court resolved
that the term “coverage” is different and distinct from the term “<i>reimbursement”</i>
…</span></span></p>
<p class="Default"><span><span style="font-family: arial;">Such that … there is no
statutory language which prohibits insurers from <i>reimbursing </i>claimants
who lawfully use medical marijuana to treat a work injury when such treatment
is medically reasonable and necessary. <o:p></o:p></span></span></p><p class="Default" style="text-align: center;"><span><span style="font-family: arial;">***</span></span></p>
<p class="Default"><span style="font-family: arial;"><b><u><span>The Commonwealth Court
reasoning and resolution is based upon several factors.</span></u></b><b><span> <span style="mso-spacerun: yes;"> </span></span></b><b><span>Given:</span></b></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span>the WC Act’s
“humanitarian objectives” ;</span></span></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span>reimbursing
Claimant for his out-of-pocket expenses for his lawful use of medical marijuana
as a reasonable and necessary treatment for his work injury would not require
Employer’s WC carrier to violate the Federal Drug Act, or be at risk of facing
federal prosecution by doing so;</span></span></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span>the General
Assembly’s express intent to provide Commonwealth citizens who are patients “<i>access
to medical marijuana</i>,” 35 P.S. §10231.102(3)(i) (emphasis added);</span></span></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span>the MMA’s
containment of an immunity provision protecting patients from government
sanctions;</span></span></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><span style="font-family: arial;"><!--[if !supportLists]--><span><span style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span><span style="mso-spacerun: yes;"> </span>and the MMA statement that “no individual
‘shall be . . . denied any right or privilege, . . . for lawful use of medical
marijuana . . .”.</span></span></span></p>
<p class="Default"><b><span><span style="font-family: arial;">…<span style="mso-spacerun: yes;"> </span>the Commonwealth Court concluded that the
Board erred, and the Court ruled that Employer’s failure to reimburse
Claimant’s out-of-pocket costs for medical marijuana to treat his work-related
injury is a violation of the WC Act.</span></span></b></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The <b><i>Fegley</i> </b>WCAB Order denying Claimant’s
Penalty Petition is reversed and the matter is remanded to the WCAB to remand
to the WCJ to determine whether a penalty should be imposed.<o:p></o:p></span></span></p><p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The <i><b>Appel</b></i> WCAB Order partially denying Claimant's Review Medical Petition was reversed. </span></span></p>
<p align="center" class="MsoNormal" style="text-align: center;"><span style="font-family: arial;"><span style="line-height: 107%;">***</span><span> </span></span></p>
<p class="Default"><b><span><span style="font-family: arial;">For a more detailed review
of the analysis of the Commonwealth Court Opinions, we will review the
background facts, procedural status and the reasoning provided:</span></span></b></p>
<p class="Default"><span style="font-family: arial;"><b><u><span><i>Fegley</i> Background and
Procedural History<span style="mso-spacerun: yes;"> </span></span></u></b><u><span><o:p></o:p></span></u></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Claimant sustained a 1977 work-related injury. Medical
treatment included back surgeries, opiates and narcotics prescribed for severe
back and leg pain. Claimant began using medical marijuana in 2019 at his
doctor’s recommendation. Medical marijuana afforded Claimant pain relief and
reduced his need for opiates and narcotics. A 2019 UR determination determined
Claimant’s medical marijuana use was reasonable and necessary. <o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Claimant filed a Penalty Petition that Employer’s
failure to pay for his medical marijuana, despite the UR Determination, was a
violation the WC Act. The WCJ 2020 Decision denied the Penalty Petition,
concluding that Claimant failed to prove that Employer’s refusal to pay for
medical marijuana treatment violated the WC Act. The WCJ decision granted
Employer’s Petition for Review of Utilization Review Determination. The WCAB
Affirmed.</span></span></p>
<p class="Default"><span style="font-family: arial;"><b><u><span><i>Appel</i> Background and
Procedural History<span style="mso-spacerun: yes;"> </span></span></u></b><u><span><o:p></o:p></span></u></span></p>
<p class="Default"><span><span style="font-family: arial;">Appel sustained cervical and
lumber injuries in 2006, which were accepted as compensable via a Stipulation
approved in a 2015 WCJ Decision.</span></span></p>
<p class="Default"><span><span style="font-family: arial;">Appel received extensive
medical treatment, including surgeries. His physician prescribed opioids for
chronic low back pain and leg symptoms. In April 2018, he received a medical
marijuana card and used medical marijuana for withdrawal symptoms while weaning
off of opioids. He testified medical marijuana was more effective than any
other medication, as opioids became less effective over time.</span></span></p>
<p class="Default"><span style="font-family: arial;"><span>A Review Medical Petition
sought a determination that his medical marijuana was causally related to his
work injury and an order directing Employer to reimburse him for the cost. A
2020 WCJ decision concluded claimant proved his medical marijuana use </span><span color="windowtext">was related to the accepted work
injury, however claimant failed to prove that Employer must reimburse him for
his out-of-pocket medical marijuana expenses pursuant to Section 2102 of the
MMA, which does not require an insurer or health plan to provide “coverage” for
medical marijuana. WCAB affirmed.</span></span></p>
<p class="Default" style="text-align: center;"><span color="windowtext"><o:p><span style="font-family: arial;"> ***</span></o:p></span></p><p class="Default" style="text-align: center;"><b style="text-align: left;"><u><span color="windowtext"><span style="font-family: arial;">Commonwealth
Court Analysis</span></span></u></b></p>
<p class="Default"><b><span color="windowtext"><span style="font-family: arial;">The<i>
Fegley</i> and <i>Appel</i> decisions utilized the same analysis and reasoning
to address and resolve the Medical Marijuana issues.</span></span></b></p>
<p class="Default"><span><span style="font-family: arial;">The analysis of the majority
opinion began with the ubiquitous statement that the Pennsylvania Workers
Compensation Act (WCA) is remedial in nature and intended to benefit the
worker, and, therefore, the Act must be liberally construed to effectuate its
humanitarian objectives.</span></span></p>
<p class="Default"><b><u><span><span style="font-family: arial;">Responsibility for
work-related medical expenses</span></span></u></b></p>
<p class="Default"><span><span style="font-family: arial;">Pursuant to Section 301(c) of
the WCA, an employer is only liable to pay for a claimant’s medical expenses
that arise from and are caused by a work-related injury.</span></span></p>
<p class="Default"><span><span style="font-family: arial;">A claimant has the initial
burden to establish an injury is work-related Once employer is established, the
claimant is not required to continually establish that medical treatment is
causally related.<span style="mso-spacerun: yes;"> </span>Thereafter the
employer has the burden to prove that a medical expense is unreasonable,
unnecessary, or is not related to the accepted work injury.</span></span></p>
<p class="Default"><b><u><span><span style="font-family: arial;">Review of the Pertinent
Medical Marijuana Act Provisions</span></span></u></b></p>
<p class="Default"><span><span style="font-family: arial;"><span style="mso-spacerun: yes;"> </span>The Commonwealth Court reviewed Section 102 of
the MMA, which provides, in part: 1) Scientific evidence suggests that medical
marijuana is one potential therapy that may mitigate suffering in some patients
and also enhance quality of life… (3) It is the intent of the General Assembly
to: (i) <i>Provide a program of access to medical marijuana </i>which balances
the need of patients to have access to the latest treatments with the need to
promote patient safety. (ii) Provide a safe and effective method of delivery of
medical marijuana to patients… 35 P.S. § 10231.102<i>).</i></span></span></p>
<p class="Default"><span><span style="font-family: arial;">Under the MMA, use or
possession of medical marijuana as set forth in the MMA is lawful within this
Commonwealth.” Section 303(a) of the MMA, 35 P.S. § 10231.303(a).</span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The Court assigned relevance to the MMA immunity
provision protecting patients from government sanctions. Per the statute, no
such individual “shall be subject to arrest, prosecution or penalty in any
manner, or <i>denied any right or privilege</i>, . . . <i>solely for lawful use
of medical marijuana </i>. . .”. <i>See </i>Section 2103(a) of the MMA.<o:p></o:p></span></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><u><span><span style="font-family: arial;">Arguments –
Application of MMA to WC Insurers<o:p></o:p></span></span></u></b></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Claimant argued the MMA did not apply to work comp
insurers.<b><u><o:p></o:p></u></b></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Employer argues a WC carrier is an <i>insurer</i>, as
defined by the WCA and Insurance law. As WC carriers are insurers under the
law, the Court held that they are “insurers” for purposes of the MMA.</span></span></p>
<p class="Default"><span style="font-family: arial;"><b><u><span>Section 2102 of the MMA –
“Coverage” Arguments</span></u></b><u><span><o:p></o:p></span></u></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Claimant argued that Section 2102 of the MMA only
prohibits an insurer or health plan from being compelled “to provide <i>coverage
</i>for medical marijuana.” 35 P.S. § 10231.2102. Claimant maintains that <i>coverage
</i>refers to the insurer <u>paying the provider directly for a medical service</u>,
while <i>reimbursement </i>signifies the insurer <u>paying the patient</u> for
the costs of medical treatment already incurred and paid.<o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Employer asserts that the MMA’s plain language exempts
employers/insurers from being required to cover medical marijuana.<o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The Court resolved this issue by reviewing the
statutory language. While the MMA provides that an insurer is not required to
include medical marijuana as a risk under its insurance policy, <b>there is no
language in the MMA precluding a WC carrier from repaying a claimant for his
out-of-pocket medical treatment cost which has been found to be reasonable and
necessary for his work-related injury.</b><o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Because the plain language of Section 2102 of the MMA
is limited to not requiring insurers to provide <b>coverage </b>for medical
marijuana, and the WC Act mandates WC carriers to <b>reimburse </b>claimants
for out-of-pocket costs of medical treatment, which has been found to be
reasonable and necessary for their work-related injury, the MMA does not
command otherwise. <o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">If the PA General Assembly intended for medical
marijuana expenses not to be reimbursable, it would have expressly included the
word reimbursement, as other states have explicitly done, but it did not.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Section 301 Section 306(f.1)(1)(i) of the WC Act
requires: “The employer shall provide payment in accordance with this section
for reasonable surgical and medical services, . . . medicines and supplies, as
and when needed.” 77 P.S. § 531(1)(i). <o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The Court rejected the Employer’s arguments. The MMA
specifically mandates that no medical marijuana patients be denied any rights
for lawful use of medical marijuana and the WC Act provides employees a
statutory right to WC medical expenses that are reasonable and necessary to
treat a work injury; therefore, if this Court was to agree with Employer, it
would be removing those express protections from the MMA and the WC Act.<o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The Commonwealth court rejected Employer’s argument
that the MMA to prohibits WC carriers from reimbursing claimants who lawfully
use medical marijuana to treat their work-related injuries – noting this
interpretation<span style="mso-spacerun: yes;"> </span>would undermine the
General Assembly’s express intent to provide patients “<i>access to medical
marijuana…”.</i><o:p></o:p></span></span></p>
<p class="Default"><span><span style="font-family: arial;">In summary the Court ruled that
“coverage” is different and distinct from “reimbursement” and while the plain
language of Section 2102 of the MMA states that insurers cannot be required to
provide <i>coverage </i>for medical marijuana, there is no statutory language
which prohibits insurers from <i>reimbursing </i>claimants who lawfully use
medical marijuana to treat an accepted work injury when such treatment is
medically reasonable and necessary.</span></span></p>
<p class="MsoNormal"><b><u><span style="line-height: 107%;"><span style="font-family: arial;">Claimant Federal Law Argument <o:p></o:p></span></span></u></b></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Claimant argued the Board erred by failing to address,
and reverse, the WCJ’s sole basis for denying the Penalty Petition - that
reimbursement would cause the WC carrier to violate federal law. As the Board
was able to resolve the issue based on Pennsylvania law, albeit erroneously, it
is of no moment that the Board did not decide the federal law issue.<o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Note Section 2103 of the MMA mandates: “Nothing in the
MMA shall require an employer to commit any act that would put the employer or
any person acting on its behalf, i.e., WC carriers, in violation of federal
law.” 35 P.S. §10231.2103.<o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Because reimbursing Claimant for his out-of-pocket
expenses for his lawful use of medical marijuana as a reasonable and necessary
treatment for his work injury would not require Employer’s WC carrier “to
manufacture, distribute, or dispense, or possess with intent to manufacture,
distribute, or dispense, a controlled substance,” 21 U.S.C. § 841(a),
Employer’s WC carrier would not violate the Federal Drug Act, or be at risk of
facing federal prosecution by doing so. <o:p></o:p></span></span></p>
<p class="MsoNormal"><b><span style="line-height: 107%;"><span style="font-family: arial;"><span style="mso-spacerun: yes;"> </span>As
the employer is not prescribing marijuana, but rather reimbursing the claimant
for his lawful use, the employer is not in violation of the Federal Drug Act.
The fact that dispensing marijuana is illegal under federal law does not
transform a medically reasonable and necessary treatment under the WC Act for a
work injury to a medically unreasonable and unnecessary treatment. Such a
determination would eviscerate the entire MMA.<span style="mso-spacerun: yes;"> </span></span></span></b></p><p class="MsoNormal" style="text-align: center;"><b><span style="line-height: 107%;"><span style="mso-spacerun: yes;"><span style="font-family: arial;">***</span></span></span></b></p>
<p class="Default"><b><u><span><span style="font-family: arial;">CONCURRING AND DISSENTING
OPINION</span></span></u></b></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">In the workers’ compensation context, and under the
current state and federal laws, I cannot conclude that the MMA requires a WC
insurance carrier to pay a claimant’s costs incurred in purchasing medical
marijuana. Therefore, for the following reasons, I respectfully disagree with
the majority’s conclusion -<o:p></o:p></span></span></p>
<p class="MsoListParagraph" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l3 level1 lfo3; text-indent: -0.5in;"><span style="font-family: arial;"><!--[if !supportLists]--><span><b><span style="line-height: 106%;"><span style="mso-list: Ignore;">I.<span style="font-feature-settings: normal; font-kerning: auto; font-optical-sizing: auto; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span></span></span></b><!--[endif]--><b><u><span style="line-height: 106%;">The MMA Does Not Require an
Insurer to Pay for Medical Marijuana<o:p></o:p></span></u></b></span></span></p>
<p class="Default"><span><span style="font-family: arial;">Section 102 of the MMA, 35 P.S.
§ 10231.102 seeks to advance medical research and enhance quality of life, but
it also reflects caution in enacting “a temporary measure” regarding access to
medical marijuana, as well as “balancing the need of patients to have access to
the latest treatments with the need to promote patient safety” <i>.</i></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Section 2102 of the MMA, relating to insurers,
provides: “Nothing in this act shall be construed to require an insurer or a
health plan … to provide coverage for medical marijuana.” 35 P.S. § 10231.2102.
The WCAB correctly concluded that the plain language of Section 2102 does not
require reimbursement for medical marijuana prescribed to a claimant to treat a
work injury. <o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Section 2102 does not expressly address
“reimbursement” of medical marijuana costs, but rather provides that the MMA
cannot be construed to require an insurer to provide “coverage” of such costs.
35 P.S. § 10231.2102. However, “coverage” is not defined in the MMA. Further,
the Board did not address whether “coverage” and “reimbursement” are synonymous
under the MMA.<o:p></o:p></span></span></p>
<p class="Default"><span><span style="font-family: arial;">The majority echoes Claimant’s
argument that “coverage” is not the same as “reimbursement,” The MMA does not
require “coverage” for medical marijuana expenses but it requires Employer to
reimburse Claimant for those expenses. I respectfully disagree.</span></span></p>
<p class="Default"><span><span style="font-family: arial;">Insurance reimbursement is when
one is reimbursed in accord with an insurance policy, for expenses that have
been incurred and are covered under the policy<i> </i>. . . . Some types of
insurance reimbursement are paid to the insured person. Other types of
reimbursements are paid directly to the provider after the provider has
submitted an assignment of benefits document to the insurance company. Each
insurance policy has specific items for which expenses are covered, not covered
or covered in part. In other words, “coverage” is the extent of the insurer’s
potential liability under an insurance policy; “reimbursement” is repayment of
claims for which there is “coverage” under the policy. “Coverage” and
“reimbursement” are two sides of the same coin: if there is coverage for a
claim, the insurer must provide reimbursement. <o:p></o:p></span></span></p>
<p class="Default"><span><span style="font-family: arial;">Thus, it makes no sense for
Claimant to argue that reimbursement may be required where coverage may not. Nonetheless,
Claimant argues that because the WC Act is to be liberally construed, the MMA
should not be interpreted to preclude reimbursement that is otherwise required
by the WC Act. The most obvious flaw in this argument is that prior to the
enactment of the MMA, there was no legal medical marijuana in Pennsylvania, and
therefore, no reimbursement was required for it under the WC Act.</span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">The MMA legalized medical marijuana for the first time
and in a limited manner; in doing so, it made clear that it was not to be
construed to require insurance coverage of medical marijuana. This makes sense,
inasmuch as medical marijuana has not yet been approved by the FDA as safe and
effective for use in medical treatment, and its use is not legal under federal
law. In any event, the legislature, not the courts, must effect any change in
the MMA’s stated policy and the balance struck regarding insurance coverage.
Therefore, I believe this Court is constrained to agree with the Board that the
MMA cannot be read to mandate reimbursement for prescribed medical marijuana
provided to WC claimants. <o:p></o:p></span></span></p>
<p class="Default"><span style="font-family: arial;"><b><span color="windowtext">II. <u>Alleged
Waiver of Employer’s MMA Defense</u> </span></b><span color="windowtext"><o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">I concur in the majority’s conclusion that Employer
did not waive its ability to assert a defense of illegality. In addition, I
believe the defense is not subject to waiver as a matter of law.<o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">An employer that unilaterally stops paying a
claimant’s medical bills is subject to penalties under the WC Act, at the
discretion of a WCJ, if the WCJ finds that the medical bills are causally
related to the employee’s work injury.A claimant who files a penalty petition
must first meet his initial burden of proving a violation of the WC Act occurred.
The burden then shifts to the employer to prove the violation did not occur. <o:p></o:p></span></span></p>
<p class="Default"><span><span style="font-family: arial;">Here, the Utilization Review
(UR) Determination found that medical marijuana was reasonable and necessary to
treat Claimant’s pain and Employer did not appeal that determination. Thus,
without more, it might be argued that Claimant met his burden of showing a
violation of the WC Act in Employer’s refusal to pay for Claimant’s medical
marijuana.</span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">However, the WCJ found that requiring Employer to pay
for Claimant’s medical marijuana would improperly force Employer to commit a
crime under federal law. The issue is whether Employer could waive its
illegality defense, as it failed to appeal the UR Determination. Both this
Court and our Supreme Court have found the defense of illegality cannot be
deemed waived in other contexts, such as employment and contract actions.<o:p></o:p></span></span></p>
<p class="Default"><span style="font-family: arial;"><b><span>III. <u>Current State of
Federal Law on Marijuana</u> </span></b><span><o:p></o:p></span></span></p>
<p class="Default"><span><span style="font-family: arial;">As the majority correctly
observes, Section 2103 of the MMA specifies that nothing in the MMA requires an
employer to commit any act that would violate federal law. Claimant argues that
the Board erred in not addressing and reversing the WCJ’s sole basis for
denying the Penalty Petition, that reimbursement would cause the WC carrier to
violate federal law. This Court need not reach this issue because, as discussed
above, the MMA expressly does not require insurance reimbursement of medical
marijuana costs. In any event, however, Claimant’s argument lacks merit.</span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">At first blush, Claimant’s argument appears somewhat
persuasive. The federal Controlled Substances Act does not expressly forbid
reimbursement for prescribed medical marijuana. Therefore, it appears an
insurer reimbursing for medical marijuana costs under state law could be
subject to federal prosecution only on a secondary basis as either an
aider/abettor or an accessory after the fact.<o:p></o:p></span></span></p>
<p class="Default"><span><span style="font-family: arial;">However, both parties’
arguments relate solely to the legality of a WC insurer’s conduct in
reimbursing costs of medical marijuana. Both parties, as well as the Board,
ignore the fact that, unlike the insurer, the provider necessarily distributes
or dispenses medical marijuana. Thus, the provider necessarily violates federal
criminal law by doing so. Case law is sparse on this issue, but in other
contexts, this Court has held that where a provider cannot provide treatment
legally, that treatment cannot be deemed reasonable and necessary, and the
provider cannot obtain reimbursement.</span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">As discussed above, although the MMA legalizes the use
of medical marijuana in Pennsylvania, a provider still cannot legally dispense
medical marijuana under federal law. Therefore, because it is illegal, such
treatment cannot be reasonable and necessary under the WC Act; accordingly, the
dispenser cannot obtain reimbursement from a WC insurer. <i><o:p></o:p></i></span></span></p>
<p class="Default"><span style="font-family: arial;"><b><span>IV. Dissenting Opinion Conclusion </span></b><span><o:p></o:p></span></span></p>
<p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;">Based on the foregoing discussion, I do not believe
the MMA can be read as requiring a WC insurer to pay the costs of medical
marijuana. Although it does not expressly forbid requiring such reimbursement
under a separate statute such as the WC Act, the MMA effects no change in the
preexisting reimbursement requirements, because it expressly cannot be read to
create a reimbursement requirement where, as here, one did not exist before. <o:p></o:p></span></span></p>
<p class="MsoNormal" style="text-align: center;"><span style="line-height: 107%;"><o:p><span style="font-family: arial;"> ***</span></o:p></span></p><p class="MsoNormal" style="text-align: left;"><span style="line-height: 107%;"><o:p><b><span style="font-family: arial;">RECOMMENDATIONS</span></b></o:p></span></p><p style="text-align: left;"><span style="font-family: arial;"><span style="line-height: 107%;"><o:p><b>1. </b></o:p></span><b>When assessing liability for medical marijuana </b><span><b>reimbursement</b></span><b> expenses - </b><b>is the medical marijuana expense in addition to ongoing medications or is it a replacement for more </b><span><b>expensive</b></span><b> treatment options?</b></span></p><p style="text-align: left;"><span style="font-family: arial;"><b>2. Is an Independent Medical Expert </b><span><b>Evaluation</b></span><b> necessary to </b><span><b>address</b></span><b> </b><span><b>questions</b></span><b> of the <u>causal relationship</u> and/or the <u>reasonableness and necessity</u> of the </b><b>medical marijuana expense to the accepted work injury?</b></span></p><p style="text-align: left;"><span style="font-family: arial;"><b>3. Is a Utilization Review </b><b>necessary to </b><span><b>address</b></span><b> </b><span><b>questions</b></span><b> of the <u>reasonableness and necessity</u> of the </b><b>medical marijuana expense to the accepted work injury?</b></span></p><p style="text-align: left;"><span style="font-family: arial;"><b>4. A this time, this intermediate appellate court decision approves the reimbursement of out-of-pocket expenses to an injured worker for </b><b>medical marijuana expense that has been determined to be </b><b><u>reasonableness and necessity</u> treatment of an</b><b> the accepted work injury. These are specific requirements for </b><span><b>reimbursement</b></span><b>.</b></span></p><p style="text-align: left;"><span style="font-family: arial;"><b>... T</b><b>his intermediate</b><b> </b><b>appellate court decision did not approve the reimbursement of </b><b>medical marijuana expense <u>to a provider.</u></b></span></p><p style="text-align: left;"><span style="font-family: arial;"><br /></span></p>
<p class="MsoNormal"><o:p><span style="font-family: arial;"> </span></o:p></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-31431330385172251922022-07-25T18:43:00.000-04:002022-07-25T18:43:56.254-04:00<p> </p><p class="MsoNormal"><b><u><span style="font-size: 12pt;">Recent </span></u></b><b><u><span style="font-size: 12pt;">PENNSYLVANIA SUPREME COURT </span></u></b><b><u><span style="font-size: 12pt;">Petition for Allowance
of Appeals</span></u></b></p><p class="MsoNormal"><b><u><span style="font-size: 12pt;">WORKERS' COMPENSATION CASES - DENIED; listed by date of Order</span></u></b></p>
<div style="text-align: left;"><span face=""Calibri",sans-serif"><i><u>July 12 2022 </u> </i> </span></div>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Kamp v.
WCAB (Green Acres Contracting Co.)</span></u></b><b><span face=""Calibri",sans-serif"> </span></b><span face=""Calibri",sans-serif">No.
1275 C.D. 2020 <o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Published
Opinion filed : January 21, 2022 <o:p></o:p></span></p>
<p class="Default"><b><span face=""Calibri",sans-serif">WCJ denied
Claimant’s Review petition <i>seeking to limit the subrogation interest of
Employer</i>. </span></b><span face=""Calibri",sans-serif">Claimant
argued Section 319 violates PA Constitution. <o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">WCAB and
Commonwealth Court affirmed.</span></p><p class="Default"><span face=""Calibri",sans-serif"><br /></span></p>
<p class="MsoNormal"><span style="font-size: 12pt;"><i><u>July 12 2022 </u> </i> <o:p></o:p></span></p>
<p class="MsoNormal"><b><u><span style="font-size: 12pt;">Blythe v. WCAB (City of
Chester)</span></u></b><span style="font-size: 12pt;"> No. 437 C.D. 2021<o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: December 29, 2021<o:p></o:p></span></p>
<p class="Default"><b><span face=""Calibri",sans-serif">Employer was
entitled to pension credit offset.<o:p></o:p></span></b></p>
<p class="Default"><span face=""Calibri",sans-serif"><o:p> </o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif"><i><u>July 6 2022</u></i><o:p></o:p></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Adams v.
WCAB (School District of Philadelphia)</span></u></b><span face=""Calibri",sans-serif"> No. 1060 C.D. 2020 <o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: March 30, 2022.<o:p></o:p></span></p>
<p class="Default"><b><i><span face=""Calibri",sans-serif">IRE -
Reinstatement date is as of filing date of Claimant petition to Reinstate <o:p></o:p></span></i></b></p>
<p class="Default"><b><i><span face=""Calibri",sans-serif"><o:p> </o:p></span></i></b></p>
<p class="Default"><span face=""Calibri",sans-serif"><i><u>July 6 2022</u></i><o:p></o:p></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Eastman
Kodak v. WCAB ( Smith) <o:p></o:p></span></u></b></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: December 23, 2021<o:p></o:p></span></p>
<p class="Default"><b><i><span face=""Calibri",sans-serif">IRE -
Reinstatement date is as of filing date of Claimant petition to Reinstate <o:p></o:p></span></i></b></p>
<p class="Default"><span face=""Calibri",sans-serif"><o:p> </o:p></span></p>
<p class="Default"><span face="Calibri, sans-serif"><i><u>July 7 2022</u></i></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Raymour
& Flanigan v. WCAB (Obeid)<o:p></o:p></span></u></b></p>
<p class="Default"><span face=""Calibri",sans-serif">Published
Opinion filed : August 16, 2021 <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 12pt;">An Employer may file a
“Medical Only” NCP to change the benefit status of the injured worker. <o:p></o:p></span></p>
<p class="MsoNormal"><b><span style="font-size: 12pt;">Changing the benefit
status after NTCP does not require “Notice Stopping” and “Notice of Denial”.<o:p></o:p></span></b></p>
<p class="MsoNormal"><b><span style="font-size: 12pt;"><o:p> </o:p></span></b></p>
<p class="MsoNormal"><span style="font-size: 12pt;"><i><u>June 22 2022</u></i><o:p></o:p></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Pullin v.
WCAB (S.D. of Philadelphia) 727 C.D. 2021 <o:p></o:p></span></u></b></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: December 22, 2021<o:p></o:p></span></p>
<p class="MsoNormal"><b><span style="font-size: 12pt;">IRE – reinstatement date
is as of filing date of Claimant petition to Reinstate.<o:p></o:p></span></b></p>
<p class="MsoNormal"><b><span style="font-size: 12pt;"><o:p> </o:p></span></b></p>
<p class="MsoNormal"><span style="font-size: 12pt;"><i><u>June 22 2022 </u></i><o:p></o:p></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Regan v.
WCAB (City of Philadelphia)</span></u></b><span face=""Calibri",sans-serif">
: No. 1277 C.D. 2020 <o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: December 13, 2021<o:p></o:p></span></p>
<p class="Default"><b><span face=""Calibri",sans-serif">Firefighter
cancer claim; Claimant not meet burden to establish general causation, the
burden of proof did not shift to Employer. <o:p></o:p></span></b></p>
<p class="MsoNormal"><span style="font-size: 12pt;"> <o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif"><i><u>June 15 2021 </u></i> <o:p></o:p></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Hughes v.
WCAB (Wawa Inc.)</span></u></b><span face=""Calibri",sans-serif">
No. 333 C.D. 2021<o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Order to Publish
filed February 28, 2022: <o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: December 13, 2021<o:p></o:p></span></p>
<p class="Default"><b><span face=""Calibri",sans-serif">Post C&R
Utilization Review of excessive Oxycontin prescriptions concluded ongoing use
was not Reasonable or Necessary. <o:p></o:p></span></b></p>
<p class="MsoNormal"><span style="color: black; font-size: 12pt;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="color: black; font-size: 12pt;"><i><u>June 7 2022</u></i><o:p></o:p></span></p>
<p class="Default"><b><u><span face=""Calibri",sans-serif">Haplin v.
WCAB (City of Philadelphia)</span></u></b><span face=""Calibri",sans-serif">
647 C.D. 20221<o:p></o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif">Memorandum
opinion filed: December 13, 2021<o:p></o:p></span></p>
<p class="MsoNormal"><span style="color: black; font-size: 12pt;">WCJ Reinstatement
of benefits was reversed on appeal as <b>Claimant made a unilateral mistake in
interpretation of the stipulation<o:p></o:p></b></span></p>
<p class="MsoNormal"><span style="color: black; font-size: 12pt;">he entered into
to suspend his benefits and relinquish future rights of reinstatement.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="color: black; font-size: 12pt;"><o:p> </o:p></span></p>
<p class="Default"><span face=""Calibri",sans-serif"><i><u>June 7 2022</u></i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace: none;"><b><u><span style="color: black; font-size: 12pt;">Hutchinson v. WCAB (Annville Township)</span></u></b><span style="color: black; font-size: 12pt;"> Nos. 16 & 17 C.D. 2021 <o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace: none;"><span style="font-size: 12pt;">Published
Opinion filed <span style="color: black;">August 9, 2021 <o:p></o:p></span></span></p>
<p class="Default"><b><span face=""Calibri",sans-serif">IRE -
Reinstatement date is as of filing date of Claimant petition to Reinstate</span></b><span face=""Calibri",sans-serif"> <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 12pt;"><o:p> </o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-81522762526413920512022-06-21T18:33:00.001-04:002022-06-22T14:54:27.128-04:00The Scope of injury description under review can be altered by an Impairment Rating Evaluator - so says a Recent PA Commonwealth Court decision<div style="text-align: center;"><b>A recent Pennsylvania Commonwealth Court decision </b><b>would allow </b><b>the Impairment Rating Evaluator to alter/revise/expand the scope of the work-related injury </b></div><br />The Impairment Rating procedure remains a powerful remedy for the Employer and Insurer to attempt to limit future indemnity wage loss benefit exposure. On October 24, 2018, Act 111 replaced the constitutionally infirm Section 306(a.2) with revised language. One requirement of Section 306(a.3) is that an injured worker receive 104 weeks of total disability benefits before an employer may require one’s submission to an Impairment Rating Evaluation (IRE).<div><br />At this time - legal challenges to the constitutionality of Section 306(a.3) continue to course their way through the appellate courts.</div><div><br /><b>Recently a Commonwealth Court panel decision impacts an important factor in</b><b> an Impairment Rating Evaluation - the description of work-related injury under review. </b><br /><br />In <b><i>Sicilia v. WCAB (API Roofers Advantage Program)</i></b> No. 747 C.D. 2021, filed: June 7, 2022, a WCJ decision granting an Employer petition to modify a Claimant’s benefit status from total to partial disability pursuant to a Section 306(a.3) Impairment Rating Evaluation (IRE) was reversed by a three Judge Panel of the Commonwealth Court. <u>The case was remanded for reinstatement of ongoing total disability benefits.</u></div><div><br />The Commonwealth Court determined that a limitation of the scope of the IRE to the accepted/recognized work-related diagnoses was an error of law, based upon their interpretation of the prior Pennsylvania Supreme Court decision in<i> Duffey v. WCAB (Trola-Dyne,Inc.), 152 A.3d 984 (Pa. 2017) (cited as Duffey II).</i><br /><br />The <i>Sicilia</i> opinion reviewed the factual background reflecting the “rounds of litigation” involving a 1999 work injury which the Notice of Temporary Compensation Payable initially described as a “lumbar strain and left knee contusion”.<br /><br />A 2003 WCJ decision expanded the work injury description, approving a stipulation which<br />added: chronic pain syndrome; chronic adjustment disorder; anxiety; depression.</div><div>A 2011 WCJ decision found that 2007 back surgery was related to the work injury. The injury description remained unchanged.<br />A 2014 WCJ decision approved a stipulation, resolving a Penalty petition for unpaid medical<br />bills. The injury description remained unchanged.<br /><br />In 2019 Employer secured an IRE, in accord with the “new” IRE procedures at Section 306a(3). Based upon the accepted work injury descriptions, the IRE whole person impairment was 23% which would support a modification of claimant’s benefits to a partial disability status. A separate score for the chronic pain syndrome diagnosis was not added as there was a diagnosis that covered the pain generator. The addition of a separate pain score would increase the Impairment percentage to 25%.<br /><br />Significantly - the IRE physician report, clinical summary section included diagnoses secondary to the 1999 work accident, which were beyond the diagnoses described in the prior WCJ decisions: <i>“lumbar protrusion or spondylolisthesis with lumbar radiculopathy”</i>. The IRE physician qualified her rating, stating that her rating was constrained to address only to the diagnoses accepted by the NTCP, NCP, Stipulations or WCJ decisions.<br /><br />Importantly - to better understand the appellate court decision – the IRE evaluator stated that she was <i>convinced that the additional diagnoses were in fact attributable to the work injury</i>.<br /><br />Employer requested an addendum IRE report to separately address the inclusion of Impairment scores for diagnoses beyond the accepted injury description - “lumbar protrusion or spondylolisthesis with lumbar radiculopathy”. With that inclusion, the whole person Impairment score was 43%. If one added a separate chronic pain score, the rate was 45%. As this addendum report Impairment rating score exceeded the 35% threshold, there would be a presumption of continuing total disability. Section 306(a.3) (2), (4), (5), (7)).</div><div><br />The WCJ decision found the IRE initial report of 25% impairment was credible. The WCJ found the portion of the IRE physician-evaluator testimony (and addendum report) that the 1999 work-related injury included the additional lumbar diagnoses, was not credible medical evidence.<br /><br />The Court's opinion in <i>Sicilia</i> reversed the modification of claimant’s benefit status, commenting that the IRE physician-evaluator <i>“misapprehended her responsibility as a physician-evaluator in her initial calculation of Claimant’s whole person impairment rating”</i>, as she felt her initial rating was constrained to the accepted injury diagnoses.<br /><br />The <i>Sicilia</i> Court exclusively relied upon the Supreme Court <i>Duffy</i> opinion in reciting:</div><div>- The IRE physician-evaluator is explicitly invested with the obligation to determine “the<br />degree of impairment due to the compensable injury,” (emphasis in original)<br />- “a physician-evaluator must consider and determine causality in terms of whether any<br />particular impairment is ‘due to’ the compensable injury”.<br />- Moreover, the required evaluation is of “the percentage of permanent impairment of the<br />whole body resulting from the compensable injury.”<br /><br /><u>The <i>Sicilia </i>Court acknowledged that the NCP (NTCP) should define “compensable injury” for purposes of this inquiry but the Court further stated that even under former Section 306(a.2) and the AMA Guides, “the physician-evaluator must exercise professional judgment to render appropriate decisions concerning both causality and apportionment.”</u><br /><br />The <i>Sicilia</i> Court stated - the AMA Guides refer to an “event” rather than an “injury,” permitting the physician-evaluator to attribute a particular condition to the event in which the claimant was injured rather than the injury itself – <i>“a physician-evaluator simply may not entirely disavow any and all responsibility to consider causality relative to a given condition.”</i></div><div><i><br /></i></div><div>The Commonwealth Court reasoning rejected the Employer arguments that:<br />1. res judicata controls and Claimant is bound by the stipulated injuries incorporated in the<br /> 2003, 2011 and 2014 WCJ decisions;<br />2. Claimant succeeded in obtaining payment of medical bills for lower back surgeries in the<br /> 2011 decision but did not amend or expand the injury description;<br />3. the WCJ was within her discretion to reject the expanded scope of the lumbar injuries<br /> given the extensive case background. The WCJ is charged with assessing the credibility<br /> of medical evidence. The WCJ rejected the credibility of the IRE addendum report.<br />4. <i>Duffey ll</i> is distinguishable as the procedural posture differs. There was<br /> extensive litigation in this matter that addressed the compensable injuries, whereas in<br /><i> Duffey II</i> a review petition seeking to modify the injury description was not filed until<br /> after the IRE.</div><div><br />The Commonwealth Court reasoned –<br />a. Employer’s arguments boil down to an assertion that the WCJ decision(s) description of<br /> the work injury controls the IRE process.<br />b. “While no petition or other request for such change was made in this case, it is<br /> disingenuous to assert that an injury description in one WCJ’s decision, or a string of<br /> such decisions, binds subsequent WCJs later in the history of a claim. Even when an<br /> injury description is not formally amended, a diagnosis may become an accepted injury<br /> if a WCJ finds it was caused or aggravated by the work injury. <br />c. The WCJ’s reasoning for rejecting the IRE testimony concerning the additional<br /> diagnoses, and the higher rating resulting from such inclusion, was not, in fact, a<br /> credibility determination based on evaluation of the evidence, but rather a<br /> misapprehension of the discretion accorded an IRE physician-evaluator. The only<br /> reason proffered for discrediting the additional diagnoses was that they had not been<br /> previously found by other WCJs. Simply put, the WCJ erred as a matter of law in<br /> constraining the IRE review solely to the earlier accepted descriptions of Claimant’s<br /> work injuries.<br /><br />The Dissent opinion stated - <u><i>Duffey II</i> has muddled the law in this area</u>. It takes the IRE into issues of liability and causation for a work injury when <u>the sole purpose of an IRE</u> <u>is to determine the claimant’s disability status after maximum medical improvement from the </u><u>adjudicated work-related injury.</u> </div><div>See: Section 306(a.3)(8)(i) which defines “impairment” as “anatomic or functional abnormality or loss that results from the compensable injury and is reasonably presumed to be permanent.”</div><div><br />Dissent would affirm the WCAB and WCJ, as the WCJ simply rejected the credibility of the IRE evaluator’s addendum opinion that Claimant’s other symptoms were attributable to his work injury. Therefore, there was no credible evidence to support a finding that Claimant has a whole-body impairment greater than 35%.<br /><br /><b>PRACTICE RECOMMENDATIONS</b>:<br /><br />1. Continue to utilize the IRE remedy as a means of limiting the duration of work-related total disability status and the overall duration of future indemnity benefit liability.<br /><br />2. Before filing the IRE physician designation request - Review the pre-IRE appointment records of medical treatment. Has there been a change or additional description of the diagnoses treated, when compared to the accepted injury description in the NTCP, NCP or prior WCJ decision?</div><div><br /></div><div>If so, consider a pre-IRE medical document review to preliminarily assess the existence of additional diagnoses that would exceed the 35% threshold. Is there a diagnosed condition that is improving … or declining?<br /><br />3. If there are additional diagnoses, beyond the accepted work-related injury, then consider an IME to attempt to secure a medical expert opinion that the additional diagnosis IS NOT work-related.</div><div><br /></div><div>In recent discussions, at least one Impairment Rating physician evaluator welcomes additional pre-exam information when there are issues regarding the description or scope of the work-related injury. An example is the case where a WCJ has defined the work-related injury in a manner that may include a medical condition that clinically is not typically attributed to the accepted type of injury.</div><div><br /></div><div>4. Also, one must consider the impact of a separate "chronic pain" diagnosis score - where the medical condition, that is the pain generator, is not considered in the IRE score.</div><div><br /></div><div>Once again, the best practice in handling this workers compensation issues depends upon the specific facts presented. One must take the time to review the medical records of treatment in your case – before</div><div>you select an appropriate worker's compensation remedy. </div><div><br /></div><div>As we always recommend, please discuss your case handling options with your workers compensation professionals.</div>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-73429948504570316732022-01-25T11:49:00.003-05:002022-01-25T11:51:54.191-05:00The Pennsylvania Bureau of Workers’ Compensation has revised the Notification of Suspension or Modification Pursuant to 413 (c) & (d); form LIBC-751<p><b><i><span style="font-size: 14pt;">This change is effective
February 20, 2022.</span></i></b></p>
<p class="Default"><b><i><span style="font-size: 14pt;">What does this mean? </span></i></b><b><i><span style="font-size: 14pt;">The form is simpler to
use!</span></i></b></p>
<p class="Default"><b><i><span style="font-size: 14pt;">Here is a copy of the
Bureau announcement -</span></i></b></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><span style="border: 1pt none windowtext; color: #aa272f; font-family: "inherit",serif; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">On Dec. 22, 2021, Governor Tom Wolf signed Act 95 (House Bill
1837) into law. This act amended Section 413(c) & (d) of the PA Workers
Compensation Act such that <b>an affidavit is no longer required </b>on the
Notification of Suspension or Modification Pursuant to 413(c) & (d) - LIBC
751, <b>effective February 20, 2022.</b><u1:p></u1:p></span><span face=""Arial",sans-serif" style="color: #aa272f; font-size: 9pt;"><o:p></o:p></span></p>
<p style="background: rgb(253, 249, 224); font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0in; overflow-wrap: break-word; vertical-align: baseline;"><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;"><br />
<!--[endif]--></span><span face=""Arial",sans-serif" style="color: #aa272f; font-size: 9pt;"></span><o:p></o:p></span></p>
<p style="background: rgb(253, 249, 224); font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0in; overflow-wrap: break-word; vertical-align: baseline;"><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">The
Bureau of Workers Compensation has revised the Notification </span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;">of Suspension or Modification, LIBC-751, to comply with
Act 95.</span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"> </span><o:p></o:p></span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"></span></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;"> </span></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">The notification now includes two verification </span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;">boxes which must be checked before the document is signed. </span><o:p></o:p><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"></span></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;"> </span></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">The notification must still be sent to the </span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;">claimant and the bureau within seven days of the
modification or suspension of </span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;">benefits. </span><o:p></o:p></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;"> </span></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><b><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">Due to the substantive change to the form, the revised form must be
used beginning February 20, 2022. <o:p></o:p></span></b></p>
<p style="background: rgb(253, 249, 224); margin: 0in; vertical-align: baseline;"><b><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;"> </span></b><b><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">After March 2, 2022, prior versions of the form will be
marked incomplete.</span></b></p><p style="background: rgb(253, 249, 224); font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0in; overflow-wrap: break-word; vertical-align: baseline;"><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">
<!--[if !supportLineBreakNewLine]--><br />
<!--[endif]--></span><span face=""Arial",sans-serif" style="color: #aa272f; font-size: 9pt;"></span><o:p></o:p></span></p>
<p style="background: rgb(253, 249, 224); font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0in; overflow-wrap: break-word; vertical-align: baseline;"><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"><span face=""Verdana",sans-serif" style="border: 1pt none windowtext; color: #aa272f; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">Please
upload completed forms into WCAIS. </span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;">Filing in WCAIS is available 24/7 and </span><span style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;">reflects a "filed date" when uploaded. This
practice offers cost savings,</span></span><span face=""Arial",sans-serif" style="color: #aa272f; font-size: 9pt;"><o:p></o:p></span></p>
<p style="background: rgb(253, 249, 224); font-stretch: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; line-height: inherit; margin: 0in; overflow-wrap: break-word; vertical-align: baseline;"><span sans-serif="" style="font-stretch: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit;"><span style="border: 1pt none windowtext; color: #aa272f; font-family: "inherit",serif; font-size: 11pt; mso-bidi-font-family: Arial; mso-border-alt: none windowtext 0in; padding: 0in;">timely filing to the bureau without the need for a valid US Post
Mark and makes the document available for instant viewing by all parties to the
claim. Uploading can be done within the Action Tab of a claim, using the
"Document Type" Notification of Suspension or Modification (LIBC-751)
in the tab's drop-down list. The form may also be mailed to the bureau for
filing.</span></span></p>
<p class="Default"><b><i><span style="font-size: 14pt;">Here is a reproduction of
the “new” sections –</span></i></b><b><i><span style="font-size: 14pt;"> </span></i></b></p>
<h3 style="text-align: center;"><span class="A3"><span style="font-size: 14pt;">NOTIFICATION OF SUSPENSION OR </span></span><b><span class="A3"><span style="font-size: 14pt;">MODIFICATION PURSUANT </span></span></b><b><span class="A3"><span style="font-size: 14pt;">TO §§ 413 (c) & (d)</span></span><span style="font-size: 14pt;"> </span></b> <span class="A2" style="font-size: 13.3333px;">LIBC-751 REV 12-21</span></h3>
<p class="Default"><b><span style="font-size: 10pt;">INSTRUCTIONS</span></b></p><p class="Default"><span style="font-size: 10pt;">This form must
be completed, mailed to the employee, and uploaded to WCAIS or mailed to the
Bureau of Workers’ Compensation within seven days of the suspension or
modification of benefits under the provisions of the Workers’ Compensation Act.
You must submit an EDI transaction to match the LIBC-751 to update the status
of the claim in WCAIS.</span></p><p class="Default"><span style="font-size: 10pt; text-align: center;">*** </span></p>
<p class="Default"><span class="A0"><span style="font-size: 10pt;">You are notified
that because you returned to work on <u>month
day year</u> </span></span><span style="font-size: 10pt;"> <span class="A0">your weekly disability benefits for this
injury have been:</span></span></p>
<p class="Default"><span style="font-size: 10pt;"> __ <span class="A0">Suspended
effective <u>month day year </u> because
you have returned to work at earnings equal to or greater </span></span></p><p class="Default"><span style="font-size: 10pt;"><span class="A0"> than </span></span><span class="A0"><span style="font-size: 10pt;">your</span></span><span style="font-size: 10pt;"> </span><span style="font-size: 10pt;">time-</span><span style="font-size: 10pt;"> of-injury earnings of $._____.</span></p>
<p class="Default"><span style="font-size: 10pt;"> OR</span></p>
<p class="Default"><span class="A0"><span style="font-size: 10pt;">__ Modified to the rate of $ ____ per week, effective
<u>month day year</u> </span></span><span style="font-size: 10pt;"> <span class="A0">because you returned to work at earnings <o:p></o:p></span></span></p>
<p class="Default"><span class="A0"><span style="font-size: 10pt;"> less
than</span></span><span style="font-size: 10pt;"> <span class="A0">your time-of-injury
earnings.<o:p></o:p></span></span></p>
<p class="Default"><span class="A0"><span style="font-size: 10pt;"> ***</span></span><span style="font-size: 10pt;"> </span></p>
<p class="Default"><span style="font-size: 10pt;"> ___ <span class="A0">I
confirm I have served a copy of this form to the Bureau of Workers’
Compensation.</span></span></p>
<p class="Default"><span style="font-size: 10pt;">___ <span class="A0">I
confirm I have served a copy of this form to the employee.</span></span></p>
<p class="Default"><span style="font-size: 10pt;">*** </span></p><div style="text-align: left;"><span style="font-size: 10pt;">Claims representative’s signature</span><span style="font-size: 10pt;">
</span><span style="font-size: 10pt;"> </span></div>
<p class="Default"><span style="font-size: 10pt;"><span class="A0">Claims representative’s name (typed/printed)</span></span><span style="font-size: 10pt;"> </span></p>
<p class="Default"><span style="font-size: 13.3333px;">phone number</span></p>
<p class="Default"><b><i><span style="font-size: 14pt;">This Insurer’s
Verification language appears to the right of the Claim rep signature lines -</span></i></b></p>
<p align="center" class="Default" style="line-height: 12.05pt; margin-bottom: 4pt; text-align: center;"> <span class="A0"><b><span style="font-size: 9pt;">INSURER’S VERIFICATION</span></b></span><span style="font-size: 9pt;"><o:p></o:p></span></p>
<p class="Default"><span class="A0"><span style="font-size: 9pt;">I verify that
this information is true and correct based upon my knowledge, information and
belief. I understand false statements are subject to the penalties of 18 Pa.
C.S. Section 4904 relating to unsworn falsifications to authorities. Any
individual filing misleading or incomplete information knowingly and with
intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’
Act and may also be subject to criminal and civil penalties through
Pennsylvania Act 165 of 1994.</span></span></p>
<b><i><span face=""Calibri",sans-serif" style="font-size: 14pt; line-height: 107%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">If you have any questions regarding the proper
usage, preparation or filing of this revised form – please feel free to ask your
workers compensation attorney at www.ChartwellLaw.com </span></i></b>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-75074647302935370322022-01-21T15:28:00.001-05:002022-01-21T15:28:09.469-05:002022 Pennsylvania Workers' Compensation - State Wide Average Weekly Wage and Total Disability Benefit Rates<h4 style="text-align: left;"> <br /><span style="font-size: medium;"><span style="color: #464646; font-family: Montserrat;">Pursuant
to the Workers’ Compensation Act, Section 105.1, the Department of Labor &
Industry has determined the statewide average weekly wage for injuries
occurring on and after January 1, 2022, shall be $1,205.00 per week. </span></span></h4><h4 style="text-align: left;"><span style="font-size: medium;"><span style="color: #464646; font-family: Montserrat;">The <u>maximum weekly compensation rate</u> for calendar year 2022 is
$1,205.00. </span></span></h4><h4 style="text-align: left;"><span style="font-size: medium;"><span style="color: #464646; font-family: Montserrat;">The weekly compensation rate is 66
2/3 percent of the employee's average weekly wage if the average weekly wage
falls between $1,807.50 and $903.76.</span></span></h4><h4 style="text-align: left;"><span style="font-size: medium;"><span style="color: #464646; font-family: Montserrat;">The weekly compensation rate is $602.50 if the employee's average weekly
wage is between $903.75 and $669.44.</span></span></h4><h4 style="text-align: left;"><span style="font-size: medium;"><span style="color: #464646; font-family: Montserrat;">If the employee's </span><span style="color: #464646; font-family: Montserrat;">average weekly wage is $669.43 or less; t</span><span style="color: #464646; font-family: Montserrat;">he </span><span style="color: #464646; font-family: Montserrat;">weekly compensation rate</span><span style="color: #464646; font-family: Montserrat;"> is 90
percent of the employee's average weekly wage.</span></span></h4><h4 style="text-align: left;"><span style="font-size: medium;"><o:p> NOTE: </o:p><span style="background-color: #fafafa; color: #464646; font-family: Montserrat;">For purposes of calculating the update to payments for medical treatment rendered on and after January 1, 2022, the percentage increase in the Statewide Average Weekly Wage is 6.6 percent.</span></span></h4>
pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-1345776028139253402022-01-04T17:31:00.001-05:002022-01-04T17:31:18.957-05:00PA Employers are not entitled to workers' comp benefit credit for Federal Pandemic Unemployment Compensation paid under the CARES Act<p><span style="font-family: Times New Roman, serif;">Federal Pandemic Unemployment Compensation paid to an Employee under the CARES Act is not equivalent to <i>"Unemployment Compensation Benefits"</i> for which an Employer is entitled to a credit under Section 204(a) of the PA Act.</span></p><p><b>See: Carbon Lehigh Intermediate Unit #21 v. WCAB (Waardal), </b>a Pennsylvania Commonwealth Court decision published at<b> </b>No. 750 C.D. 2021; filed on January 3, 2022.</p>
<p class="Default"><b><span style="font-family: "Times New Roman", serif; font-size: 12pt; line-height: 17.12px;">HOLDING: </span></b><span style="font-family: "Times New Roman", serif; font-size: 12pt;">The sole issue before the Court was whether Federal
Pandemic Unemployment Compensation under the CARES Act is the equivalent to UC
benefits for which a PA Employer is entitled to a credit under Section 204(a) of the Workers Compensation Act.</span></p><p class="Default"><span style="font-family: "Times New Roman", serif; font-size: 12pt;">The </span><b>Carbon Lehigh</b><span style="font-family: "Times New Roman", serif; font-size: 12pt;"> decision relied upon its prior analysis i</span>n <i>Dietrich</i> <i>Industries, Inc. v. WCAB (Shank) </i>(Pa. Cmwlth. 1999) to conclude that n<span style="font-family: "Times New Roman", serif; font-size: 12pt;">o credit is
available to the Employer for the CARES benefits paid. </span><o:p>In <i>Shank</i></o:p> the Court disallowed a credit under Section 204(a) for federally funded trade readjustment allowance (TRA) benefits a claimant received.</p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The </span><b>Carbon Lehigh </b><span style="font-family: "Times New Roman", serif; font-size: 12pt;">decision arose from Employer's appeal of the WCAB order affirming the WCJ decision to deny the Employer a credit against its payment of
workers’ compensation benefits for the Federal Pandemic Unemployment Compensation that Claimant received pursuant to Section 2104(b)(1) of the Coronavirus Aid,
Relief, and Economic Security (CARES) Act, 15 U.S.C. § 9023(b)(1).</span></p>
<p class="MsoNormal"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">REASONING of the COURT<o:p></o:p></span></b></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">As one may have anticipated, the Commonwealth Court relied upon its
decision at <i>Shank </i>to deny the Employer a credit in the instant matter.</span></p>
<p class="Default">In<i> Shank</i> the claimant received sickness and accident benefits following
a work-related lower back injury along with UC benefits and TRA benefits, which
“were intended to supplement state unemployment insurance benefits.” <i>Shank’s</i>
receipt of TRA benefits was subject to various statutory requirements,
including exhaustion of his entitlement to “unemployment insurance benefits.”</p>
<p class="Default"><i>Shank’s</i> employer sought a credit against workers’ compensation
<span style="color: windowtext;">in the amount of <i>Shank’s</i> UC and TRA benefits. A
WCJ <u>granted</u> the credit for Shank’s sickness and accident and UC benefits
but <u>disallowed</u> a credit for his TRA benefits.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The </span><span style="font-family: "Times New Roman", serif; font-size: 16px;">Commonwealth Court </span><span style="font-family: "Times New Roman", serif; font-size: 12pt;">analyzed the employer’s right to a credit under
Section 204(a). The Court noted that TRA benefits, which were intended to
supplement UC benefits, </span><u style="font-family: "Times New Roman", serif; font-size: 12pt;">were funded entirely by the federal government</u><span style="font-family: "Times New Roman", serif; font-size: 12pt;">,
as was the cost of administering the TRA program. </span></p><p class="MsoNormal"><span style="font-family: "Times New Roman", serif; font-size: 12pt;"><i>Shank’s</i> Employer argued that
the funding source for <i>Shank’s</i> TRA benefits was irrelevant, as Section 204(a)
made no such distinction when mandating a credit for a claimant’s receipt of UC
benefits. The Court disagreed, stating that an Employer’s credit against its obligation
to pay workers’ compensation stems from its payment of “regular stated amounts,
</span><b style="font-family: "Times New Roman", serif; font-size: 12pt;">out of its own general funds </b><span style="font-family: "Times New Roman", serif; font-size: 12pt;"><b>or from sick or accident benefits</b>,” which
do not constitute “wages or salary for work performed, but which are paid in
relief of the employee’s incapacity to work.”</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The Court further reasoned that <b>TRA benefits were not
among the types of payments delineated</b> in Section 204(a) from which an employer
could seek a credit towards its workers’ compensation obligation. They
recognized that, where certain items are specifically designated in a statute,
omissions are understood to be excluded<i>. </i>Having concluded that TRA
benefits were “distinct from the type of benefits contemplated” under Section
204(a), the Court affirmed the denial of a credit to the Employer<i>.<o:p></o:p></i></span></p>
<p class="MsoNormal"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">In support of its right to a credit for
Claimant’s receipt of </span></b><span style="font-family: "Times New Roman", serif; font-size: 16px;"><b>Federal Pandemic Unemployment Compensation</b></span><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">, this Employer essentially resurrects
the argument the Court rejected in <i>Shank </i>– that Section 204(a) makes no
distinction as to the funding source of a claimant’s UC benefits.</span></b></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The Court stated – “We are similarly unpersuaded by
Employer’s attempts to distinguish this matter from our holding in <i>Shank”. </i>They found it was</span><span style="font-family: "Times New Roman", serif; font-size: 12pt;"> noteworthy that Pandemic Compensation is
available to individuals who are not otherwise eligible to receive “regular” UC
benefits, and the CARES Act provides for federal reimbursement of the amounts
paid by a state for Pandemic Compensation. Furthermore, Pandemic Compensation
is referenced separately from “regular compensation” throughout the relevant
provisions of the CARES Act.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">The Court concluded that these distinctions render Pandemic Compensation
sufficiently “distinct from the type of benefits contemplated” under Section
204(a) of the Act.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">It was acknowledged that Section 204(a), which was last
amended in 1996, did not contemplate the benefits at issue here. However, it is clear that the General Assembly has not seen fit to amend Section 204(a) in
the two decades following the decision in <i>Shank, </i>so as<i> </i>to specify that the
credit provisions of Section 204(a) encompass the types of federally
funded benefits at issue in <i>Shank </i>and the instant matter.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 107%;">Ultimately, the legislative intent behind Section
204(a) is to prevent an employer from having to pay <b>“duplicate benefits for
the same loss of earnings.” </b>(emphasis added). <i>Allegheny Ludlum Corp. v.
Workers’ Comp. Appeal Bd. (Bascovsky), </i>(Pa. Cmwlth. 2009).
Disallowing a credit for Pandemic Compensation <u>that is wholly paid for by
another entity</u> does no disservice to the overall purpose of Section 204(a),
nor does it place Employer in the position of “paying duplicate benefits for
the same loss of earnings.”<o:p></o:p></span></p>
<br />pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-79948810717368309932021-12-03T11:21:00.010-05:002021-12-03T11:33:34.223-05:00Supreme Court of PA reviewed the scope of Employer liability for a traveling employee injury after attendance at an Employer-sponsored social event.<p><span face="Arial, sans-serif" style="font-size: 12pt;"><b>The
Supreme Court of Pennsylvania recently reviewed the scope of an Employer’s
liability for an injury sustained after a traveling employee attended an Employer-sponsored social event.</b></span></p>
<h1 style="line-height: normal; margin-bottom: 0in; text-align: left;"><span face=""Arial",sans-serif" style="font-size: 12pt; font-weight: normal;">As
we approach the time of the year for Employer-sponsored Holiday and End-of
-the- Year social gatherings, the analysis of the traveling employee doctrine
by the Pennsylvania Supreme Court is both informative and instructive for
employers, insurers and workers’ compensation practitioners.</span></h1><div><span face=""Arial",sans-serif" style="font-size: 12pt;"><br /></span></div>
<div style="line-height: normal; margin-bottom: 0in; text-align: left;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;">See:
<u>PETERS v. WCAB (CINTAS CORPORATION)</u>, No. 1 MAP 2020; </span></b></div><div style="line-height: normal; margin-bottom: 0in; text-align: left;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;">DECIDED:
November 17, 2021, authored by JUSTICE MUNDY </span></b></div><div style="line-height: normal; margin-bottom: 0in; text-align: left;"><span face="Arial, sans-serif" style="font-size: 12pt;">(</span><i style="font-family: Arial, sans-serif; font-size: 12pt;">Appeal
from the Commonwealth Court at No. 1835 CD 2017 dated July 18, 2019 Affirming
the decision of the WCAB at No.A16-1263 dated November 16, 2017.)</i></div>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><u><span face=""Arial",sans-serif" style="font-size: 12pt;">HOLDING:</span></u></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;">An
Employee who travels in the course of their work-related duties is presumed to
remain within the scope of employment when attending an Employer-sponsored
social event. An Employer is responsible for injury sustained by the Employee, <u>after</u>
his departure from that work-related event - if he did not abandon his employment
prior to the accident, via actions which <i>“were so foreign to and removed
from his usual employment that they constitute an abandonment of that
employment.”</i></span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;">This
case was remanded to the WCJ for additional fact-finding to resolve the
conflicting testimony of the Employee and his sales manager, as to whether the
Employee was traveling back to his home or traveling to/from another non-work
event, at the time of his accident.</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;">Although
there was no announcement of a new rule of law, or even a final determination
in this specific case, the analysis employed by the Pennsylvania Supreme Court
is instructive for Employers and their Workers’ Compensation insurers, when assessing
issues of responsibility for injury occurring in work-related travel and social
function attendance.</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;"><u>Factual
Background</u></span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Factual
distinctions may determine the compensability of an injury. In the instant case,
the facts reflect that this Employee was engaged in work-related travel as a
regular part of his work duties. He was employed as a uniform sales
representative, which included three half-days in the Employer’s office and
travel for the remainder of the work week, to meet with potential customers and
present products in his sales region.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Following
his last sales appointment, Employee drove pass the highway exit to his home,
on his way to an Employer-sponsored event at a local pub. After leaving that event,
the Employee was injured in a motor vehicle accident. A claim petition was
filed to seek benefits, as Employee alleged the motor vehicle accident occurred
during the course of his employment.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Employee
testified that his sales manager invited the sales representatives to this pub
event. Employee described this event as a celebration to mark the end of a
“sales blitz”.<i> </i>These types of events were held on prior occasions during
sales blitzes.<span style="mso-spacerun: yes;"> </span>He believed these events
to be “sort of” mandatory. At the event, he said there was a recap of the work
performed during the sales blitz. Food and drinks were paid by the Employer.
Employee testified that after he left the event he was involved in a motor
vehicle accident, which occurred on his way home.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Conflicting
testimony was presented regarding the description and nature of the pub event.
Employer testimony from a sales representative and a Sales Manager confirmed this
type of event was routinely held during sales blitzes, as a “voluntary perk”. Contrary
to the Employee’s testimony, they both emphasized the voluntariness and social
nature of the event. They described this as a chance for the sales
representatives to relax after the sales blitz. They<i> </i>disputed the Employee’s
representation that the sales blitz work was recapped at the event. <i><span style="mso-spacerun: yes;"> </span></i>The<i> </i>sales representative
specifically testified that work was not discussed during the event, rather the
conversations were general “chit chat.”</span><span face="Arial, sans-serif" style="font-size: 12pt;"> </span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
Sales Manager testified that he received a call from the Employee later that
evening, reporting that he had been in a motor vehicle accident. <u>Significantly,
He<i> </i>further testified that during this phone conversation that Employee
stated that he was not on his way home from the pub event at the time of the
motor vehicle accident, but rather he was on his way from some other event</u>.
However, the Sales Manager<i> </i>testified that he could not recall
specifically where the Employee said he was coming from. </span><i><span face=""Arial",sans-serif" style="font-size: 12pt;">(this
becomes relevant in the final analysis of this claim).</span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><u><span face=""Arial",sans-serif" style="font-size: 12pt;">Supreme
Court Analysis</span></u></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">As
noted above, the Supreme Court did not announce a new rule of law regarding the
scope of compensability of injury sustained by a traveling employee. As a
starting point in its analysis, the Supreme Court cited Section 301(a) of the
Act, for the proposition that an employer is liable for compensation for injury
or death sustained in the course of one’s employment. An employee’s injury is
considered to have <i>arisen in the course of employment</i> in the following
two circumstances: </span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt; text-indent: -0.5in;">When an employee is injured on or off the employer’s premises while engaged in
furtherance of</span><span face="Arial, sans-serif" style="font-size: 12pt; text-indent: -0.5in;"> the employer’s business or affairs; </span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span style="font-size: 12pt; text-indent: -0.5in;">When
an employee is not furthering the employer’s business or affairs but
nonetheless </span><span face=""Arial",sans-serif" style="font-size: 12pt; mso-fareast-font-family: Arial; text-indent: -0.25in;"><span style="mso-list: Ignore;"><span style="font-size: 7pt; font-stretch: normal; font-variant-east-asian: normal; font-variant-numeric: normal; line-height: normal;"> </span></span></span><!--[endif]--><span face=""Arial",sans-serif" style="font-size: 12pt; text-indent: -0.25in;">is
on the premises occupied or under the control of the </span><span face="Arial, sans-serif" style="font-size: 12pt; text-indent: -0.25in;">employer; </span><span style="font-size: 12pt; text-indent: -0.25in;">upon which the
employer’s business or affairs are being carried on; </span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt; text-indent: -0.25in;">When required by the nature of his employment to
be present</span><span face="Arial, sans-serif" style="font-size: 12pt; text-indent: -0.25in;"> </span><span face="Arial, sans-serif" style="font-size: 12pt; text-indent: -0.25in;">on his employer’s premises; and </span><span face="Arial, sans-serif" style="font-size: 12pt; text-indent: -0.25in;">sustained
injuries caused by the condition of the premises or by operation of the
employer’s business or affairs thereon. (</span><span face="Arial, sans-serif" style="font-size: 16px; text-indent: -0.25in;">301(a).</span><span face="Arial, sans-serif" style="font-size: 16px; text-indent: -0.25in;"> </span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span style="font-size: 12pt; text-indent: -0.25in;">In the litigation of a claim petition, the injured worker has the burden of proof to
demonstrate that his/her injury was sustained in the course of employment.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">In
the instant case this Employee was injured off Employer’s premises. Therefore, for
this accident to be considered to have “arisen in the course of his
employment”, the Employee must have been <i>furthering the business and affairs
of the Employer</i> at the time of his motor vehicle accident.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;"><u>The
Traveling Employee Presumption</u></span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
Supreme Court reviewed the historical development of the <i>traveling employee
doctrine</i>. Employee argued that he was in the course of his employment at
the time of his motor vehicle accident, pursuant to this doctrine.<o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
<i>traveling employee doctrine</i> provides:</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">When
a traveling employee is injured after setting out on the business of his employer,
<span style="mso-spacerun: yes;"> </span>it is presumed that he was furthering
the employer’s business at the time of the injury. The employer bears the
burden of rebutting the presumption. To meet its burden, the employer must
prove that the employee’s<i> actions were so foreign to and removed from his
usual employment that they constitute an abandonment of that employment</i>.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Temporary
departures from the work route for the purpose of administering to the comforts
of an off-the-premises employee, including authorized breaks for lunch, will
not interrupt the continuity of the one’s course of employment.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">For
example, a traveling salesperson cannot carry out the business of the employer
without traveling to present products and solicit business. As such, the act of
traveling, in and of itself, furthers the business and affairs of a traveling
employee’s employer. So too do the activities incidental to travel such as
lodging, refueling, and stopping for food and drink. During their travels,
traveling employees are subject to the risks associated with travel that
stationary employees are not. Therefore, the “hazards of travel become the
hazards of employment”. See: <span style="mso-spacerun: yes;"> </span><i>Ball-Foster
Glass Container Co.</i></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;"><u>Application
of the Traveling Employee Doctrine</u></span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
Supreme Court rejected the Employer’s argument (and the WCJ, WCAB and Commonwealth
Court conclusion) that this Employee abandoned his employment when he passed
the highway exit to his home and proceeded to the pub event, as his attendance
was not mandatory for his employment nor was the event “work-related.”</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">It
was not disputed that this individual was a traveling employee. As such, he is
presumed to remain in the course of his employment, unless the employer rebuts
the presumption by showing that his actions, at some point prior to the injury,
constituted </span><span face="Arial, sans-serif" style="font-size: 12pt;">abandonment of his employment.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
Supreme Court concluded that this Employee did not abandon his employment by
attending the pub event. The WCJ found testimony was credible that these types
of events were regularly held during sales blitzes. The Court reasoned that it
would be difficult to conclude that attending a regularly held type of event
constituted an act so foreign to and removed from his regular employment to be
considered abandonment of employment.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Also,
the WCJ found the event to be voluntary and social in nature. However, those
facts, do not mean the event was not work related! The Employer hosted and
sponsored the event. While work may not have been discussed at the event, the
event still benefited Employer by fostering relationships and improving morale.
<i>See: Investors Diversified Services.</i></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
Supreme Court could not conclude that this Employee abandoned his employment by
attending the pub event. But their analysis did not end there, as there remains
a question as to whether the Employee abandoned his employment sometime between
leaving the pub event and the occurrence of the motor vehicle accident.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">The
record reflects conflicting testimony as to where this Employee was coming from
at<o:p></o:p></span></p>
<p class="MsoNormal"><span face=""Arial",sans-serif" style="font-size: 12pt; line-height: 106%;">the time of the motor vehicle accident. The WCJ did not
explicitly resolve this conflicting testimony. As the conflicting witness
testimony was unresolved, this leaves open the question of whether the Employee
took some action after leaving the pub event that could constitute abandonment
of his employment.<o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">As often stated, <i>“the WCJ is the ultimate finder of fact and the exclusive arbiter of
credibility and </i></span><span face="Arial, sans-serif" style="font-size: 12pt;"><i>evidentiary
weight".</i> The Supreme Court remanded this case to the WCJ to resolve the
conflicting testimony with respect to whether the Employee was coming from the
pub event at the time of his accident or coming from some other unknown non-work event.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><b><span face=""Arial",sans-serif" style="font-size: 12pt;"><u>Recommendations:</u></span></b></p>
<p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l1 level1 lfo3; text-autospace: none; text-indent: -0.25in;"><!--[if !supportLists]--><span face=""Arial",sans-serif" style="font-size: 12pt; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">1.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><b><span face=""Arial",sans-serif" style="font-size: 12pt;">This decision was not an announcement of a new rule of law
regarding the extent of compensability for injury to a traveling employee</span></b><span face=""Arial",sans-serif" style="font-size: 12pt;">. Rather, this decision
reflects an analysis of the existing law with application to the specific facts
presented, to reach a different conclusion regarding the compensability of an injury
sustained after attendance at a work event.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">To properly assess the compensability
of an injury to a traveling employee, the Work Comp professional must engage in
a thorough investigation of the facts, including the past practices of the
Employer.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l1 level1 lfo3; text-autospace: none; text-indent: -0.25in;"><!--[if !supportLists]--><span face=""Arial",sans-serif" style="font-size: 12pt; mso-bidi-font-weight: bold; mso-fareast-font-family: Arial;"><span style="mso-list: Ignore;">2.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><b><span face=""Arial",sans-serif" style="font-size: 12pt;">The assessment of responsibility for injury to a non-traveling
employee, sustained after attendance at a work-related event is different.</span></b></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">As cited by the Supreme
Court, <i><u>in the past,</u></i> a non-traveling employee, injured after attendance
at a work related event, <u>may</u> not be in the course of employment after
the event has ended and the employee is traveling home. </span></p><p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Citing: </span><span style="font-family: "Arial,Italic"; font-style: italic;">Brown
</span><span style="font-family: "Arial,Italic"; font-size: 12pt;"><i>v. W</i></span><span face="Arial, sans-serif" style="font-size: 12pt;"><i>CAB
(Liken Employment Nursing Services)</i> </span><span face=""Arial",sans-serif" style="font-size: 12pt;"><i>(Pa.Cmwlth. 1991)</i>, and </span><i><span style="font-family: "Arial,Italic";">Canning</span><span face=""Arial\,Italic"" style="font-size: 12pt; mso-bidi-font-family: "Arial\,Italic";">
v. WCAB</span></i><i><span face=""Arial",sans-serif" style="font-size: 12pt;">
(Pa. Senate)</span></i><span face=""Arial",sans-serif" style="font-size: 12pt;">
<i>(Pa. Cmwlth. 2015) </i>The claimant in <i>Brown</i>, who was not a traveling employee,
was struck by a motor vehicle while crossing a public roadway after leaving her
employer’s annual Christmas party held at the employer’s office. The Commonwealth
Court concluded that even if the party benefited the employer by cultivating
interpersonal relationships, the claimant was not furthering her employer’s
business at the time of her accident because she was injured while returning
from the employer’s party and not while attending the social event.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">Query: would the result
in <i>Brown</i> be different after the <i>Peters</i> decision ?</span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">What about the “special
mission” line of cases, which can expand the Employer’s liability to a non-traveling
employee?</span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;">In preparation of one's defense to a claim, one must carefully investigate
the facts presented regarding: (i) the details of the employment; (ii) the
details of the event; (iii) the past practices of the Employer regarding events.
<o:p></o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;"><o:p> </o:p></span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;"><o:p> </o:p></span></p>
<p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;"><o:p> </o:p></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; mso-layout-grid-align: none; text-autospace: none;"><span face=""Arial",sans-serif" style="font-size: 12pt;"><o:p> </o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-16486183365610049072021-11-23T18:20:00.000-05:002021-11-23T18:20:48.674-05:00Two PA Appellate Court Decisions affirm the denial of Claim Petitions where the WCJ authored a reasoned decision.<p>Two Recent Commonwealth Court decisions provide similar reasoning for the affirmation of the denial of claim petitions by the Workers Compensation Judge.</p><p>The Commonwealth Court emphasized that the "Reasoned Decision" standard for review of live testimony does not require the articulation of specific reasons for rejection of testimony that was found to be not credible.</p><p>Also the WCJ does not err in failing to make a specific credibility determination of the Employer medical evidence – where the claimant does not meet his/her burden of proof.</p><p><b><i>Beristain v. WCAB (Broadcom Inc.): No. 46 C.D. 2021; </i></b> Memorandum Opinion filed: November 15, 2021</p><p>In <i style="font-weight: bold;">Beristain, </i>the Claimant appealed the Workers' Compensation Appeal Board (WCAB) order which affirmed the Workers' Compensation Judge (WCJ) denial of Claim petition. The issue on appeal was whether the WCJ failed to issue a reasoned decision under Section 422(a) of the Act. upon review, the Commonwealth Court affirmed the claim denial.</p><p>The Claimant petition alleged he suffered a work injury of lumbar disc protrusions caused by the repetitive nature of his job. Claimant’s job duties consisted of polishing and grinding lightweight silicon wafers, which required that he stand and lean forward while rotating his upper body.</p><p>The WCJ rejected Claimant’s testimony as not credible based on his personal observation of Claimant. Claimant's medical witness - Dr. Grodofsky was also deemed not credible to establish a causal connection between work duties and Claimant's lumbar spine condition.The WCJ noted that Dr.Grodofsky’s knowledge of Claimant’s work duties came exclusively from Claimant, whose testimony was discredited. The WCJ reasoned that Dr. Grodofsky lacked sufficient knowledge of Claimant’s work duties to support his opinion that their repetitive nature caused the alleged work injury.</p><p>Employer's medical expert was Dr. Componovo. In his IME report he stated a MRI showed a disc protrusion at the L5-S1 level but he did not believe this finding was responsible for Claimant’s symptoms. The MRI findings were “extremely mild,” and he did not correlate this finding with Claimant’s subjective complaints. Further, Dr. Componovo was not aware of any mechanism of injury or work exposure that would have caused Claimant’s symptoms. He felt that Claimant’s symptoms were “more likely than not” unrelated to his job.</p><p>On Appeal, Claimant argued the WCJ failed to issue a reasoned decision as: (1) the WCJ did not articulate his reasons for finding Claimant’s testimony not credible, and (2) he did not make any credibility determinations with regard to the testimony of Employer’s expert, Dr. Componovo. .</p><p><b>Commonwealth Court Reasoning</b></p><p>The Commonwealth Court<b> </b>analysis began with a review of the well established principle that the<b> </b>burden of proof in an original claim petition rests on the claimant to prove all the elements necessary to support an award of benefits under the Act.<i> Inglis House v. WCAB (Reedy) (Pa. 1993)</i>. The claimant’s burden to prove disability never shifts to the employer. See:<i> Morrison v. WCAB (Rothman Inst.) (Pa. Cmwlth. 2010)</i>.</p><p>An equally well established legal standard is the Section 422(a) requirement that the WCJ issue a decision that allows for adequate review by the appellate courts. <i>Daniels v. WCAB (Tristate Transp.)(Pa. 2003)</i>. When the WCJ has the advantage of seeing the witnesses testify and assessing their demeanor, a mere conclusion as to which witness was deemed credible is sufficient to render the decision adequately reasoned under Section 422(a).</p><p>In the instance case, Claimant argued, without citation to relevant legal authority, that the WCJ’s rejection of Claimant’s live testimony necessitated additional fact finding beyond the standard articulated in <i>Daniels.</i> The Commonwealth Court stated there is no merit to Claimant's argument. The WCJ is not compelled to specify the basis for his rejection of Claimant’s testimony.</p><p>Claimant also argued the WCJ erred when he failed to address Dr. Componovo’s testimony. Claimant asserted this testimony corroborates his evidence that he suffered a compensable work injury.</p><p>The Commonwealth Court concluded that the WCJ did not err when he failed to render a credibility determination regarding the testimony of Dr. Componovo. Although Section 422(a) required the WCJ to make “findings of fact and conclusions of law based upon the evidence as a whole,” he was not required to address all the evidence presented. See: <i>Montgomery Tank Lines v. WCAB (Humphries)</i>, 792 <i>(Pa. Cmwlth.2002). </i>The<i> </i>WCJ only had to make the findings necessary to resolve the issues raised by the evidence and relevant to the decision. </p><p>***</p><p>A second recent Commonwealth Court reported at <b>Sufran v. WCAB (C&S Wholesale); Memorandum Opinion filed November 15, 2021</b>, articulated a similar analysis and reasoning in the affirmation of another claim petition denial. </p><p>In <b>Sufran</b>, the Claimant appealed WCAB order which affirmed the WCJ decision to deny a Claim petition. The WCJ found that she failed to establish she sustained a work injury. The Claim petition alleged a work-related injury, in the nature of: a rotator cuff sprain; right and left knee pain; upper right arm pain; a knee sprain, which she allegedly sustained while working as a selector for Employer.</p><p>The WCJ denied the Claim petition, rejecting Claimant’s live testimony as not credible. This credibility determination was the basis for the WCJ’s rejection of Dr. Levinstein’s testimony, as his understanding of the alleged work injury was based on information Claimant provided. TheWCJ found the testimony of Dr. Levinstein was not credible as his testimony that Claimant did not return to work after February 24, 2017, was contradicted by Claimant’s testimony. Dr. Levinstein opined that Claimant’s alleged work injury was caused by the repetitiveness of her work duties; however, no evidence was presented that established the repetitive nature of those duties. Dr. Levinstein diagnosed and treated Claimant, even though his initial examination failed to reveal any objective findings.</p><p>The WCJ rejected Claimant’s and Dr. Levinstein’s testimony as not credible. On this basis, the WCJ did not address the credibility of Employer medical witness, Dr. Mauthe. The WCJ found there was no credible evidence that Claimant suffered a work injury in the course and scope of her employment. Claimant failed to meet her burden of proof</p><p>On appeal Claimant argued: (1) the WCJ failed to issue a reasoned decision as the WCJ did not adequately explain his credibility determinations with respect to Claimant’s and Dr. Levinstein’s testimony; (2) the WCJ’s brief statement rejecting Claimant’s live testimony does not permit adequate appellate review; (3) the WCJ’s credibility findings as to Dr. Levinstein cannot be properly reviewed absent further explanation regarding Claimant’s credibility, given that Dr. Levinstein’s testimony was rejected in part because it relied on Claimant’s information; (4) the WCJ erred when he failed to make any findings or render a credibility determination of Dr. Mauthe’s testimony.</p><p>The Commonwealth Court affirmed the denial of the Claim petition and explained that as Claimant testified live before the WCJ - who assessed Claimant’s demeanor and concluded that “Claimant’s live testimony was not credible" - under the <i>Daniels</i> standard , the WCJ’s conclusion that Claimant lacked credibility is sufficient, and, therefore, the reasoned decision requirement under Section 422(a) was satisfied.</p><p>In regards to Claimant's argument with respect to Dr. Levinstein’s testimony, the WCJ clearly articulated multiple objective bases for his credibility determination. While Dr. Levinstein opined that Claimant’s alleged work injury was caused by the repetitive nature of her work duties, Claimant presented no evidence in this regard. Finally, the WCJ found that Dr. Levinstein diagnosed and treated Claimant despite an apparent lack of objective findings in his initial examination.</p><p>The Court reasoned, that once the WCJ rejected the testimony of Claimant and Dr. Levinstein as not credible, there was no further evidence of record that Claimant could have relied on to satisfy her burden of proof. Because Claimant failed to offer credible evidence in support of her claim petition, it was not necessary for the WCJ to assess Dr. Mauthe’s credibility to render a reasoned decision.</p><p><b>Practice Pointers:</b></p><p><b>1. Yes, it is possible to succeed in the litigation of a Pennsylvania workers compensation claim petition. </b></p><p><b>One must present sufficient evidence to allow the </b><b>Workers' Compensation Judge to conclude that the Claimant's medical expert opinion is not based upon the facts established by the evidence.</b></p><p><b>One may also prevail when conflicting medical expert opinions are presented. If the Employer presents an unequivocal medical expert opinion - which is found to be credible by the Workers' Compensation Judge - then conflicting evidence may be resolved in favor of the Employer's position. </b></p><p><b>2.</b> <b>A successful claim petition litigation result begins with an investigation of the accident circumstances, followed by the discovery of all pertinent medical records and the retention of a medical expert, who will review and address all of the issues presented. </b></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-8327719737014263262021-10-28T16:43:00.000-04:002021-10-28T16:43:53.217-04:00Pennsylvania Employers – Now is a good time to review your Post-Injury Drug Testing Procedures & Policies.<p> </p><p class="Default"><b><span face=""Calibri",sans-serif" style="font-size: 11pt; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">Pennsylvania Employers – Now is a good time to review your
Post-Injury Drug Testing Procedures & Policies.</span></b></p>
<p class="Default"><span face=""Calibri",sans-serif" style="font-size: 11pt; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">A recent Commonwealth Court decision considered an employee’s
entitlement to wage loss benefits when he was <span style="mso-spacerun: yes;"> </span>terminated for noncompliance with the Employer’s
post-injury drug-testing policy.</span></p>
<p class="Default"><span face=""Calibri",sans-serif" style="font-size: 11pt; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">See:<b> Bear Staffing v. WCAB (Shawn Logan):</b> No. 949 C.D. 2020;
Memorandum Opinion, not reported; Filed October 15, 2021.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The Commonwealth
Court concluded the Workers’ Compensation Judge properly determined that the Employer
failed to meet its burden of proving that Claimant was discharged for
work-related misconduct, the misconduct being his <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">noncompliance with the Employer’s post-injury
drug-testing policy. </span>The WCJ’s found the reasons for Employer’s
termination of Claimant were not “credible”. <span style="mso-spacerun: yes;"> </span>As the WCJ has sole authority over issues of
credibility of witnesses, this finding and conclusion was not reviewed by the
Court on appeal.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The facts presented
warrant our further review...</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><u>Factual
and Procedural History<o:p></o:p></u></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Claimant worked
for a temporary employment agency, which assigned him to work at a chocolates
manufacturer. Claimant slipped and fell, striking his head and back on the
ground. He sustained injuries to his head, neck, and lower back. A Claim
petition was filed and Employer filed a timely answer. Employer issued an
amended Notice of Temporary Compensation Payable; Medical-Only (NTCP-MO),
acknowledging Claimant’s work-related injury. Employer subsequently filed a
Petition to Terminate based upon it’s IME results.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">One day
post-injury, Claimant was directed to a drug test at WorkNet in accordance with
Employer’s policies. <span style="mso-spacerun: yes;"> </span>A WorkNet employee
testified she took Claimant through the drug and alcohol testing. A breathalyzer
test for the presence of alcohol, returned no indications. For the drug
screening, Claimant was required to provide a urine sample. The first sample
exceeded the 100-degree temperature threshold for an acceptable sample. The Employer
policies required Claimant to <u>provide a second sample under observation</u>.
Claimant said he was unable to provide another sample right away, so he was
given some water and waited.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">A male
physician was available to observe Claimant when he provided the second sample.
Claimant and the physician went into a bathroom. Shortly thereafter, they came
out and Claimant appeared angry. He declared the observation was an invasion of
his privacy. <b>Claimant did not provide a second urine sample</b>. The WorkNet
employee testified the original sample was outside the required temperature
range. As a second sample was not obtained, the drug testing was not completed.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The physician also
testified regarding the procedures. He has encountered people who have
difficulty providing a second sample as they recently urinated and/or assert
that they cannot do so while someone is watching them. The physician testified he
went with Claimant and Claimant stated that he was uncomfortable being
observed. Claimant appeared angry and objected to “an invasion of his privacy’.
He cautioned Claimant that this was something that could cause him to lose his
job, but Claimant left without providing a second urine sample.<o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Employer’s Executive
Vice President and COO, testified about its drug-testing policy and the actions
after Claimant’s testing. The Employer policies concerning drug and alcohol
testing following work-related injuries <u>are covered in the hiring process. Claimant
signed an acknowledgment of these policies when he was hired.</u></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">When Claimant was
released for restricted duty work, he sent a letter to Claimant, indicating the
Employer was unable to offer Claimant future work due to his failure to comply
with the post-injury drug-testing policy. Mr. Johnson testified the <u>termination
of Claimant’s employment was due solely to the violation of the policy</u>. If
Claimant had not violated their policy, Employer would have found work for
Claimant within his restrictions, without a loss in earnings.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><u>Workers’
Compensation Judge Decision</u></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The WCJ found
that “Claimant is also credible and convincing that <b>he was not purposefully
refusing to provide a urine sample as required</b> <b>by . . . Employer’s work
policy.”</b> The WorkNet employee and physician were found to be credible
regarding their attempts to obtain a second urine sample; however, the WCJ
credited Claimant’s testimony “as to <b>Claimant’s inability</b> to provide the
second urine sample and <b>not his refusal</b> to provide that sample.”</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The WCJ found
that Claimant met his burden of proof to establish he sustained work-related
injuries that rendered him unable to perform his job. The WCJ concluded, Employer
failed to establish that Claimant fully recovered from his work injuries. <i><span style="font-size: 9pt;">(Claimant’s medical evidence <span style="mso-spacerun: yes;"> </span>reflected diagnoses of: a scalp contusion,
post-concussive syndrome, post-traumatic cephalgia, cervical strain/sprain, thoracic
sprain/strain, lumbosacral strain/sprain with evidence of radiculopathy).</span></i></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The Appeal
Board affirmed the WCJ’s decision, reasoning the WCJ determined that Claimant’s
discharge from employment resulted from <u>his inability</u> rather than his <u>bad
faith</u> <u>refusal</u> to comply with Employer’s drug-testing policy. The
Employer failed to establish the requisite “bad faith willful misconduct”
necessary for the suspension of Claimant’s disability benefits.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><u>Commonwealth
Court Reasoning for its Conclusions</u></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">On appeal Employer
argued the WCJ erred in awarding Claimant ongoing disability benefits where he
was terminated for failing to comply with Employer’s drug-testing policy, as his
termination, rather than his injury, was the cause of his subsequent wage loss.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Employer
acknowledged the WCJ made credibility determinations regarding Claimant’s
inability to provide a second urine sample - but this should not be the end of
the analysis, as the WCJ also credited the WorkNet employee and physician
descriptions of the Claimant’s failure to provide a second sample, including
Claimant’s angry behavior and use of profanity. Employer argued this
demonstrated that Claimant refused to cooperate with the testing and there was
a lack of good faith.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Employer argued
it terminated Claimant and was unable to offer him future work due to his
failure to comply with the drug-testing policy - this was the sole reason for his
loss of earnings.<o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Employer
compared this case to <i>Edwards v. WCAB (Sear’s Logistic Services)</i> (Pa.
Cmwlth. 2001) where an employee sustained a work injury and took a post-injury
drug test, which indicated his use of an illegal drug. Employer terminated him
due to this result. The Court affirmed the suspension of benefits following his
employment termination, as the employee “was discharged for violating the
employer’s policy prohibiting a use of illegal drugs. His loss of earnings after
discharge was a result of his own action, not the work injury”.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">In the instant
case, the Court did not reverse the benefit award based upon <i>Edwards,</i> as
this WCJ credited Claimant’s explanation that <u>he was unable</u> to provide a
second urine sample while being observed, and that <u>he did not intentionally
refuse to comply</u> with Employer’s drug-testing policy.</p>
<p class="Default"><span color="windowtext" face=""Calibri",sans-serif" style="font-size: 11pt; mso-ascii-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">When an employer alleges the claimant’s loss of
earnings is the result of a post-injury involuntary discharge, the employer has
the burden of proving that suitable work was available or would have been
available, but for, the circumstances which lead to the claimant’s discharge.</span><span style="font-size: 11pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">See:
<i>Reyes v. WCAB (AMTEC) (Pa. Cmwlth. 2009) quoting</i> <i>Second Breath v.
WCAB (Gurski)</i> (Pa. Cmwlth. 2002).</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">A claimant
is not entitled to disability benefits where the loss of earnings is a result
of a discharge for bad faith conduct that was committed by the claimant
subsequent to the injury or was not known to the employer until after the
injury. See; <span style="mso-spacerun: yes;"> </span><i>Vista International
Hotel v. WCAB (Daniels) (Pa. 1999) and BJ’s Wholesale Club v. WCAB (Pearson)</i>(Pa.
Cmwlth. 2012).</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The WCJ must determine
whether a claimant was discharged for conduct evidencing a lack of good faith. This
is a question of fact to be determined by the WCJ.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The Court noted
the short-coming in this Employer’s argument is that case precedents emphasize
the initial credibility determination of the WCJ, in his role as fact-finder,
as to whether the claimant acted in bad faith with respect to an employer’s
rule or policy, resulting in the discharge. <i>See, e.g.</i>, <i>Vista
International Hotel</i>, 742 A.2d at 659.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The Court
concluded <span style="mso-spacerun: yes;"> </span>the WCJ properly determined
that employer failed to meet its burden of proving that claimant was discharged
for work-related misconduct. The WCJ specifically found the reasons for
employer’s termination of claimant were not credible.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The WCJ
expressly credited Claimant’s testimony that he did not intentionally refuse to
comply with the drug-testing policy. Instead he was unable to comply as he
could not produce a second urine sample while observed. The WCJ’s findings
support the conclusion that Claimant did not act in bad faith with respect to
the Employer’s drug test policy, even though his failure to comply resulted in
his termination. <span style="mso-spacerun: yes;"> </span>Once again, the Court
emphasized the WCJ has sole authority over issues of credibility of witnesses.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">PRACTICE
POINTERS:</p>
<p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-text-indent-alt: -.25in; text-indent: -0.5in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font: 7pt "Times New Roman";">
</span>1.<span style="font: 7pt "Times New Roman";"> </span></span></span>We recommend review of the Employer post-injury
drug testing policies with your legal counsel and<span style="text-indent: -0.5in;"> Human Resources professionals.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-text-indent-alt: -.25in; text-indent: -0.5in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font: 7pt "Times New Roman";"> </span>2.<span style="font: 7pt "Times New Roman";"> </span></span></span>Address this issue of an Employee asserting he/she
is unable to provide a first or second urine sample. Do your testing policies require
observation of the employee? Are there alternative policies or procedures that
will allow for valid testing?</p>
<p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-text-indent-alt: -.25in; text-indent: -0.5in;"><!--[if !supportLists]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font: 7pt "Times New Roman";"> </span>3.<span style="font: 7pt "Times New Roman";"> </span></span></span>A simple Google search - will identify the validity
issues raised by the receipt of a urine sample that exceeds the 100-degree
temperature threshold for an acceptable sample.<o:p></o:p></p>
<p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0in; mso-add-space: auto;">Review the testing procedures utilized to maintain the test
site integrity.<o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><o:p> </o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-24749449364079864962021-10-04T15:15:00.002-04:002021-10-05T10:32:57.262-04:00Important PA Work Comp Update: Notification of Suspension/Modification; LIBC-751 form must be Notarized. COVID suspension of Notary Requirement has ended.<p> Bureau of Workers Compensation message - </p><div align="center">
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<p align="center" class="MsoNormal" style="text-align: center;"><b><span face=""Verdana",sans-serif" style="color: #00346d; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">Notary Requirement for LIBC-751 <o:p></o:p></span></b></p>
<p align="center" class="MsoNormal" style="text-align: center;"><b><span face=""Tahoma",sans-serif" style="color: #00346d; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"></span></b><b><span face=""Verdana",sans-serif" style="color: #00346d; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">(Notification of Modification/Suspension)<o:p></o:p></span></b></p>
<p align="center" class="MsoNormal" style="text-align: center;"><b><span face=""Verdana",sans-serif" style="color: #00346d; font-size: 12pt; mso-fareast-font-family: "Times New Roman";">as of Oct. 1, 2021<o:p></o:p></span></b></p>
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<p align="center" class="MsoNormal" style="text-align: center;"><span style="display: none; mso-fareast-font-family: "Times New Roman"; mso-hide: all;"><o:p> </o:p></span></p>
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<p class="MsoNormal" style="text-align: justify;"><span face=""Verdana",sans-serif" style="color: #00346d; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">As of Sept. 30, 2021, the suspension of regulations
governing the notary requirement on the Notification of
Suspension/Modification (LIBC-751) ended. As of Oct. 1, 2021, the
signature required on the LIBC-751 should be properly notarized.</span></p><p>The Notification of Suspension or Modification Pursuant to Section (C) & (D); LIBC-751 form allows the Employer and Insurer to suspension or modify the indemnity wage loss benefit status of the injured worker, upon a return to work, without the necessity of having the worker sign a document. </p><p>The LIBC- 751 document must be signed by the employer, notarized and filed within seven (7) days of the return to work. The Notice must be provided to the worker.</p><p>If the worker disputes the change of status, a "challenge" may be filed within 20 days by completing the appropriate section of the LIBC form. A prompt hearing will be scheduled before a Workers' Compensation Judge. </p><p>In the WCJ Challenge hearing, the only issue before the WCJ is the worker's status. If the worker is no longer employed or working at reduced wages, indemnity wage loss benefits will be reinstated.</p><p class="MsoNormal" style="text-align: justify;"><span face=""Verdana",sans-serif" style="color: #00346d; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";"></span></p><p>If the Employer/Insurer wishes to pursue a Suspension or Modification remedy - they must file a separate petition.</p>
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</div>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-73540902931628298632021-09-29T12:13:00.002-04:002021-09-29T12:13:42.191-04:00PA Work Comp Act allows for assessment of 50% penalty for delay in Fatal Claim Award<p> </p><p class="MsoNormal"><span style="line-height: 107%;"><span style="font-family: arial;"><span style="font-size: 12pt;">Timely benefit payment is required by the Pennsylvania Workers' </span>Compensation<span style="font-size: 12pt;"> Act. </span></span></span><span style="font-family: arial; font-size: 16px;">Section 428 of</span><span style="font-family: arial; font-size: 12pt;"> states that an employer violates the Act if it fails to make payments within 30 days of the date on which its obligation to pay arises. </span></p><p class="MsoNormal"><span style="font-size: 12pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: arial;">Section 430(b) of the Act specifically cautions that “any insurer or employer who . . . refuses to make any payment provided for in the WCJ’s decision without filing a petition and being granted a supersedeas shall be sub</span><span style="font-family: arial;">ject to a penalty as provided in section 435.</span></span></p><p class="MsoNormal"><span style="font-size: 12pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: arial;">Only a grant of supersedeas relieves an employe/insurer of its obligation to pay an award.</span></span></p><p class="MsoNormal"><span style="font-family: arial;"><span style="font-size: 12pt;"> A recent appellate </span>decision<span style="font-size: 12pt;"> addressed the propriety of a WCJ assessment of a 50 % </span></span><span style="font-family: arial; font-size: 12pt;">penalty for delay in payment of a Fatal Claim petition award. </span></p><p class="MsoNormal"><span style="font-family: arial; font-size: 12pt;">See: <b><i>City of Philadelphia v. WCAB (Thompson) </i></b>217 C.D. 2020; </span><span style="font-family: arial; font-size: 12pt;">May 26, 2021; (order for publication September 28, 2021) </span></p><p class="MsoNormal"><span style="font-family: arial;"><b><u><span style="font-size: 12pt;">Factual & </span>Procedural<span style="font-size: 12pt;"> Background</span></u></b></span></p>
<p class="MsoNormal"><span style="font-size: 12pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: arial;">A WCJ order granted a Firefighter Cancer Fatal Claim. The WCJ ordered Employer to pay indemnity benefits, funeral expenses, reasonable
litigation costs and statutory interest. “Claimant is entitled to weekly
benefits at the rate of [50%] of Decedent’s average weekly wage at the time he
last worked in 2010 …”.</span></span></p><p class="MsoNormal"><span style="font-size: 12pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="font-family: arial;">Employer appealed this award to the WCAB. The Board issued a denial of supersedeas.</span></span></p>
<p class="Default"><span color="windowtext"><span style="font-family: arial;">Claimant filed a penalty petition as Employer failed to pay
benefits following the WCJ’s fatal claim petition award and the Board’s order
denying supersedeas.</span></span></p>
<p class="Default"><span color="windowtext"><span style="font-family: arial;">After the penalty petition hearing, WCJ found Employer admitted
that it had not paid Claimant any indemnity benefits. Instead, Employer argued
that <b>its failure to comply with the WCJ’s order and the Board’s denial of
supersedeas was justified because<u> it was unclear whether Claimant’s benefit
rate was 50%, as provided for in the WCJ’s order, or 51% as provided for in the
Act.</u> </b>Employer also asserted that it was unable to calculate Decedent’s AWW
and the benefit rate.</span></span></p>
<p class="Default"><span style="font-family: arial;">In the WCJ
penalty petition decision (rendered prior to Board remand order) WCJ rejected
Employer’s arguments. <span style="mso-spacerun: yes;"> </span>WCJ found the initial
decision and order was “clear that 50% of Decedent’s AWW calculated at the time
he last worked for Employer in 2010 should be paid with a statutory interest.<o:p></o:p></span></p>
<p class="Default"><span style="font-family: arial;">WCJ
further found that irrespective of whether the benefit rate should have been 50%
or 51% percent, this is not sufficient grounds for the Employer to blatantly
disregard the WCJ order and the WCAB supersedeas denial.</span></p>
<p class="Default"><span style="font-family: arial;">WCJ stated - while there was no earning documentation submitted in the claim petition
litigation, <b>Employer cannot credibly argue an inability to calculate an AWW
and compensation rate inasmuch as wage records are within the complete control
of <span style="mso-spacerun: yes;"> </span>Employer.</b></span></p>
<p class="Default"><span style="font-family: arial;">Employer cannot credibly argue an inability to ascertain Claimant’s last date
of work and/or retirement date as any attendance records for Claimant are
within the complete control of the Employer. Any information presented by
Claimant would have come directly from attendance records generated by
Employer.</span></p>
<p class="Default"><span style="font-family: arial;">WCJ noted - If a Board order calculates the wages differently than what was paid by Employer,
Employer would have a Supersedeas Fund remedy for reimbursement of any
overpayment.</span></p>
<p class="Default"><span style="font-family: arial;">WCJ
found – the Employer arguments “to be <b>disingenuous” </b>as the initial WCJ order was
clear<b> and the information missing was within the control of Employer.</b></span></p>
<p class="Default"><span style="font-family: arial;">WCJ
Penalty petition decision - Employer violated the Act. WCJ imposed a 50%
penalty upon Employer for failing to comply with the WCJ order and the Board’s
order denying supersedeas. <o:p></o:p></span></p>
<p class="Default"><i><span style="font-family: arial; font-size: 16px;">Note: </span><span style="font-family: arial; font-size: 16px;">the Board subsequently remanded the Employer appeal of the Fatal Claim award for the WCJ to reconsider the merits of the fatal claim petition based on intervening case law; the PA Supreme Ct decision in Sladek.</span></i></p>
<p class="Default"><span style="font-family: arial;"><u><b>Employer
appeal Penalty award to WCAB</b></u> <o:p></o:p></span></p>
<p class="Default"><span style="font-family: arial;">Employer
argued that Claimant had an affirmative duty to establish Decedent’s AWW and
thus Employer did not violate the Act.</span><span style="font-family: arial;"> </span></p>
<p class="Default"><span style="font-family: arial;">WCAB-
rejected Employer’s contention that the WCJ’s decision was unclear as to the
date to be used to calculate the AWW and benefits due, as these issues are
decided by statutory law “and the benefits due were discernable.”<o:p></o:p></span></p>
<p class="Default"><span style="font-family: arial;">WCAB
- Employer presented no evidence of a good faith payment.<i><span style="mso-spacerun: yes;"> </span></i>Employer violated the Act. WCJ did not
abuse her discretion in imposing a penalty.</span></p>
<p class="Default"><u><span style="font-family: arial;"><b>Employer
appeal of penalty petition award to Commonwealth Court</b></span></u></p>
<p class="Default"><span style="font-family: arial;">CW
CT - <span style="mso-spacerun: yes;"> </span>“<span color="windowtext">It is
well-settled that where an employer fails to commence payment of compensation
in accordance with a WCJ’s order, the failure to make payment constitutes a
violation of the Act and the employer is subject to the imposition of penalties”.</span></span></p>
<p class="Default"><span style="font-family: arial;"><span color="windowtext">CW CT - </span>Section 428 states that an employer violates the Act if it fails
to make payments within 30 days of the date on which its obligation to pay
arises. Further, section 430(b) of the Act specifically cautions that “any
insurer or employer who . . . refuses to make any payment provided for in the WCJ’s
decision without filing a petition and being granted a supersedeas shall be
sub</span><span style="font-family: arial;">ject to a penalty as provided in section 435 … “Indeed, only a grant of
supersedeas relieves an employer of an obligation to pay.”</span><span style="font-family: arial;"> </span></p>
<p class="Default"><span style="font-family: arial;">CW
CT reviewed prior decisions assessing 50% penalties. The CW CT concluded - WCJ
did not abuse her discretion in imposing a 50% penalty for Employer’s
significant delay in tendering payments for indemnity benefits to Claimant
after the Board denied supersedeas.</span></p>
<p class="Default"><span style="font-family: arial;">…
As both the WCJ and the Board recognized, Employer was (and presumably
continues to be) in possession of records that not only pertain to—but also
serve as a sufficient basis to verify—Claimant’s actual wages and AWW. Employer
does not assert that it did not have access to such information.</span></p><p class="Default"><span style="font-family: arial;"><span style="font-size: 18.6667px;"><b>Recommendations/ Practice Pointers </b></span></span></p><p class="Default"><span style="font-family: arial;"><span style="font-size: 18.6667px;">As suggested by the Appeal Board, a best practice is to issue payment of a disputed award. Only submission and grant of a supersedeas request, allows the Employer to withhold benefit payments during the pendency of one's appeal.</span></span></p><p class="Default"><span style="font-family: arial;"><span style="font-size: 18.6667px;">Denial of the supersedeas request, requires timely benefit payment. </span></span></p><p class="Default"><span style="font-family: arial;"><span style="font-size: 18.6667px;">As a general rule, the claimant has the burden of proof to establish each element of the claim petition. This would include the first date that benefit are requested, together with submission of documentation of the average weekly wage. </span></span></p><p class="Default"><span style="font-family: arial;"><span style="font-size: 18.6667px;">However, in this instance, the WCJ, WCAB and Commonwealth Court concluded the Employer has access to this information - such that, its explanation of its failure to commence payment, lacked merit. </span></span></p><p class="Default"><br /></p><p class="Default"> </p><p class="Default"><br /></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-9245659808519290392021-09-22T14:52:00.000-04:002021-09-22T14:52:04.521-04:00A WCJ approved Compromise and Release Settlement cannot be negated by a subsequent allegation there was no "meeting of the minds" regarding MSA medical expenses. <p><b style="font-size: 14pt;"><i>Lehigh Specialty Melting, Inc.
v. WCAB (Bosco)</i></b><span style="font-size: 14pt;">: No. 569 C.D. 2020</span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">Employ</span><span style="font-size: 14pt; line-height: 107%;">er’s Petition to Review requested relief and enforcement of the terms of an approved Compromise and
Release settlement. Consistent with the terms of a C&R settlement, Employer obtained a Medical Set-Aside (MSA) approved
by CMS. Claimant refused to execute the paperwork necessary to secure the
MSA (as agreed upon in the C&R) as the MSA did not include expenses for medical marijuana. <o:p></o:p></span><span style="font-size: 14pt; line-height: 19.9733px;">Lehigh Specialty Melting, Inc. </span></p><p class="MsoNormal"><span style="font-size: 14pt; line-height: 19.9733px;">WCJ Decision granted </span><span style="font-size: 18.6667px;">Employer's</span><span style="font-size: 14pt;"> Petition. </span><span style="font-size: 18.6667px;">WCAB Order reversed.</span><span style="font-size: 18.6667px;"> </span><span style="font-size: 18.6667px;">Commonwealth</span><span style="font-size: 18.6667px;"> Court reinstated WCJ decision.</span></p><p class="MsoNormal"><i style="font-size: 18.6667px;">September 21, 2021 ordered that the Memorandum Opinion filed on July 13, 2021 shall be designated OPINION and it shall be reported.</i></p><p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;"><span style="font-size: 18.6667px;">The </span></span><span style="font-size: 18.6667px;">Commonwealth </span><span style="font-size: 18.6667px;">Court ruled that once a C&R has been approved, a claimant cannot ask a workers’ compensation judge to negate it based on the contention that there was no meeting of the minds. After WCJ approval, the only means for a party to negate the C&R is to convince a WCJ that the agreement was entered into as a result of fraud, deception, duress, mutual mistake, or unilateral mistake caused by an opposing party’s fault. As none of these conditions exist in the case </span><i style="font-size: 18.6667px;">sub judice, </i><span style="font-size: 18.6667px;">the WCJ decision was reinstated.</span></p>
<p class="MsoNormal"><b><span style="font-size: 14pt; line-height: 107%;"><u>Factual
Background</u> </span></b></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The parties
entered into a Compromise and Release Agreement (C&R), which was approved
in a 2014 WCJ decision. An amended 2014 WCJ order specified that Employer was to
continue to pay medical expenses associated with Claimant’s work injury
until it funded a Workers’ Compensation Medicare Set Aside Arrangement (MSA)
approved by the Center for Medicare & Medicaid Services (CMS).</span><span style="font-size: 8pt; line-height: 107%;"><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">In 2018,
Employer filed a Petition to Seek Approval of a C&R, a Petition to Review
Medical Treatment and/or Billing and a
Petition to Review Compensation Benefits.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The gist the
three petitions was that Claimant entered into a C&R wherein he agreed
not only to a lump sum settlement but also to the potential establishment and
funding of an MSA. <span style="mso-spacerun: yes;"> </span>Claimant agreed to
timely complete all paperwork necessary for Employer to apply for and secure an
MSA or Allocation. Thereafter, when Employer obtained a set-aside approved by CMS, Claimant
refused to follow through with executing the paperwork necessary to secure the
MSA.<o:p></o:p></span></p>
<p class="Default"><b><span style="font-size: 14pt;"><u>WCJ Decision</u></span></b></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The WCJ
found Claimant testimony was credible that he knowingly and voluntarily agreed that if Employer
obtained approval of an MSA and properly funded it, Claimant’s medical benefits
would end. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;"><u>Summary of the WCJ
findings of fact reflect</u> -<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">Claimant
agreed to cooperate with Employer’s efforts to obtain an MSA. Under the
C&R, Employer’s only obligation [if it chose to exercise it], was to obtain
approval of an MSA and fund the same. There was no provision that Employer
needed to pay for anything other than the MSA. Employer’s evidence demonstrated
that it submitted an MSA to CMS, the MSA was approved, the paperwork was
forwarded to Claimant and Claimant’s refused to sign the paperwork because the
MSA did not include all of Claimant’s ongoing work-related medical treatment -
including medical marijuana.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">Employer
resubmitted the MSA proposal to CMS, which again approved it with a <i>“notation
that medical marijuana is not covered by Medicare and is thus not considered
part of an MSA"</i>. WCJ found the Employer’s obligation was solely to obtain an MSA and fund it,
“not to obtain an MSA and cover other services not covered by Medicare.” The evidence clearly shows that Claimant failed to cooperate by signing
the documents needed to finalize the MSA. Employer could not obtain final
approval of the MSA.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The WCJ
noted Claimant’s position - he wants to be reimbursed for his past
usage of medical marijuana and he does not want to agree to the MSA unless
there is some provision for the funding of his future use of medical marijuana.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The WCJ
concluded that Claimant was attempting to re-write the C&R to include
payment for non-Medicare covered services as part of Employer’s obligation.
However, Claimant has shown no basis for a re-writing of a contract. The
WCJ concluded as a matter of law that (claimant's request) is not part of the legal obligation
that the parties contractually agreed to in the C&R.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The WCJ decision stated that, if Employer wished to end its obligation for Claimant’s medical
benefit payments, it was to obtain a new MSA structured settlement quote and
forward the paperwork to Claimant for signing. </span></p><p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">If Claimant signs the MSA paperwork,
Employer and its Insurer are relieved of all future liability of medical
expenses related to the work injury. </span><span style="font-size: 14pt;"> </span><span style="font-size: 18.6667px;">If Claimant does not sign the MSA paperwork, then </span><span style="font-size: 14pt;">Employer may send Claimant a check for the value of the MSA and its
obligation to pay for work-related medical expenses shall end.</span></p>
<p class="MsoNormal"><b><span style="font-size: 14pt; line-height: 107%;"><u>Claimant
Appeal to WCAB</u><o:p></o:p></span></b></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The WCAB
agreed with Claimant that the WCJ has no authority to require Claimant to
execute the MSA documents. Citing <i>Stroehmann Bakeries v. Workers’
Compensation Appeal Board (Plouse)</i>, 768 A.2d 1193 (Pa. Cmwlth. 2001). The
Board determined that a C&R is enforceable only where there has been a “meeting
of the minds” on all of its terms.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">WCAB
reasoned - circumstances have changed and medical use of marijuana is now
approved in Pennsylvania. Claimant contends that medical marijuana is a
reasonable treatment for his work injury. Employer disagrees. Accordingly,
there is no meeting of the minds. The C&R provision requiring Claimant execute documents for the approval of the MSA and final
settlement of his claim for medical benefits - is not enforceable.<o:p></o:p></span></p>
<p class="MsoNormal"><b><span style="font-size: 14pt; line-height: 107%;"><u>Commonwealth
Court Appeal of Employer</u><o:p></o:p></span></b></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The Commonwealth
Court analysis began with a review of section 449 regarding approval of a C&R agreement - <o:p></o:p></span></p>
<p class="MsoNormal"><b><span style="font-size: 14pt; line-height: 107%;">The
workers’ compensation judge shall not approve any C&R unless he first
determines that the <u>claimant understands the full legal significance of the
agreement</u>. The agreement must be explicit with regard to the payment, if any,
of reasonable, necessary and related medical expenses.<o:p></o:p></span></b></p>
<p class="Default"><span style="font-size: 14pt;">The Court reviewed the<b> </b>C&R
terms - Claimant’s wage loss benefits were settled for a lump sum payment; <span style="mso-spacerun: yes;"> </span>the C&R did not resolve Claimant’s medical
benefits but, instead, provided Employer with the option of funding an MSA or
continuing to pay the medical bills related to Claimant’s work injury.</span></p>
<p class="Default"><span style="font-size: 14pt;">The C&R specifically stated Employer shall continue to remain liable for payment of all reasonable and
necessary medical expenses related to Claimant’s work injury through CMS approval
of an MSA and Employer’s funding of the same. <b>Claimant agrees to timely
complete all paperwork necessary for Employer and its Insurer/Third-Party
Administrator to apply for and secure an MSA or Allocation</b>. (emphasis in
original).</span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The Court emphasizeded the C&R was approved by a WCJ, who confirmed via Claimant’s testimony
that Claimant understood its terms. Although the medical aspect of Claimant’s
workers’ compensation claim was left open at the time, the language clearly
demonstrated that the parties agreed that Employer could submit an MSA for CMS
approval at a later date. If the MSA was approved by CMS, and Employer chose to
fund it, Employer would be absolved of further responsibility for Claimant’s
medical bills. As part of this agreement, Claimant agreed to cooperate by
preparing all necessary paperwork for Employer to submit the MSA proposal.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">Now,
Claimant refuses to cooperate as he had promised in the C&R because the MSA
and/or Employer will not pay for his use of medical marijuana, which became legal
in Pennsylvania approximately two years <b>after </b>the C&R became
effective. Claimant relied upon <i>Stroehmann </i>to suggest there is no
meeting of the minds and a new C&R was required to relieve Employer of its
responsibility for Claimant’s medical expenses.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The Court
rejected Claimant’s assertion that <i>Stroehmann </i>requires the C&R to
reflect a “meeting of the minds”, noting - nowhere in <i>Stroehmann </i>is the
expression “meeting of the minds” used. The focus of <i>Stroehmann </i>was on
bringing final resolution to workers’ compensation claims in a way that had not
been available to parties in workers’ compensation litigation prior to 1996.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The Court
explained that a WCJ’s evaluation of a C&R is primarily focused upon the
claimant’s understanding of the terms of the agreement. The fact that the
parties have agreed upon a resolution of the claim seems indicative of a
meeting of the minds. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">Once a C&R has been approved, a claimant cannot ask a workers’ compensation
judge to negate it, based on the contention that there was no such meeting of
the minds. After approval, the only means for a party to negate the C&R is
to convince the workers’ compensation judge that the agreement was entered into
as a result of fraud, deception, duress, mutual mistake, or unilateral mistake caused
by an opposing party’s fault. </span><span style="font-size: 14pt;">None of these conditions exist in the matter </span><i style="font-size: 14pt;">sub
judice</i><span style="font-size: 14pt;">.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">To the
extent any of these reasons could even remotely apply to the present case, only
mistake might come at all close. Having said as much, we stress that we do not
equate a change in law, after the C&R’s approval, with a "mistake" <u>at the
time the C&R was negotiated and approved by the WCJ</u>.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">At the time
the parties entered into their C&R, and it was approved, there was
apparent agreement on its terms. The only notable change is that medical marijuana
became available in Pennsylvania. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">However,
given that (1) medical marijuana was neither contemplated nor legal in
Pennsylvania when the C&R was approved, (2) Claimant never appealed
approval of the C&R, (3) Claimant accepted $155,000 to resolve the
indemnity portion of his claim, (4) Claimant agreed to cooperate in Employer’s
efforts to secure an MSA, (5) it was up to Employer’s sole discretion whether
to fund the MSA, and (6) CMS will not fund medical marijuana, despite changes
in State law - <span style="mso-spacerun: yes;"> The Court </span>cannot agree with
Claimant that a new C&R is required for Employer to exercise its option to
resolve the medical portion of Claimant’s workers’ compensation claim.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The Court
referenced the Pennsylvania Superior Court’s opinion in <i>Felix v. Giuseppe
Kitchens & Baths, Inc.</i>, 848 A.2d 943 (Pa. Super. 2004). regarding a trial court’s enforcement of a settlement agreement. The <i>Felix
</i>Court stated that “settlement agreements are enforced according to
principles of contract law. Courts will enforce a settlement agreement if all
its material terms are agreed upon [sic]. A settlement agreement <b>will not be
set aside absent a clear showing of fraud, duress or mutual mistake.</b>” <i>Felix</i>,
848 A.2d at 947 The Superior Court added that “it is well settled that a party
assumes the risk of his or her own inability to perform contractual duties.” <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The
Commonwealth Court reasoned – </span><span style="font-size: 14pt;">that in the
instant matter - we are not faced with a party’s </span><i style="font-size: 14pt;">inability </i><span style="font-size: 14pt;">to perform
contractually agreed upon duties. We are presented with something more
substantial - an </span><i style="font-size: 14pt;">unwillingness </i><span style="font-size: 14pt;">to perform.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">Thus, as per the Superior Court in <i>Felix</i> and in light of
the inability of the WCJ to require Claimant to sign the MSA paperwork, we see
no error in the WCJ’s decision to enforce the settlement agreement rather
than set it aside. The remedy imposed by the WCJ, <i>i.e.</i>, requiring
Employer to obtain a new quote for the MSA from CMS and giving Claimant two
weeks to review and sign the paperwork, followed by the opportunity for
Employer to send Claimant a check for the value of the MSA should Claimant
choose not to cooperate, is reasonable.</span></p>
<p class="MsoNormal"><span style="font-size: 14pt; line-height: 107%;">The Court noted - Employer is correct that the Board’s standard would open a Pandora’s
box that could potentially unravel countless C&Rs - based on the contention
that there was no “meeting of the minds” at the time the agreements were
approved. This, in turn, would defeat the true meaning of <i>Stroehmann - </i>which was to underscore the value of bringing permanent resolution to workers’
compensation claims by encouraging settlements and stressing finality.</span></p><p class="MsoNormal"><b style="font-size: 14pt;">PRACTICE POINTERS</b></p><p class="MsoNormal"></p><ol style="text-align: left;"><li><span style="font-size: 14pt; line-height: 107%;">Negotiate and itemize specific settlement terms regarding wage loss medical expense and all other type of payment due at the time of settlement and at any future point. </span></li><li><span style="font-size: 14pt; line-height: 107%;">Draft specific settlement terms regarding the obligations of each party, particularly regarding future medical expense liability. Consider options and alternatives that are available to each party.</span></li><li><span style="font-size: 14pt; line-height: 107%;">Present testimony before the WCJ of the claimant's understanding of: specific settlement terms; payments due; future benefit rights; future obligations. </span></li></ol><p></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-34486269684203634442021-09-13T15:44:00.000-04:002021-09-13T15:44:39.093-04:00PA Work Comp total disability benefit status reinstatement, after unconstitutional IRE, is the date of filing of the Petition to Reinstate<p><br /></p>
<p class="Default">In a series of Memorandum Opinions issued throughout 2021, the
Pennsylvania Commonwealth Court has consistently held that a Claimant is
entitled to reinstatement of<span style="mso-spacerun: yes;"> </span>total
disability benefit status, as of the filing date of the Claimant Petition to
Reinstate, where the change in benefit status was based upon an unconstitutional IRE.<o:p></o:p></p>
<p class="Default"><b>Marcellini v. WCAB (Brighthouse Life Insurance Company and Travelers </b><b>Indemnity Company)</b> No. 1014 C.D. 2020; Memorandum Opinion filed September 13, 2021</p>
<p class="Default">In <i>Marcellini</i> the Commonwealth Court dismissed Claimant arguments that (1) the <i>White </i>decision and its progeny are erroneous
regarding the correct date for reinstatement and (2) the claimant has a “vested
right” to workers’ compensation benefits.</p>
<p class="Default"><b>Procedural Background</b></p>
<p class="Default">Claimant appealed the WCAB decision that reinstated her total disability benefits as of July 18, 2017, the date she filed her petition
for reinstatement. <i>(After the 1<sup>st</sup> WCJ decision there was a remand to
WCJ, to consider the effects of the Whitfield decision and Act 111 enactment. The WCJ decision was
unchanged.)</i> The WCAB affirmed the WCJ decision. On appeal, Claimant
argued the WCAB erred, as properly she was entitled to reinstatement as of
March 19, 2009 - the date her status was modified from total to partial on the
basis of an unconstitutional impairment rating evaluation (IRE).</p>
<p class="Default">In affirming the WCAB decision, The Commonwealth
Court relied upon a recent decision in<i> Whitfield. </i>That opinion held a claimant, who showed that her work-related disability continued, was
entitled to reinstatement of her total disability status, as of the date she
filed her reinstatement petition.</p>
<p class="Default">The <i>Whitfield </i>Court reasoned - <i>Simply because Protz is being applied
to a case that arose from a work injury and a change in disability status that
predates it does not mean it operates retroactively…. This (Protz) decision
does not alter the claimant’s past status. Rather, it gives effect to the
claimant’s status as it existed at the time she filed her reinstatement
petition. </i>Citing: <i>Whitfield</i>, 188 A.3d at 617.</p>
<p class="Default">The Commonwealth Court compared the date of reinstatement
ordered in <i>Dana Holding Corporation v. Workers’ Compensation Appeal Board
(Smuck)</i> (Pa. Cmwlth. 2018), <i>aff’d</i>, 232 A.3d 629 (Pa. 2020), to that
ordered in <i>Whitfield. </i>In <i>Dana Holding</i>, claimant had appealed the
modification of compensation based upon an IRE, and <b>that appeal was pending
when <i>Protz </i>was decided.</b></p>
<p class="Default">In the <i>Dana Holding</i> situation, the Court held that the
claimant was entitled to reinstatement as of the date of the IRE. By contrast,
in <i>Whitfield</i>, claimant did not appeal the modification but, rather,
filed a reinstatement petition following the <i>Protz </i>decision. <b>Because
the claimant in <i>White </i>had not appealed the initial modification, this
Court held that she was entitled to reinstatement as of the date of her
petition, not the date of the change in her disability status from total to
partial.</b> <i>See White</i>, 237 A.3d at 1231 (explaining the different
paradigms of <i>Dana Holding </i>and <i>Whitfield</i>).</p>
<p class="Default">In the instant case, <span style="mso-spacerun: yes;"> </span>Claimant did not challenge the validity of her
2009 IRE until after <i>Protz </i>was decided in 2017. On this basis, the Board
properly reinstated her total disability status as of the date she filed her
petitions. Citing: <i>White, supra.</i></p>
<p class="Default">Claimant argued she has a vested right in workers’
compensation benefits. She argued she was deprived of a vested right to
total disability compensation by an unconstitutional procedure. This requires
the 2009 modification of her disability status to be set aside. However, as noted by the Court in <i>Perillo
v. Workers’ Compensation Appeal Board (Extended Healthcare Services, Inc.) </i>(Pa.
Cmwlth., <b>a claimant does not have a vested
right in workers’ compensation benefits</b> and, thus, there is no entitlement
to reinstatement of total disability benefits effective as of the date of the prior invalid IRE.</p>
<p class="Default">The Court explained that the Pennsylvania Supreme Court has
limited the scope of the protection to vested rights: “It must be something
more than a mere expectation, based on an anticipated continuance of existing
law. It must have become a title, legal or equitable, to the present or future
enforcement of a demand, or a legal exemption from a demand made by another.” <i>Perillo</i>, slip op. at 5, n.10.</p>
<p class="Default">Because workers’ compensation benefits can be changed at any
time, “there are no vested rights in workers’ compensation benefits.” <i>Perillo</i>,
slip op. at 4. In the instant case, the Court reject
Claimant’s premise that she had a vested right to total disability compensation.</p>
<p class="Default"><b>PRACTICE POINTERS</b></p>
<p class="Default">1. Continue to pursue the Impairment Rating Evaluation (IRE) as
a remedy to limit the duration of total disability benefit payment. After the
injured worker receives 104 weeks of total disability benefits, file an IRE
request for designation of an expert to conduct an evaluation.</p>
<p class="Default">2. As the IRE physician is limited to address only issues of MMI
status and the degree of impairment – if you wish to contest the extent or
duration of work-related disability – an Independent Medical Examination (IME) is
the remedy to pursue. <o:p></o:p></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-45808345629310205282021-09-01T17:14:00.000-04:002021-09-01T17:14:43.294-04:00<p> </p><p class="Default"><span style="font-size: 16.0pt;">PA Bureau of Work Comp Fee
Review Hearing Office may determine – who is a “medical provider” with standing
to pursue a fee review remedy.<o:p></o:p></span></p>
<p class="Default"><br /></p>
<p class="Default"><span style="font-size: 14.0pt;">Fee Review provides a forum to medical
providers to contest the amount or timeliness of the payments received from an
employer or insurer. In 2019, The Commonwealth Court issued a decision,
allowing jurisdiction to the Hearing Office to address the issue of whether an
entity was a provider. The definition of “who is a provider” continues to be
disputed.</span></p>
<p class="Default"><span style="font-size: 14.0pt;">See: <i>Harburg Medical Sales
Co. v. PMA Management Corp. (Bureau of Workers’ Compensation, Fee Review
Hearing Office), </i>No. 635 C.D. 2020; August 30, 2021</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Harburg
Medical Sales Co., appealed two adjudications of the Bureau of Workers’
Compensation, Fee Review Hearing Office, that denied Harburg’s requests for <i>de
novo </i>hearings to contest the Bureau’s administrative denial of fee review applications
on the ground that Harburg was not a provider within the meaning of Section 109
of the Workers’ Compensation Act and, therefore, lacked standing to invoke the
fee review process.</span></p>
<p class="MsoNormal"><b><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Factual
Background</span></b></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">A
worker sustained an injury in the course of his employment . After he developed
chronic pain, his doctor sent orders for certain pain treatment modalities to
Harburg. Upon receiving the orders, Harburg communicated with various
distributors (never identified, except—at one point—as Amazon, in these
proceedings), advanced payment for the items, and directed them to be delivered
to Maximo’s residence via UPS or FedEx. Thereafter, Harburg billed PMA
Management Corporation.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Following
a dispute between Harburg and PMA as to the amount properly payable for the
items, Harburg filed fee review applications with the Bureau.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Upon
the Bureau’s denial of the applications, Harburg sought further review by
requesting <i>de novo </i>hearings.<span style="mso-spacerun: yes;"> </span>PMA
moved to dismiss the applications on the grounds that Harburg was not a
provider and that the Hearing Office lacked jurisdiction to address the issue
of whether an entity was a provider. The Hearing Office denied the motion to
dismiss based on the then-controlling case law. The Hearing Office relied on <i>Selective
Insurance Co. of America v. Bureau of Workers’ Compensation Fee Review Hearing
Office (The Physical Therapy Institute)</i>, 86 A.3d 300 (Pa. Cmwlth. 2014),
which the Commonwealth Court subsequently overruled.</span></p>
<p class="Default"><span style="color: windowtext; font-size: 14.0pt;">Subsequently,
t</span><span style="font-size: 14.0pt;">he Commonwealth </span><span style="color: windowtext; font-size: 14.0pt;">Court issued two decisions impacting
the instant case. In <i>Armour Pharmacy v. Bureau of Workers’ Compensation Fee
Review Hearing Office (Wegman’s Food Markets, Inc.)</i>, 206 A.3d 660, 671 (Pa.
Cmwlth. 2019) (en banc) (<i>Armour I</i>),<span style="mso-spacerun: yes;">
</span>the Court held that the Hearing Office <u>had jurisdiction</u> to
determine whether a supplier was a provider.</span></p>
<p class="Default"><span style="color: windowtext; font-size: 14.0pt;">Thereafter,<span style="mso-spacerun: yes;"> </span>t</span><span style="font-size: 14.0pt;">he
Commonwealth </span><span style="color: windowtext; font-size: 14.0pt;">Court
directed the Hearing Office in a related series of cases to adjudicate the
threshold issue of whether Harburg was a provider. See: <i>PMA Mgmt. Corp. v.
Bureau of Workers’ Comp. Fee Rev. Hearing Off. (Harburg Med. Sales, Co., Inc.) </i>(Pa.
Cmwlth., No. 1757 C.D. 2017, filed Apr. 12, 2019). <span style="mso-spacerun: yes;"> </span>Pursuant to that directive, Hearing Officer
David Torrey conducted a hearing and concluded that Harburg was not a provider.
Harburg filed this appeal.</span></p>
<p class="Default"><b><span style="color: windowtext; font-size: 14.0pt;">Decision
and Reasoning of the Court</span></b></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">In
determining that Harburg does not meet the definition of provider, the
Commonwealth Court noted that Harburg is neither licensed nor authorized by the
Commonwealth to provide health care services.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Additionally,
there are no government agencies specifically authorizing Harburg to distribute
medical supplies, no state or federal quality standards for suppliers of such
items, and no continuing education requirements for operating a medical supply
company. Review of the facts do not warrant a legal determination that Harburg
is an agent of a licensed health care provider.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">The
Court rejected Harburg’s argument that the Hearing Officer’s decision violated
Harburg’s due process rights by depriving it of a forum to contest the amount
or timeliness of the payments received from the employer or the insurer.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Even
though Harburg may have rendered convenient services or assisted injured
workers to obtain equipment or supplies that were part of his or her treatment
plan, the pertinent legislation does not dictate that any person or entity
which does so be afforded an opportunity to invoke the fee review process.</span></p>
<p class="Default"><span style="color: windowtext; font-size: 14.0pt;">Pursuant to
the clear language of Section 306(f.1)(5) of the Act, only providers have
standing to do so. If the General Assembly wishes to expand the definition of
provider in legislation pertaining to medical cost containment and the fee
review process, then it needs to enact appropriate laws.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">The
Court concluded that Harburg was not deprived of its due process rights. In <i>Armour
I</i>, the Commonwealth Court held that “it offended due process . . . as well
as the Act’s careful scheme for resolving fee disputes to place the question of
whether a putative provider is actually a ‘provider’ beyond the reach of
judicial review.” <i>Armour I</i>, 206 A.3d 670. The Court determined that the
Hearing Office has jurisdiction to determine whether a supplier is a provider.</span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">In
the instant case, Harburg was given a full hearing on this issue and afforded
due process; it simply did not agree with either the result or the consequences
necessarily following therefrom—its inability to invoke the fee review process.
Determining the legal status of Harburg ends our inquiry. As Hearing Officer
Torrey concluded: “It may well be that some medical supply houses are, somehow,
providers under the Act, and have standing to file Requests in this forum.
However, on the evidence presented in this case, Harburg is not one of them.”</span></p><p class="MsoNormal"><b><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">PRACTICE
POINTERS:</span></b></p><p class="MsoNormal"><span style="font-family: "Times New Roman", serif; font-size: 14pt;">Carefully<b> </b></span><span style="font-family: "Times New Roman", serif; font-size: 14pt; text-indent: -0.25in;">review
medical billing statements. Is the statement from the medical provider or from
another entity? If not a provider, the employer/insurer may seek dismissal of
the review request.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><b><span style="font-size: 14.0pt;">Fee Review</span></b><span style="font-size: 14.0pt;">
provides a </span><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">forum
to </span><span style="font-size: 14.0pt;">medical providers to </span><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">contest the amount
or timeliness of the payments received from </span><span style="font-size: 14.0pt;">an</span><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;"> employer or
insurer</span><span style="font-size: 14.0pt;">.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><b><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">Utilization Review</span></b><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;"> provides a forum
to employers, insurers and claimants to request prospective, concurrent or
retrospective review of the <b>reasonableness or necessity </b>of medical
treatment expense.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">The Employer and
Insurer have additional remedies to contest medical expenses. A Petition to
Review may challenge the causal relationship of a medical expense and the work
injury. A medical expense may be denied outright – but a WCJ may ultimately
determine the denial was unreasonable and assess counsel fees.</span></p>
<p class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; mso-bidi-font-size: 14.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><!--[endif]--><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;">When reviewing
medical expenses, consider your options. What is the focus of your dispute ? Is
it the expense amount, the frequency of care or type of care? Discuss your remedies
with your work comp counsel.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 14.0pt;"><o:p> </o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-27842598798156332872021-08-24T14:08:00.003-04:002021-08-24T14:08:32.805-04:00 Post-Protz Commonwealth Court decision reinstates total disability status as of the Petition filing date, not as of the unconstitutional IRE date, rejecting the "void ab initio" argument.<p>Commonwealth Court Reinstates Worker's Total Disability benefit status as of the Petition filing date, not as of the date of the prior unconstitutional IRE, thus rejecting the <i>"void ab initio"</i> argument. </p><p class="Default"><span style="font-size: 14.0pt;"><b>Ellison v. WCAB (SEPTA), </b></span><span style="font-size: 14pt;">No. 1080 C.D. 2020 </span><span style="font-size: 14pt;">MEMORANDUM OPINION; </span><span style="font-size: 14pt;"> August
20, 2021</span></p><p class="Default"><span style="font-size: 14pt;">Another appellate decision addresses the date of reinstatement of total </span><span style="font-size: 18.6667px;">disability</span><span style="font-size: 14pt;"> status following the PA Supreme Court decision in </span><i style="font-size: 14pt;">Protz. </i><span style="font-size: 14pt;">The </span><span style="font-size: 18.6667px;">Commonwealth</span><span style="font-size: 14pt;"> Court has consistently held that the date of reinstatement is the date of the filing of the Worker's Petition to Reinstate.</span><span style="font-size: 14pt;"><i> </i>Arguments for Reinstatement as of the date of the unconstitutional IRE have been rejected. In <i>Ellison</i>, the Court rejects an argument based upon the "void ab initio" doctrine.</span></p><p class="Default"><span style="font-size: 14pt;"><b>Factual & Procedural Background </b></span></p>
<p class="Default"><span style="font-size: 14.0pt;">Claimant appealed a WCAB order which affirmed a WCJ decision to grant Claimant’s petition to reinstate
disability benefits, in part, and reinstated benefits as of July 18, 2017, which is the filing date of Claimant's petition. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">Claimant sustained a work related injury on February 11, 1998. </span><span style="color: windowtext; font-size: 14pt;">Employer
issued a NTCP which accepted a work-related injury of a “lumbar strain/sprain.” A 2007 WCJ decision granted Claimant’s Petition to Review the injury description to include two lumbar surgeries.</span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">A 2009 IRE resulted in a whole person impairment of 29%.<span style="mso-spacerun: yes;"> </span>Employer
issued a Notice of Change of Workers’ Compensation Disability Status and Claimant
benefits status was changed effective September 24, 2009, Claimant did not appeal the change of his disability status.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">In 2017 Claimant
filed a Petition to Reinstate Compensation Benefits. The 500-week period of partial disability benefits</span><span style="font-size: 8.0pt; line-height: 107%;"> </span><span style="font-size: 14.0pt; line-height: 107%;">had expired on July 11, 2015, before Claimant filed the
Reinstatement Petition. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">Following an
initial WCJ decision denying the Reinstatement Petition, and a remand by the
Board, following further hearings, the WCJ issued a new decision granting the Reinstatement Petition in part, and directing Employer
“to reinstate Claimant’s workers’ compensation benefits to total
disability status as of July 18, 2017.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">Claimant
appealed the WCJ’s decision to the Board, arguing that under <i>Protz II</i>,
the IRE provisions of former Section 306 (a.2) of the Act were determined to be
void <i>ab initio</i>, so his disability benefits should have been reinstated
as of September 24, 2009, the date of his unconstitutional IRE and not as of July 18,
2017, the date that he filed his Reinstatement Petition. The Board rejected
this claim citing <i>Whitfield.</i></span><o:p></o:p></p>
<p class="Default"><span style="font-size: 14.0pt;">In his Commonwealth Court appeal, Claimant argued the Board erred in affirming the WCJ’s decision as the Board erroneously applied the <i>Whitfield </i>decision - which Claimant argued was effectively overruled by <i>Commonwealth
v. McIntyre (Pa. 2020)</i></span></p><p class="Default"><span style="font-size: 14pt;">In</span><i style="font-size: 14pt;"> McIntyre, </i><span style="font-size: 14pt;">the PA Supreme Court</span><span style="font-size: 14pt;">, applied the </span><span style="font-size: 14pt;">void </span><i style="font-size: 14pt;">ab
initio </i><span style="font-size: 14pt;">doctrine in a criminal proceeding, which challenged a purportedly invalid
judgment of sentence. Claimant argued, his disability benefits should have been reinstated as
of the date of the unconstitutional IRE, </span><i style="font-size: 14pt;">i.e.</i><span style="font-size: 14pt;">, September 24, 2009, and
not the date of his filing of the Reinstatement Petition, July 18, 2017.</span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">The Commonwealth Court rejected this argument, noting that in <i>Weidenhammer</i>, they considered the application of the void <i>ab initio </i>doctrine in <i>Glen-Gery (a Pa. 2006 case)</i>,
and applied it to the reinstatement of disability benefits under <i>Protz II</i>,
explaining, in relevant part:<o:p></o:p></span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">The right to disability benefits for a work injury was created by the Act. The Act has imposed limits and conditions on an injured workers right to benefits. A WCJ may reinstate, suspend or terminate compensation "at any time".</span></p><p class="MsoNormal"><span style="font-size: 14pt;">Section 413 (a) acts as a statute of repose. A claimant whose benefits were suspended may seek reinstatement within three (3) years of the last benefit payment or the 500 weeks allowed for partial disability, which ever is later. </span></p><p class="MsoNormal"><span style="font-size: 14pt;">In </span><i><span style="font-size: 14pt;">Weidenhammer</span></i><span style="font-size: 14pt;"> the claimant’s
statutory right to total disability compensation had been extinguished at the
point in time that she filed her reinstatement petition. To allow claimant to
resuscitate her right to disability compensation would violate Section 413(a)
of the Act, 77 P.S. §772. Claimant may be correct that <i>Protz II </i>rendered
former Section 306(a.2) of the Act, <i>formerly </i>77 P.S. §511.2(1), void <i>ab
initio</i>, but it does not follow that the Pennsylvania </span><span style="font-size: 14pt;">Supreme
Court intended its ruling in </span><i style="font-size: 14pt;">Protz II </i><span style="font-size: 14pt;">to be given a fully retroactive
effect or to nullify the statute of repose in Section 413(a) of the Act.</span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">Importantly,
this Court also noted the distinction between applying the void <i>ab initio </i>doctrine
in a criminal matter, as in <i>McIntyre</i>, and applying it in proceedings
under the Act, observing - "full retroactive effect is generally reserved for criminal cases where life or liberty is at stake. Citing: </span><i><span style="font-size: 14.0pt;">Weidenhammer</span></i><span style="font-size: 14pt;">, 232 A.3d at 995 n.12.</span></p>
<p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">Based upon it's analysis, the Commonwealth Court stated - it is clear that Claimant’s assertion that the Supreme Court’s opinion
in <i>McIntyre </i>effectively overruled this Court’s holding in <i>Whitfield </i>is
patently without merit. </span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">To the contrary, like the claimant in <i>Weidenhammer</i>,
Claimant’s statutory right to total disability compensation had been
extinguished at the point in time that he filed his reinstatement
petition. To allow Claimant to resuscitate his right to disability
compensation would violate Section 413(a) of the Act.</span><o:p></o:p></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;"><b>Recommendations:</b></span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">We anticipate continued appeals of IRE reinstatement petition decisions, until the PA Supreme Court rules on these issues and arguments.</span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">IMO, it is noteworthy that the PA Supreme Court denied a claimant's application for allowance of appeal in the <i>Pierson v. WCAB (Consol Coal Co.</i>) 59 WAL 2021<i> </i>(08/17/2021). (</span><span style="font-size: 18.6667px;">04/26/2021 </span><span style="font-size: 14pt;">order for publication of CW CT decision).</span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">In </span><i style="font-size: 18.6667px;">Pierson, </i><span style="font-size: 14pt;">Claimant raised several constitutional issues for review</span><span style="font-size: 14pt;">: </span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">- Act 111 should not apply to injury dates before its enactment; </span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">- credit should not be given for pre-Act 111 TTD weeks for the 104 week threshold; </span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">- Act 111 language does not have clear language to have a retroactive effect; </span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">- as prior IRE procedures were unconstitutional, they should not be applied to calculation of compensation; </span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">- Act 111 interferes with vested benefit rights.</span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">***</span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;">We recommend continued use of the IRE remedy as an effective means to limit the duration of future wage loss benefit liability.</span></p><p class="MsoNormal"><span style="font-size: 14.0pt; line-height: 107%;"><br /></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-10493512453049929822021-08-17T08:45:00.001-04:002021-08-19T10:07:40.585-04:00PA Work Comp benefits paid pursuant to A Notice of Temporary Compensation Payable may be changed via a timely Medical Only NCP document<p> </p><p class="Default"><b>Changing the benefit status of a PA Work Comp injured
worker, who is compensated via a Notice of Temporary Compensation Payable (NTCP)
LIBC-501 document is now less cumbersome.</b></p>
<p class="Default">An Employer may file a “Medical Only” Notice of Compensation
Payable (MO-NCP) to change the benefit status of the injured worker, when the
MO- NCP<span style="mso-spacerun: yes;"> </span>is filed within the ninety-day
temporary compensation payable period. In this circumstance, the Employer is
not required to also file a Notice Stopping Temporary Compensation Payable
(NSTCP) and a Notice of Compensation Denial (NOCP). <i>This case was successfully argued by Chartwell Law founding partner Andrew Greenberg.</i></p>
<p class="Default"><b><i>See: Raymour & Flanigan v. WCAB (Obeid);<span style="mso-spacerun: yes;"> </span>No. 371 C.D. 2020 </i>Filed: August 16, 2021.</b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt;">The Commonwealth
Court reversed a decision of the PA Workers’ Compensation Appeal Board, noting
this was an issue of first impression. The Board decision reinstated ongoing indemnity
wage loss benefits payable to Claimant, back to the date the Employer stopped
those indemnity payments<span style="mso-spacerun: yes;"> </span>pursuant to the
filing of the MO-NCP. The Board concluded the Employer violated the Act as the
NTCP “converted” to a NCP after 90 days - by operation of law – in the absence
of the filing of the Notice Stopping Benefits and Notice of Compensation Denial.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Times New Roman",serif; font-size: 12pt;">Factual &
Procedural Background</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt;">This litigation
commenced when the injured worked file a Petition for Penalties and requested
reinstatement of indemnity wage loss benefits. Initially, after the report of a
work-related injury,<span style="mso-spacerun: yes;"> </span>the Employer
commenced work comp benefits to the injured worker via NTCP an injury described
as inflammation of her coccyx/sacrum . Sixteen days later the Employer issued a
MO-NCP.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt;">The WCJ found that
under Section 121.17(d) of the workers’ compensation regulations, 34 Pa. Code §
121.17(d), there was no requirement to file a Notice Stopping Temporary
Compensation Payable if, during the 90 day temporary compensation payable
period, the employer decided to issue a notice of compensation payable The
WCJ<span style="mso-spacerun: yes;"> </span>concluded that Claimant failed to
prove that Employer violated the Act and dismissed the penalty petition.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt;">The Appeal Board
concluded that under its interpretation of Section 406.1(d)(5)-(6) of the Act
and Section 121.17(d) of the regulations, that the Employer had violated the
Act and the Board ordered reinstatement of indemnity benefits as of the date as
indemnity payments were stopped and further ordered continuing benefits.<span style="mso-spacerun: yes;"> </span>Employer appealed this ruling.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt;">The Commonwealth
Court reviewed the statutory language at Section 406.1, which addresses the
requirements for commencement of work comp benefits via NCP or NTCP. The Court
noted that an employer may initiate compensation payments without prejudice and
without admitting liability pursuant to a notice of temporary compensation
payable.</span></p>
<p class="Default"><span color="windowtext">If an employer decides to stop
making payments pursuant to a NTCP the employer must provide notice to the
injured worker via, a form prescribed by the Bureau.</span></p>
<p class="Default"><span color="windowtext">If the employer does not file a
notice within the ninety-day period during which temporary compensation is
paid, then the employer is deemed to have admitted liability and the notice of
temporary compensation payable is converted to a notice of compensation
payable.</span></p>
<p class="Default"><b><span color="windowtext">Reasoning & Holding</span></b></p>
<p class="Default"><span color="windowtext">The Commonwealth Court reviewed
Section 121.17(d) of the Bureau’s regulations. This regulation states that if temporary
payments are stopped,<b> an employer must do <i>one </i>of the following:</b></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">file both a
notice stopping temporary compensation, Form LIBC-502, <i>and </i>a notice of
compensation denial, Form LIBC-496; <o:p></o:p></span></p>
<p class="Default"><i><span color="windowtext">or <o:p></o:p></span></i></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">file a notice of
compensation payable, Form LIBC-495; <o:p></o:p></span></p>
<p class="Default"><i><span color="windowtext">or<o:p></o:p></span></i></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">-<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><i><span color="windowtext"><span style="mso-spacerun: yes;"> </span></span></i><span color="windowtext">file
an agreement for compensation for disability or permanent injury, Form
LIBC-336</span></p>
<p class="Default"><span color="windowtext">In the instant case – the
Employer filed a version of the NCP the “Medical Only” version. The NCP form
LIBC-495 included a check box – which was checked by the Employer – stating
“Check only if compensation for medical treatment (medical only, no loss of
wages) will be paid subject to the Act.” The Court concluded -<span style="mso-spacerun: yes;"> </span>by filing a NCP, albeit a “Medical Only” the
Employer clearly complied with the regulation. The NCP was sufficient notice to
the injured worker that their work comp benefit status had changed.</span></p>
<p class="Default"><span color="windowtext">Employer arguments relied upon
the prior decisions at <i>City of Philadelphia v. WCAB (Brown)</i> and <i>Waldameer
Park v. WCAB (Morrison)</i> for the proposition that the acknowledgement of
compensability, accomplished by filing a Medical Only NCP, is sufficient to
meet the Employer’s obligations under Section 406.1. The Court agreed.</span></p>
<p class="Default"><b><span color="windowtext">Practice Pointers &
Recommendations</span></b></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">A work-related
injury may be recognized via: a Notice of Compensation Payable LIBC-495; A
Notice of Temporary Compensation Payable LIBC-501; an Agreement for
Compensation for Disability of Permanent Injury LIBC- 336.</span></p>
<p class="Default" style="margin-left: 0.5in;"><span color="windowtext">The NTCP
provides the Employer and Insurer with a period of 90 days for review and
possible revocation.</span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">A NTCP may be
revised and/or corrected via an <b>Amended</b> NTCP during the 90 day temporary
compensation benefit period.</span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">A NCP may be “amended”
to expand the description of injury and/or to increase the benefit rate. <o:p></o:p></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">Consistent with
this Commonwealth Court decision – a NTCP may be followed by a Medical Only NCP,
to change the benefit status of an injured worker from indemnity/medical
liability to medical only liability.<o:p></o:p></span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">A NTCP may be
followed by a Notice Stopping Temporary Compensation Payable LIBC-502 and a
Notice of Compensation Denial LIBC-496 – IF the Employer and Insurer wish to totally
deny liability for the alleged work-related injury.</span></p>
<p class="Default" style="margin-left: 0.5in; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><!--[if !supportLists]--><span color="windowtext" style="mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span color="windowtext">As the Workers’
Compensation Judge may assess attorney fees for an unreasonable contest of the
claim – one must be judicious when making the claim acceptance/denial decision.</span></p>
<p class="Default" style="margin-left: 0.5in;"><span color="windowtext">As
always … when you have questions regarding the proper LIBC document to be
issued in a specific factual situation … contact your workers compensation attorney
to discuss your options. As a matter of strategy, one form may provide more
appropriate handling options that you wish to pursue.<o:p></o:p></span></p>
<p class="Default"><span color="windowtext"><o:p> </o:p></span></p>
<p class="Default"><span color="windowtext"><o:p> </o:p></span></p>
<p class="Default"><span color="windowtext"><o:p> </o:p></span></p>
<p class="MsoNormal"><o:p> </o:p></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-6484496097671189572021-07-13T13:12:00.000-04:002021-07-13T13:12:19.447-04:00Examining the PA Work Comp Criteria to Establish the Existence of an Employer - Employee Relationship<p style="text-align: center;"><b>Examining the Pennsylvania Workers Compensation Criteria to Establish </b><b>the Existence of an </b><b>Employer - Employee Relationship</b> </p><p style="text-align: center;"><br /></p><p style="text-align: left;">One of the early published decisions of the newly constituted Commonwealth Court was the J. Miller Co. v. Mixter decision in 1971. That decision determined the existence of an employer-employee relationship via application of the "control test". This analysis remains the standard, to this day.</p><p style="text-align: left;">The existence of an Employer-Employee relationship is an essential element of a compensable workers compensation disability claim. New positions in developing service industry areas (rideshare drivers) give rise to new questions of the existence of an employment relationship.</p><p style="text-align: left;">We will assess the existence of an employment relationship in these new economy endeavors ... by application of existing caselaw and past precedents. . Past caselaw decisions have reviewed many relationships in the trucking industry. A recent case examines the employment relationship.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;">Berkebile Towing & Recovery v. WCAB (Harr, SWIF & UEGF) </span></b><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;">No. 220 C.D. 2020 Memorandum Opinion by Judge Fizzano Cannon filed May 10,
2021.</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;"><o:p> </o:p></span></b><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;">QUESTION PRESENTED:</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;">Was the worker performing tow truck operator duties functioning as an “Employee”
or as an “Independent Contractor” at the time of injury?<o:p></o:p></span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;"><o:p> BACKGROUND </o:p></span></b><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt;">FACTS:</span></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">The Commonwealth Court provided
a rather detailed analysis of the evidence presented to determine if an
individual functioned as an “Employee” within the intent and meaning of section
104 of the <span style="mso-spacerun: yes;"> </span>Pennsylvania Workers
Compensation Act. Worker’s when he sustained a fatal injury in the performance of
his duties as a tow truck operator<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">As Appellate decisions
assessing the existence of an employment relationship delve into the details of
the relationship of the parties, to determine the degree of “control” maintained
and exercised by the purported Employer, we recite the detailed facts found in
the WCJ decision to award fatal claim benefits. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">The WCJ reviewed the
facts presented in the context of the <u>Universal Am-Can</u> case and expressly
considered <u>the extent of <span style="letter-spacing: .1pt;">Berkebile’s right
of control over the work to be completed by Decedent Harr and other drivers</span></u><span style="letter-spacing: .1pt;">.<span style="mso-spacerun: yes;"> </span>The WCJ reviewed
the factors concerning: the nature of work; the skills required to do the work;
the centrality of the work to Berkebile’s business; Berkebile’s supply of the tools
and equipment; their right to terminate the relationship.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">Berkebile
owned the tow trucks, </span><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">set the rates, and collected payment for
the jobs. <span style="mso-spacerun: yes;"> </span><span style="letter-spacing: .1pt;">Berkebile prohibited drivers from using Berkebile </span>trucks to take tow
calls from other companies.<span style="mso-spacerun: yes;"> </span>The WCJ found
these facts were analogous to those that established an employment relationship
in <i>Sarver Towing v. WCAB (Bowser), </i>736 A.2d 61 (Pa. Cmwlth. 1999)<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">The WCJ concluded that
although <span style="letter-spacing: .1pt;">Berkebile </span>did not “micromanage”
any individual tow job, <span style="letter-spacing: .1pt;">Berkebile </span>did maintain
extensive domain over Harr’s work day. <span style="mso-spacerun: yes;"> </span>Trucks
had very large placards with the <span style="letter-spacing: .1pt;">Berkebile</span>
name and very small signage that the trucks were driver leased.<span style="mso-spacerun: yes;"> </span><span style="letter-spacing: .1pt;">Berkebile maintained
a significant </span>degree of control over how the drivers could and could not
use the trucks – they could take them home but they could not use them to
perform jobs for other towing companies.<span style="mso-spacerun: yes;">
</span>Drivers did not set the prices. If customers paid directly, the payment was
turned over to <span style="letter-spacing: .1pt;">Berkebile.<span style="mso-spacerun: yes;"> </span>If a driver </span>declined too many calls,
then <span style="letter-spacing: .1pt;">Berkebile could stop assigning calls and
</span>reclaim its truck. <span style="mso-spacerun: yes;"> </span>The WCJ found
these facts overrode the existence of other facts in favor of contractorship - such
as the IC Agreement, the driver ability to decline jobs, payment by the job
rather than time, and the driver’s responsibility for taxes.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt;">Appellate Court HOLDING</span></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">The Commonwealth Court
denied the Employer appeal from the award of fatal claim benefits and challenge
to the conclusion that Decedent Harr was an employee of <span style="letter-spacing: .1pt;">Berkebile </span>Towing rather than an independent contractor. <span style="mso-spacerun: yes;"> </span>The Commonwealth Court performed a detailed
analysis of the factual evidence presented, in accord with the “control”
standard.<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-bottom: 10.0pt; margin-left: .25in; margin-right: .25in; margin-top: 0in; text-align: justify;"><i><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">“While no hard and fast rule
exists to determine whether a particular relationship is that of employer-employee
or owner-independent contractor, certain guidelines have been established and
certain factors are required to be taken into consideration.”</span></i><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span><u>Universal Am-Can Ltd. WCAB (Minteer)</u>,
762 A.2d 328 (Pa. 2000).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="margin-bottom: 10.0pt; margin-left: .25in; margin-right: .25in; margin-top: 0in; text-align: justify;"><i><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">“The following indicia and
principles are part of the inquiry: control of manner (in which) work is to be
done;<b> </b>responsibility for result only; terms of agreement between the
parties; the nature of the work or occupation; skill required for performance; whether
once is engaged in a distinct occupation or business; which party supplied the
tools; whether payment is by the time or by the job; whether work is part of the
regular business of the employer and also the right to terminate the employment
at any time.”<o:p></o:p></span></i></p>
<p class="MsoNormal" style="margin-bottom: 10.0pt; margin-left: .25in; margin-right: .25in; margin-top: 0in; text-align: justify;"><i><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">“Whether some or all of
these factors exist in any given situation is not controlling. <span style="mso-spacerun: yes;"> </span>Further, while each factor is relevant, there
are certain guidelines that have been elevated to be dominant considerations … <b>[C]ontrol
over the work to be completed and the manner in which it is to be performed are
the primary factors in determining employee status. <span style="mso-spacerun: yes;"> </span></b>Moreover, it is the existence of the right
to control that is significant irrespective of whether the control is actually exercised.”
<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></i></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">The Commonwealth Court reviewed
the instant case in the context of prior similar decisions regarding the
employment status of the tow truck drivers such as <i>Sarver Towing v. WCAB (Bowser),
</i>736 A.2d 61 (Pa. Cmwlth. 1999) (where the right to control the manner of
the claimant’s work was critical even if that right is not exercised) and <i>Baykhanov
v. WCAB (Onixe Express), </i>(Pa. Cmwlth. 245 C.D. 2018 filed October 12, 2018)
(where a car carrier driver was found to not be an employee).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">In the <i>Baum</i> case,
a truck driver was found to be an employee even though he had some degree of
ability to decline work which was found to be evidence of flexibility in work
scheduling rather than a negation of an employment relationship.<span style="mso-spacerun: yes;"> </span>The instant Court noted the facts found <span style="letter-spacing: .1pt;">by the WCJ</span> in the <span style="letter-spacing: .1pt;">Berkebile case - Berkebile </span>ownership control over the availability
and use of trucks - favored a finding an employer-employee relationship, but
contrasted the <i>Baykhanov</i><u> </u>case, where similar facts led to a
finding of an independent contractor relationship.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">This Court assessed these
two case law precedents and distinguished weight afforded a published decision
in <u>Sarver</u> from the unreported divided opinion in <i><u>Baykhanov</u>.</i><span style="mso-spacerun: yes;"> </span>Additionally, in the instant case, the WCJ found
Harr’s witnesses to be credible regarding the employment relationship, which
was not true in <i><u>Baykhanov</u>.</i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">In support of its
conclusion that an Employee-Employer relationship existed, the Court reviewed
the detailed evidence and testimony that was available to the WCJ –<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; line-height: 115%;">Harr drove a tow truck with
a permanent <span style="letter-spacing: .1pt;">Berkebile </span>placard.<span style="mso-spacerun: yes;"> </span>Harr did not own the truck<span style="letter-spacing: .1pt;">. H</span>e did not pay any formal lease or rental
payments. <span style="mso-spacerun: yes;"> </span>Harr did not pay for the truck’s
registration, inspections, or insurance. <span style="mso-spacerun: yes;"> </span><span style="letter-spacing: .1pt;">Berkebile provided
a fuel card. Berkebile testified he had verbal agreements with the drivers to </span>lease
the truck for a 10% fee. <span style="letter-spacing: .1pt;">Berkebile did not m</span></span><span style="font-family: "Book Antiqua",serif; letter-spacing: .1pt;">aintain workers’
compensation insurance.<span style="mso-spacerun: yes;"> </span></span><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;"><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">Berkebile’s
tow trucks were fully equipped so drivers did not bring their own tools or equipment.<span style="mso-spacerun: yes;"> </span>Harr wore clothing with Berkebile’s name.<span style="mso-spacerun: yes;"> </span>Harr had no employers and did not do any (similar)
side work.<span style="mso-spacerun: yes;"> </span>Harr did not have a set schedule,
he received calls from Berkebile’s dispatcher on a 24/7 basis.<span style="mso-spacerun: yes;"> </span>He did not get paid if he did not go out on
calls. Berkebile had drivers perform odd jobs at the shop when they were not
dispatched.<span style="mso-spacerun: yes;"> </span>Berkebile provided little training
and did not supervise Harr when he performed tow jobs or service calls. Berkebile
negotiated mandatory corporate clients rates.<span style="mso-spacerun: yes;">
</span>If customers paid Harr, he would turn over the payment to Berkebile. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">RECOMMENDATIONS:<o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">This appellate
case law review provides a lengthier and more detailed factual review, when
compared to the typical workers’ comp case review. <o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">This
is intentional – as a means to demonstrate the amount of detail the WCJ, WCAB
and Commonwealth Court will analyze in the weighing of evidence of the presence
or absence of an Employee – Employer relationship. <o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">Consequently
– this level of detail in the evidence presented - reflects the detail the workers’
comp defense attorney must strive to present – to allow a full assessment of
the evidence and testimony in support of the existence of an employment or independent
contractor relationship. <o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;">Discovery
of Employer documents and witness interviews are essential components of the initial
case review and litigation preparation process. One must emphasize to the Employer/Insurer
client that our early involvement and client cooperation with evidence
production are essential to an attempt to achieve a successful litigation
result or a favorable negotiated resolution.<o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Times New Roman",serif; font-size: 12.0pt; letter-spacing: .1pt; line-height: 115%;"><o:p> </o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Book Antiqua",serif;"><o:p> </o:p></span></b></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-7678845345887985812021-06-30T18:28:00.003-04:002021-06-30T18:28:48.574-04:00Best Practices – WCAB Appeals and Medical Expense Denials<p> </p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Book Antiqua",serif;"><b>Best Practices – WCAB Appeals and
Medical Expense Denials</b></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Book Antiqua",serif;">A recent Memorandum Opinion of the
Commonwealth Court highlighted the necessity for the Workers’ Compensation
practitioner to carefully draft the averments in the Appeal Documents filed
with the Pennsylvania Workers’ Compensation Appeal Board.</span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Book Antiqua",serif;">The Court also reviewed the appropriateness
of an assessment of penalties where there is a unilateral cessation of medical
expense reimbursement where the employer liability for medical expenses has
been established.<span style="mso-spacerun: yes;"> </span>The “risk” involved in
the denial of medical expenses based upon a causal relation argument was
reviewed.</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; letter-spacing: .1pt; mso-bidi-font-weight: bold;">In <u>W&W Contractors v.
WCAB (Holmes);</u> 836 C.D. 2020; </span><span style="font-family: "Book Antiqua",serif;">Commonwealth
Court Memorandum Opinion filed June 28, 2021<span style="letter-spacing: .1pt; mso-bidi-font-weight: bold;"> A</span>n Employer appealed the decision of the
Workers’ Compensation Judge and WCAB to grant in part and deny in part, the Employer’s
termination petition and to grant claimant’s unreasonable contest attorney’s
fee request and penalty petition. (the termination issue was not appealed).<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Commonwealth Court affirmed the underlying decision that found the Employer
contest of certain medical expenses was unreasonable and further, that
unilateral cessation of medical expense payments was a violation of the Act,
particularly where the employer liability for medical expenses has been
established.<span style="mso-spacerun: yes;"> </span><u><span style="letter-spacing: .1pt; mso-bidi-font-weight: bold;"><o:p></o:p></span></u></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">As
noted above, the Commonwealth Court found the Employer did not preserve their
argument on appeal regarding the assessment of attorney fees for an
unreasonable contest.<span style="mso-spacerun: yes;"> </span>Although the Employer
prepared the proper appeal document and listed the contested findings of fact and
conclusions of law “by number” that were the subject of appellate review, the Employer
did not make <i><u>a statement of</u></i><u> <i>the particular grounds upon
which the appeal is based</i>.</u><span style="mso-spacerun: yes;"> </span>The
citation of the finding of fact by number alone, is insufficient and the
appealing party must provide a description of the grounds on which the appeal
is filed. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Claimant penalty petition was filed based upon the Employer unilaterally
ceasing payment of certain medical supplies such as heating pads, electrical
stimulation supplies, etc.<span style="mso-spacerun: yes;"> </span>When the
medical supply company attempted to file a fee review, that request was denied
because the Employer contested the causal relationship of the expenses.<span style="mso-spacerun: yes;"> </span>The Employer presented a medical opinion of
an IME physician approximately one year after the medical expense denials.<span style="mso-spacerun: yes;"> </span>That IME opinion found that the claimant had
fully recovered and the medical supplies were not necessary or related to the
accepted injury.<span style="mso-spacerun: yes;"> </span>Claimant presented the
testimony of his treating physician to relate the expenses to the work injury.<span style="mso-spacerun: yes;"> </span>The Judge found the Claimant’s physician to
be more credible and found that the Employer violated the Act by the unilateral
cessation of medical expense payments.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Commonwealth Court rejected the Employer’s argument that the Termination petition
was filed to address a genuinely-disputed issue.<span style="mso-spacerun: yes;"> </span>Employer argued the issue of – What is the
“scope” of medical supplies where the supplies were not “medical” in nature,
such as alcohol patches, lotion and the batteries for the electrical stim unit.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Court explained that if the Employer unilaterally ceases the payment of medical
expenses, it takes the risk that the WCJ will hold that those bills are
related.<span style="mso-spacerun: yes;"> </span>In this circumstance, there is
a violation of the Act.<span style="mso-spacerun: yes;"> </span>Employer cited
the prior cases where there was no penalty assessed - <span style="mso-spacerun: yes;"> </span>where the Workers’ Compensation Judge did not
find a causal relationship of the denied medical expenses.<span style="mso-spacerun: yes;"> </span>The Commonwealth Court cited Section 306(f.1)
for the proposition that an employer has a responsibility to pay for reasonable
and necessary medical expenses that are causally related.<span style="mso-spacerun: yes;"> </span>Once liability is established, the employer
may not unilaterally cease payment.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><span style="mso-spacerun: yes;"> </span>The Court noted there is a clear line between
the argument of “reasonableness” or argument of “causation” when addressing
liability for medical expense reimbursements.<span style="mso-spacerun: yes;">
</span>If the employer questions the causal relationship of the medical
expense, there is no penalty if the WCJ ultimately decides the expense was not
related.<span style="mso-spacerun: yes;"> </span>Claimant argued on appeal that
the employer changed its argument as they originally alleged that the medical
supplies were not causally related to the accepted work injuries.<span style="mso-spacerun: yes;"> </span>It was said that they later raised the issues
of the “scope” of what is a “medical” supply and the alleged inflation of
medical costs.<span style="mso-spacerun: yes;"> </span>These arguments were
unpersuasive to the Court. The assessment of a Penalty was affirmed.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><b>Practice
Pointers:</b><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><b>1.
Regarding WCAB Appeals</b> – carefully draft the appeal document to identify each
finding of fact and each conclusion of law that should be the subject of review
on appeal. Then add the particular legal argument to identify the alleged error
of law. One may broadly draft or specifically state their reasons for assertion
of an error.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><b>2.
Regarding Medical Expense Denials</b> - The Employer and Insurer may contest the
causal relationship of any medical expense. But as noted above – this position
comes with the risk - that the WCJ may disagree and may further assess a
penalty. One may increase their chance for success by having medical evidence to
support their assessment that an expense is not related to the work injury. If
the WCJ does not rule in favor of the Employer position, the existence of
medical evidence may result in the avoidance of a penalty. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><b>3. Regarding Challenge to the Reasonableness of a Medical Expense</b> – the Employer remedy is to
file an application for Utilization Review. <o:p></o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-62238886392074636952021-04-12T15:17:00.002-04:002021-04-12T15:17:49.119-04:00Indicia of the Independent Contractor versus Employer – Employee Relationship<p> </p><p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Indicia of the Independent Contractor
versus Employer – Employee Relationship <o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The Pennsylvania Workers’ Compensation
Act does not have a “hard and fast rule” that governs the distinction between
an employer-employee relationship and an owner-independent contractor
relationship.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Past cases were decided on a case-by-case
basis. Specific facts may alter the outcome of the assessment of a purported employer-employee
relationship.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The <i>Construction Workplace Misclassification
Act</i> (43 P.S. 933.3 effective 02/10/2011) was a significant step to advancing
certainty in the assessment of the presence/absence of an independent contractor
in the construction industry. An individual who performs services for
renumeration in the construction industry is an independent contractor only if
all three of the following criteria are satisfied: <o:p></o:p></span></p>
<ol start="1" style="margin-top: 0in;" type="1">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The
individual has a written contract to perform such services;</span><b><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: HE;"><o:p></o:p></span></b></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The
individual is free from control or direction over performance of such
services both under contract of service and in fact;</span><b><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: HE;"><o:p></o:p></span></b></li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">As
to such services, the individual is customarily engaged in an independently
established trade, occupation, profession or business. </span><b><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: HE;"><o:p></o:p></span></b></li>
</ol>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">A recent memorandum appellate decision addressed
the presence/absence of an independent contractor relationship in the
soon-to-be archaic - newspaper delivery boy position. The court gave review of
the independent contractor status in Pennsylvania Workers’ Compensation Law and
the indicia necessary to establish an employer-employee relationship. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">See: the Commonwealth Court Decision at
<u>Shannon v. WCAB (Ogden Newspapers of Pennsylvania)</u>, No. 46 C.D. 2020,
Memorandum Opinion filed August 25, 2020.<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">An application for allowance of appeal was recently denied by the
Supreme Court of Pennsylvania at 292 WAL 2020 on April 1, 2021.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The facts are not remarkable.<span style="mso-spacerun: yes;"> </span>Claimant was engaged in delivery work for the
Altoona Mirror, a newspaper owned by Ogden Newspapers. (Ogden hereinafter). He
was injured in a customer’s icy driveway.<span style="mso-spacerun: yes;">
</span>(NOTE: The case was bifurcated for the issue of employee status;
therefore, the Appeal Board and Commonwealth Court did not evaluate the medical
evidence presented). <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The ”modern” newspaper delivery person
is unlike quintessential figure of a teen riding a bicycle with a canvas
carrying bag - Claimant worked for Ogden for approximately <i>nine years.</i><span style="mso-spacerun: yes;"> </span>On an average day, he would receive 500-600
newspapers at his home between 2:00 a.m. and 3:00 a.m.<span style="mso-spacerun: yes;"> </span>He traveled approximately 70 miles per day to
deliver these papers.<span style="mso-spacerun: yes;"> </span>Ogden imposed a
6:00 a.m. deadline for delivery to all customers in homes, stores, and
newspaper vending machines.<span style="mso-spacerun: yes;"> </span>Claimant did
not select his own delivery route but was instead instructed by Ogden. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Ogden imposed several requirements in
addition to delivery time and manner.<span style="mso-spacerun: yes;"> </span>At
times, claimant was required to deliver newspapers to non-customers, in hope they
would become customers.<span style="mso-spacerun: yes;"> </span>Claimant was
also provided with advertising inserts he was required to place within the
newspapers.<span style="mso-spacerun: yes;"> </span>At times claimant was
required to use holiday-themed advertising bags as delivery packaging.<span style="mso-spacerun: yes;"> </span>Claimant did not have control or discretion
over these requirements.<span style="mso-spacerun: yes;"> </span>He did not
collect money from customers or select customers to be included on his
route.<span style="mso-spacerun: yes;"> </span>If customers had complaints or
concerns, claimant did not handle, <span style="mso-spacerun: yes;"> </span>it
was directed to Ogden.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><i><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">One customer complained her newspaper
was being thrown in her driveway and it should be delivered on her front
porch.<span style="mso-spacerun: yes;"> </span>As a result, claimant was
required to get out of his car and walk on the customer’s driveway to deliver
the newspaper.</span></i><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";"><span style="mso-spacerun: yes;">
</span>On December 17, 2017, claimant left his vehicle, walked on the
customer’s driveway to deliver her newspaper to her front porch as
requested.<span style="mso-spacerun: yes;"> </span>While walking on the driveway
he slipped and fell, fracturing his ankle.<span style="mso-spacerun: yes;">
</span>He was hospitalized for 11 days.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Claimant previously signed an
independent contractor agreement.<span style="mso-spacerun: yes;"> </span>This
document stated claimant was “an independently established business
enterprise”, and that as an independent contractor, he understood that he was
not entitled to employee benefits from Ogden, including workers’ compensation
benefits.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The claim petition was denied by the
Workers’ Compensation Judge and the Appeal Board affirmed that denial.<span style="mso-spacerun: yes;"> </span>On appeal to the Commonwealth Court, claimant
argued his case is distinguishable from prior case law based upon <i>the
evolution and change in the newspaper delivery boy position.</i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The Commonwealth Court denied the claim
petition based upon an analysis and assessment of the employment
relationship.<span style="mso-spacerun: yes;"> </span>As often stated – the existence
of the employer-employee relationship is a question of law based upon the
Workers’ Compensation Judge findings of fact.<span style="mso-spacerun: yes;">
</span>Claimant had the burden to establish an employment relationship existed
at the time of the injury and the injury was related to the employment.<span style="mso-spacerun: yes;"> </span>As often stated - the findings of a Workers’
Compensation Judge can only be disturbed if there is no competent evidence to
support those findings.<span style="mso-spacerun: yes;"> </span>Citing: <span style="mso-spacerun: yes;"> </span><i><u>Universal Cyclops Steel Corporation</u>,
305 A.2d 757 (Pa. Cmwlth. 1973).</i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The Court noted that Pennsylvania does
not have a “hard and fast rule” that governs the distinction between an
employer-employee relationship and an owner-independent contractor
relationship.<span style="mso-spacerun: yes;"> </span>Citing <i><u>Hammermill
Paper Company v. Rust</u> (Pa. 1968).</i><span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Factors to be considered in the
establishment of an employment relationship include: <o:p></o:p></span></p>
<ol start="1" style="margin-top: 0in;" type="a">
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">control
of the manner of work to be done; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">responsibility
for result only; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">terms
of agreement between the parties; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">the
nature of the work or occupation; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">skills
required for performance; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">whether
one is engaged in a distinct occupation or business; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">which
party supplied the tools; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">whether
payment is by the time or by the job; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">whether
work is part of the regular business of the employer; <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">also
the right to terminate the employment at any time. <o:p></o:p></span></li>
</ol>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">While each factor is relevant, certain
guidelines have been elevated to be dominant considerations, such as<b> control
over the work to be completed and the manner in which it is to be performed </b>are
primary factors in determining employee status.<span style="mso-spacerun: yes;">
</span>Citing <i><u>JFC Temps Incorporated</u> (Pa. 1996).</i><span style="mso-spacerun: yes;"> </span>Claimant argued Ogden controlled the manners
and methods by which he was required to deliver newspapers: they set a delivery
time deadline, a delivery route, and the means of delivery (although not explicitly
stated, his motor vehicle). <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The Workers’ Compensation Judge
identified 11 factors that suggested that claimant entered into an independent contractor
relationship with Ogden.<span style="mso-spacerun: yes;"> </span>This was based
upon testimony of Ogden’s District Manager.<span style="mso-spacerun: yes;">
</span>He stated he would often not see claimant for months.<span style="mso-spacerun: yes;"> </span>The WCJ considered this was an indication there
is not a degree of supervision that one normally sees in an employment
relationship and is more akin to the standard independent contractor
relationship.<span style="mso-spacerun: yes;"> </span>Also while claimant was
shown the quickest delivery route by Ogden, he was free to use his own
route.<span style="mso-spacerun: yes;"> </span>He was required to supply his own
vehicle for use in deliveries but he was not reimbursed for mileage or use.<span style="mso-spacerun: yes;"> </span>The WCJ noted that employees are generally reimbursed
for use of their privately-owned vehicles for activities in the furtherance of
the business affairs of their employers. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">The controlling case in this area is <i><u>Johnson
v. Workers’ Compensation Appeal Board (Dubois Courier Express)</u>.</i><span style="mso-spacerun: yes;"> </span>In <i><u>Johnson</u>,</i> the Commonwealth
Court held a <u>13-year-old newspaper carrier</u> was an independent contractor
because the newspaper did not exercise substantial control over his
activities.<span style="mso-spacerun: yes;"> </span>As in the present case - the
13-year-old was only told to deliver papers by a specific time, he was never
directed otherwise as to the time or mode of delivery or the route
traveled.<span style="mso-spacerun: yes;"> </span>Following drop-off of the
newspapers, the company had no further investigation or supervision regarding
delivery of the papers.<span style="mso-spacerun: yes;"> </span>That carrier was
also eligible to deliver competing newspapers and was permitted to substitute a
person to deliver his papers without giving the newspaper company notice or
receiving prior approval.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">In the instant case, Claimant also had
the opportunities for “unrestricted substitutions” and additional delivery
routes for competing publications.<span style="mso-spacerun: yes;"> </span>Claimant
asked the Court to consider the erosion of the newspaper boy independence that
has occurred since the <u>Johnson</u> case; however, the Court thought this
consideration was beyond its scope of review.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Claimant attempted to distinguish the
prior case law by noting that they involved newspaper distributors who
purchased the newspapers from the publishing company and after making sales to
customers, kept the profits.<span style="mso-spacerun: yes;"> </span>These newspaper
distributors were considered to be independent contractors.<span style="mso-spacerun: yes;"> </span>Claimant attempted to draw a distinction
which was not convincing.<span style="mso-spacerun: yes;"> </span>Citing: <i><u>Balinski</u>
(Pa. Superior 1935)</i> and <i><u>Rodgers</u> (Pa. Super. 1960).</i><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Claimant attempted to distinguish a
more recent case, <i><u>Gallagher</u> (Pa. Cmwlth. 2015).<span style="mso-spacerun: yes;"> </span></i>The Court did not accept this
argument.<span style="mso-spacerun: yes;"> </span>Claimant was similar to the
carrier in <i><u>Gallagher</u></i> in that he was able to enlist a substitute
without prior notice or permission and there is no prohibition on delivering
competing newspapers.<span style="mso-spacerun: yes;"> </span>However, this
supports the conclusion that the individual company did not control claimant’s
work or the manner of his performance, only the results.<span style="mso-spacerun: yes;"> </span>On this basis, claimant’s position was not
distinguishable from the prior caselaw reflecting the understanding of a
newspaper delivery person to be an independent contractor.<span style="mso-spacerun: yes;"> </span>The company’s lack of control over claimant’s
newspaper delivery constituted an independent contractor relationship.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Although the newspaper delivery position
had been historically somewhat unique, the analysis of the employer-employee
relationship employed by the Court for workers’ compensation purposes was
not.<span style="mso-spacerun: yes;"> </span>The Court has employed the “control
test” as a determining factor in the assessment of the existence of employment
relationship or an independent contractor relationship.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">It is noteworthy that one of the early
decisions of the then-newly constituted Commonwealth Court addressed the
employee-employer relationship question.<span style="mso-spacerun: yes;">
</span>See: <span style="mso-spacerun: yes;"> </span><i><u>J. Miller Company v.
Mixter</u>, 277 A.2d 867 (Pa. Cmwlth. 1971).</i><span style="mso-spacerun: yes;"> </span>It is safe to say that this may be one of the
few legal principles that has remained untouched by the Commonwealth Court
since 1971.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">“Control in an employment relationship
exists where the alleged employer possesses the right to select the employee,
the right and power to discharge the employee, the power to direct the manner
of performance and the power to control an employee.<span style="mso-spacerun: yes;"> </span>See: <span style="mso-spacerun: yes;"> </span><i><u>American
RD Lines v. WCAB (Royal)</u>, (Pa. Cmwlth 2012).<span style="mso-spacerun: yes;"> </span></i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Recommendation<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">Although each case may present a unique
set of facts, the assessment of the presence or absence of an employer-employee
relationship will be made based upon a review of the facts presented and application
of these legal principles.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Times New Roman";">When addressing the question of the
presence or absence of an employment relationship, obtain as many factual<span style="mso-spacerun: yes;"> </span>details as available regarding the
relationship of the parties, the “control” exercised by the purported employer
and the “freedom” of the purported employee to conduct his/her affairs.<o:p></o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-22010785285434523502021-03-22T11:32:00.001-04:002021-03-22T11:32:46.188-04:00A Changing Work Injury description may defeat an attempt to Terminate Benefits.<p> <b><span style="font-family: "Book Antiqua",serif;">A Changing Work Injury description may
defeat an attempt to Terminate Benefits.</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-family: "Book Antiqua",serif;">A recent Commonwealth Court Memorandum
decision highlights the difficulty of addressing <span style="mso-spacerun: yes;"> </span>a Changing Injury Description during
Termination Petition Litigation.</span></b></p>
<p class="MsoNormal"><span style="font-family: "Book Antiqua",serif;">A Petition to
Terminate benefits will be denied where the Employer medical evidence does not
address the full extent of the work-related injury. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Book Antiqua",serif;">When a Petition
to Terminate is filed, we sometimes observe a Petition to Review is filed in
response – to <span style="mso-spacerun: yes;"> </span>correct/amend/expand the
description of the work related injury.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Book Antiqua",serif;">In the
instant case, the Employer medical expert addressed the issue of the extent of
the work related injury. However the WCJ did not find the employer medical
evidence to be credible. <o:p></o:p></span></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-family: "Book Antiqua",serif;">In <b>City of Allentown,</b> a Commonwealth
Court decision affirmed a WCJ denial of an Employer’s Petition to Terminate
benefits, as the Employer failed to prove that Claimant was fully recovered
from the work-related injury. The description of the injury was amended/enlarged
by the Workers Compensation Judge decision in the Termination petition litigation.</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">See:
<b><i>City of Allentown v. WCAB (Bryant, Jr.)</i></b> No. 593 C.D. 2020, (March
11, 2021) a memorandum opinion authored by President Judge Leavitt.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: center;"><b><u><span style="font-family: "Book Antiqua",serif;"><i>SYNOPSIS
OF DECISION</i><o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Commonwealth Court affirmed the decision of the WCJ that Claimant’s
work-related injuries <u>exceeded</u> what had been listed on the Notice of
Compensation Payable (NCP). For this reason, the Employer failed to prove that Claimant
was fully recovered from the work-related injuries, as described in the WCJ in
his corrected injury description. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Book Antiqua",serif;">The Employer
medical expert addressed the question of any work-relation of the cervical disc
herniations. He stated the neck pain and right shoulder pain were work related
but had resolved. He believed the cervical disc displacement was not work related
- but expressed the opinion- that he did not know the origin of that condition.
This opinion of causation was not assigned credibility by the WCJ. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Book Antiqua",serif;">On appeal, the
Employer multiple arguments were not persuasive -<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 36.75pt; mso-list: l6 level1 lfo11; text-align: justify; text-indent: -18.75pt;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">(1)<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">Expansion
of the work injury description to include cervical disc herniations violated Employer’s
due process rights and, <o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 36.75pt; mso-list: l6 level1 lfo11; text-align: justify; text-indent: -18.75pt;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">(2)<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">also
violated the three-year statute of limitations in Section 413; <o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 36.75pt; mso-list: l6 level1 lfo11; text-align: justify; text-indent: -18.75pt;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">(3)<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">WCJ
erred in overruling Employer’s objection to the claimant medical evidence, which
was the basis for revising the injury description; <o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 36.75pt; mso-list: l6 level1 lfo11; text-align: justify; text-indent: -18.75pt;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">(4)<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">It
was an error to deny the termination petition as Employer proved Claimant had
fully recovered from the “accepted” work injury; <o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 36.75pt; mso-list: l6 level1 lfo11; text-align: justify; text-indent: -18.75pt;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">(5)<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">Claimant’s
medical testimony was equivocal <o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 36.75pt; mso-list: l6 level1 lfo11; text-align: justify; text-indent: -18.75pt;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">(6)<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">WCJ
finding that Claimant was not fully recovered was not supported by substantial
evidence.<o:p></o:p></span></p>
<p class="MsoNormal"><b><u><span style="font-family: "Book Antiqua",serif;">Detailed
Review of Commonwealth Court Decision<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Background Facts<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">In
<b>City of Allentown,</b> Claimant was injured on December 9, 2013 in the
course of his duties as a firefighter. He felt right scapula pain while lifting
a patient. <span style="mso-spacerun: yes;"> </span>Employer issued a Medical-Only
NCP describing this work injury as <i>“upper back strain”.</i><span style="mso-spacerun: yes;"> </span>Employer issued an amended NCP, describing
the work injury as <i>“acute strain to the thoracic spine”</i>. Claimant was
paid benefits until his return to work on July 3, 2014. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">A
Petition to Terminate benefits was filed by Employer on August 22, 2018, asserting
Claimant had fully recovered.<span style="mso-spacerun: yes;"> </span>At the
initial hearing, the WCJ and attorneys discussed the proper description of the
work-related injury. The Commonwealth Court opinion recited this discussion, as
it was relevant to their rejection of Employer’s arguments: <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCJ
noted the first NCP, medical-only, described an <i>“upper back”</i> injury. In
their discussions (off the record) he was advised the area of the body under discussion
is <i>“cervical”</i> with possible symptomatology going into the “<i>thoracic region</i>”.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCJ:
“<i>So the</i> <i>upper back</i> <i>seems to be a fairly good way to describe
it.</i><span style="mso-spacerun: yes;"> </span><i><u>However, everyone is in agreement
that we are also talking (about) the neck</u>. <span style="mso-spacerun: yes;"> </span>So we’re not being that specific about thoracic
levels or cervical levels, we’re talking about <b><u>neck and upper back area</u></b>
– does that fairly accurately summarize the discussions we had off the record
about the body part(s) and the injury we’re talking about?</i> <span style="mso-spacerun: yes;"> </span></span><u><span style="font-family: "Book Antiqua",serif;">Employer’s
counsel: <b><i>Yes, Judge, it does.</i></b> </span></u></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><o:p> </o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Employer Medical Evidence for Termination<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Employer’s
medical evidence was the independent medical evaluation (IME) report of Dr. Don
Ko of December 28, 2017. Claimant was working full time, with continued right
shoulder pain.<span style="mso-spacerun: yes;"> </span>He reported good results with
cervical epidural steroid injections. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Dr.
Ko testified Claimant’s physical examination was unremarkable except for trigger
point tenderness in the <u>right paraspinal cervical muscles and right upper
trapezius muscle</u>; which he attributed to a “sprain/strain type of injury”. The
cervical spine MRI of January 11, 2016 showed a disc protrusion at the C6-C7
level.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Dr.
Ko opined Claimant suffered from <i><u>neck pain</u></i><u> attributed to the
cervical strain</u> and <i><u>right shoulder pain </u></i><u>attributed to the
thoracic strain and right cervical disc displacement at the C6-C7 level</u>.<span style="mso-spacerun: yes;"> </span>The neck pain and right shoulder pain <u>were
work related</u> but had resolved - - as a soft tissue injury would not last beyond
six months.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
cervical disc displacement <u>was not work related</u>.<span style="mso-spacerun: yes;"> </span>Claimant’s right shoulder pain was not attributed
to the right cervical disc herniation at C6-C7 - as herniation at that level
would cause radiating pain in the arm and hand, not into his shoulder region.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">On
cross-examination, Dr. Ko agreed 2015 and 2016 cervical MRIs both showed a
right-side disc protrusion at the C5-C6 level.<span style="mso-spacerun: yes;">
</span>There were no medical records of any pre-existing condition or any other
injury. <span style="mso-spacerun: yes;"> </span>The Commonwealth Court opinion footnote
recited testimony of Dr. Ko that he “did not know” the cause of trigger point tenderness
noted at IME.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><i><span style="font-family: "Book Antiqua",serif;"><o:p> </o:p></span></i></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Claimant Testimony & Medical Evidence<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Claimant
testified and described his medical treatment since the 2013 injury. <span style="mso-spacerun: yes;"> </span>In 2016, as he continued to experience right
scapular pain with radiation into his neck, he was referred to Dr. Wertz for
cervical injections which reduced symptoms for three-four months. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Claimant’s
medical witness, Dr. Wertz, commenced treatment in February 2016 as Claimant complained
of pain at the neck and right shoulder blade. Cervical MRI 2016 revealed two small
disc herniations at C5-C6 and C6-C7.<span style="mso-spacerun: yes;"> </span>Dr.
Wertz believed these herniations caused Claimant’s pain and treated him with cervical
epidural injections. Cervical MRI 2018 also showed disc herniations at the
C5-C6 and C6-C7 levels.<span style="mso-spacerun: yes;"> </span>These cervical herniated
discs caused axial pain. Claimant’s complaints were consistent and matched the
MRI results. <u>He opined the disc herniations were caused by Claimant’s work
injury from which he has not fully recovered. </u><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Employer
objected to Dr. Wertz’s testimony as he attributed Claimant’s right shoulder
pain to the cervical disc herniations, which were not accepted in the NCP. <span style="mso-spacerun: yes;"> </span>Employer asserted that Claimant was barred by
a three-year statute of limitations in Section 413 from amending the description
of injury to include the cervical disc herniations.</span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">WCJ Decision</span></u></b><u><span style="font-family: "Book Antiqua",serif;"><o:p></o:p></span></u></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCJ
denied Employer’s termination petition based upon Claimant’s credible testimony
that he continues to experience pain in the neck and scapular area which is
relieved by cervical epidural injections. <span style="mso-spacerun: yes;"> </span>The WCJ credited the testimony of Dr. Wertz
over Dr. Ko.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCJ
found Claimant’s cervical disc herniations were work related based on Dr.
Wertz’s testimony.<span style="mso-spacerun: yes;"> </span>Conflicting testimony
of Dr. Ko was rejected. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCJ
found the work injury description in the NCP to be <b>“materially incorrect”</b>
and amended it to include <b>“annular tears/disc herniations at C5-C6 and C6-C7,
from which claimant had not fully recovered”.<span style="mso-spacerun: yes;">
</span></b>The WCJ stated this amendment more accurately described the “upper
back strain” that Employer accepted in its medical-only NCP.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCJ
rejected Employer’s statute of limitations argument on the basis that Section
413 authorizes an amendment of an incorrect NCP at any time.<span style="mso-spacerun: yes;"> </span>WCJ overruled Employer’s objection to the testimony
of Dr. Wertz.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Employer WCAB Appeal<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">WCAB
held the WCJ did not violate Section 413 or Employer’s due process rights by
amending the NCP.<span style="mso-spacerun: yes;"> </span>Employer had <b>notice
</b>the injury description was an issue. The WCAB concluded the WCJ acted
within his discretion to credit Dr. Wertz’s testimony to find Claimant had not
fully recovered from his work-related cervical disc herniations.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Employer Commonwealth Court Appeal<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Employer
alleged several errors of law: (1) WCJ expansion of the work injury description
to include cervical disc herniations violated Employer’s due process rights and
(2) also violated the three-year statute of limitations in Section 413; (3) WCJ
erred in overruling Employer’s objection to the testimony of Dr. Wertz, which was
the basis for revising the accepted work injury described in the NCP; (4) Employer
argued WCJ and WCAB erred in denying the termination petition as Employer
proved Claimant had fully recovered from the accepted work injury; (5) Dr.
Wertz’s testimony was equivocal regarding Claimant’s herniated cervical disc
condition; (6) WCJ finding that Claimant was not fully recovered was not
supported by substantial evidence.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: center;"><b><u><span style="font-family: "Book Antiqua",serif;">Commonwealth Court Analysis<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Book Antiqua",serif;"><u>Review/Amendment
of Injury Description</u><o:p></o:p></span></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Commonwealth Court began its analysis with a review of Section 413 which states,
in part:<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">“…
a Workers’ Compensation Judge may, <u>at any time</u>, review and modify or set
aside a Notice of Compensation Payable <span style="mso-spacerun: yes;"> </span>…
in course of the proceedings under any petition pending before such WCJ, if it
is proved that such Notice of Compensation Payable or Agreement <u>was in any
material respect incorrect. <span style="mso-spacerun: yes;"> </span></u><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">“…
no Notice of Compensation Payable agreement or award shall be reviewed or
modified or reinstated unless a petition is filed with the Department <u>within
three years</u> after the date of the most recent payment of compensation made
prior to the filing of such petition.”<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Court explained in its analysis, that an NCP may not be modified unless a
petition is filed within three years of the most recent payment of compensation,
but <u>it may be “corrected at any time”.</u><span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Previously,
the Pennsylvania Supreme Court interpreted the first paragraph of Section 413
to mean that <i>“corrective amendments”</i> to an accepted work injury do not require
a review petition.<span style="mso-spacerun: yes;"> </span>Rather, the WCJ can
order a correction where the evidence supports it.<span style="mso-spacerun: yes;"> </span>See: <u>Cinram Manufacturing Inc. v. WCAB
(Hill), (Pa. 2009).</u><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Due
process requires that an employer be given a reasonable opportunity to contest
a corrective amendment: “… moreover, the procedures applied by a Workers’
Compensation Judge must obviously comport with due process norms … and therefore
reasonable prior notice and an opportunity to respond must be provided to the
employer, prior to the implementation of a corrective amendment ….”. <u>Cinram</u>,
<i>supra.</i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">In
<u>Cinram Manufacturing</u>, the NCP described the work injury as a lumbar strain/sprain.<span style="mso-spacerun: yes;"> </span>In the termination proceeding, claimant’s
medical expert testified work injury was an aggravation of a pre-existing disc
condition that caused nerve impingement. <span style="mso-spacerun: yes;"> </span>The WCJ accepted that evidence <span style="mso-spacerun: yes;"> </span>and amended the NCP to include nerve
impingement. The termination was denied. The Supreme Court affirmed the WCJ’s corrective
amendment as the medical experts addressed nerve impingement in their testimony.
<span style="mso-spacerun: yes;"> </span>Further, the employer did not specify
what other evidence it would have presented had it been given express notice
that claimant sought a corrective amendment.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Court cited another similar result. In <u>Walter</u>, a WCJ amended a NCP in a
termination petition proceeding to include left suprascapular neuropathy. <span style="mso-spacerun: yes;"> </span>The WCAB reversed the WCJ as the employer did
not have notice that the injury description was at issue. <span style="mso-spacerun: yes;"> </span>The Commonwealth Court reversed and concluded the
employer had adequate notice of the corrective amendment as it was announced at
the first hearing and medical experts of both parties testified about the claimant’s
chronic suprascapular neuropathy. <span style="mso-spacerun: yes;"> </span>The Court
concluded the employer had a fair opportunity to contest the corrective
amendment, as it was unclear what additional evidence the employer could have
presented.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><span style="font-family: "Book Antiqua",serif;">In
the instant case</span></b><span style="font-family: "Book Antiqua",serif;"> - the
City of Allentown issued both the medical-only NCP and the NCP which described
the work injury as an acute strain of the upper back and thoracic spine. <span style="mso-spacerun: yes;"> </span>However, Claimant was treating for cervical
pain and Employer paid for cervical epidural injections. <span style="mso-spacerun: yes;"> </span>At the first hearing, the WCJ and parties
agreed they were dealing with Claimant’s <u>neck and upper back area.</u> <span style="mso-spacerun: yes;"> </span>Also, Employer’s medical expert testified Claimant’s
work injury involved a neck strain, but he opined the herniated cervical discs
were not work related. Employer cross-examined Claimant’s medical witness on whether
the work injury included cervical disc herniations. <span style="mso-spacerun: yes;"> </span>Again – it is unclear what other evidence Employer
would have presented had it been given notice of a corrective amendment.<span style="mso-spacerun: yes;"> </span>For these reasons, the Commonwealth Court
concluded the employer had a fair opportunity to contest the corrective
amendment to claimant’s NCP in this case.<u><o:p></o:p></u></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Three-Year Statute of Limitations Argument<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Commonwealth Court rejected the Employer’s argument that the three-year statute
of limitations in Section 413 requires a different result. <span style="mso-spacerun: yes;"> </span>Citing: <u>Fitzgibbons v. WCAB (City of
Philadelphia)</u> (Pa.Cmwlth. 2010). <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Court explained the first paragraph of Section 413 applies when a party is
seeking to <b><u>correct</u></b> an NCP. The second paragraph applies when a party
is seeking to <b><u>expand </u></b>the description of the work injury to
include <u>consequential injuries</u>, i.e., injuries that occurred as a result
of the work injury after issuance of the NCP. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">In
either case, a petition must be filed within three years of the most recent
payment of compensation.<span style="mso-spacerun: yes;"> </span>In the instant
case, the WCJ decision corrected the NCP injury description based upon evidence
presented in litigation of the termination petition.<span style="mso-spacerun: yes;"> </span>The Court noted the WCJ is allowed to do so “at
any time … in the course of the proceedings under any petition pending … if it
is proved that such Notice of Compensation Payable … was in any material
respect incorrect”.<span style="mso-spacerun: yes;"> </span>Citing Section 413; 77
P.S. § 771. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
WCJ corrective amendment of the NCP - to include cervical disc herniations - did
not violate Section 413 of the Act or the Employer’s due process rights.<span style="mso-spacerun: yes;"> </span>The WCJ appropriately allowed Dr. Wertz’s
testimony that the work injury involved more than an acute strain of the upper
back and cervical spine.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Substantial Evidence Argument<o:p></o:p></span></u></b></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Court rejected Employer’s argument that substantial evidence does not support
the WCJ finding that cervical disc herniations were part of the 2013 work
injury.<span style="mso-spacerun: yes;"> </span>Employer argued the termination
petition should have been granted as Dr. Ko testified that cervical disc
herniations would cause radiating pain, which Claimant did not have.<span style="mso-spacerun: yes;"> </span>Dr. Ko testified that claimant had fully
recovered from injury listed on NCP.<span style="mso-spacerun: yes;"> </span><b><o:p></o:p></b></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">However,
Dr. Ko did not contest the MRI findings of cervical disc herniations.<span style="mso-spacerun: yes;"> </span>Claimant argued Dr. Ko’s testimony - that
claimant had fully recovered from the work injury is not supported by his IME
results.<span style="mso-spacerun: yes;"> </span>There was no evidence of a
pre-existing condition or an intervening event. The Court concluded the WCJ did
not err in crediting Dr. Wertz’s testimony.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Dr.
Wertz testified that complaints of pain correlated with the MRI findings and
have been consistent since 2016. Cervical disc herniations were caused by the
2013 work injury as there was no evidence of any other trauma. The WCJ credited
the testimony of Dr. Wertz over Dr. Ko and that is the prerogative of the
finder of fact.<span style="mso-spacerun: yes;"> </span>The WCJ determines the credibility
of witnesses and the weight to be accorded evidence. Citing: <u>Casne v. WCAB
(Stat Couriers Inc.)</u>, (Pa.Cmwlth. 2008).<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Commonwealth Court repeated the often-cited principle that a substantial
evidence analysis - is not whether there is evidence in the record which
supports a finding contrary to that made by the WCJ - but rather, whether there
is any evidence which supports the WCJ’s factual finding.<span style="mso-spacerun: yes;"> </span>Citing: <u>Hoffmaster v. WCAB (Sunoco Products
Inc.)</u>, (Pa.Cmwlth 1998).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">An
Appellate Court must view the evidence in the light most favorable to the party
that prevailed before the WCJ. The Court concluded there was substantial
evidence to support the WCJ finding Claimant had not fully recovered from the
2013 work injury which included cervical disc herniations.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
Court concluded the WCJ was empowered under Section 413 of the Act to amend the
description of claimant’s work injury - where the evidence proved that the NCP
was materially incorrect.<span style="mso-spacerun: yes;"> </span>Employer had a
fair opportunity to contest the corrective amendment. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Substantial
evidence supported the WCJ’s findings that Claimant sustained cervical disc
herniations in the 2013 work injury and had not fully recovered from those
injuries. <span style="mso-spacerun: yes;"> </span>As such, the WCJ did not err
in amending the NCP to include cervical disc herniations.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><b><u><span style="font-family: "Book Antiqua",serif;">Best Practices Recommendations:<o:p></o:p></span></u></b></p>
<ol start="1" style="margin-top: 0in;" type="1">
<li class="MsoNormal" style="mso-list: l10 level1 lfo9; text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Before the scheduling of an IME
appointment – confirm the description of work-related injury to be
addressed by your medical expert -<o:p></o:p></span></li>
</ol>
<p class="MsoNormal" style="margin-left: 0.75in; mso-list: l9 level1 lfo10; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">a.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">Was
the injury description is amended by subsequent Agreement?<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 0.75in; mso-list: l9 level1 lfo10; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">b.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">…
by Subsequent WCJ decision?<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 0.75in; mso-list: l9 level1 lfo10; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: "Book Antiqua",serif; mso-bidi-font-family: "Book Antiqua"; mso-fareast-font-family: "Book Antiqua";"><span style="mso-list: Ignore;">c.<span style="font: 7pt "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Book Antiqua",serif;">…
or by subsequent actions – paying for the medical treatment?<o:p></o:p></span></p>
<ol start="2" style="margin-top: 0in;" type="1">
<li class="MsoNormal" style="mso-list: l10 level1 lfo9; text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Obtain all medical records of treatment
to assess the presence/absence of any other condition or event that could
cause the symptoms under review. <o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l10 level1 lfo9; text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Identify to the IME expert – any disputed
issues regarding causal relationship of any medical conditions to be addressed
in the IME report.<o:p></o:p></span></li>
<li class="MsoNormal" style="mso-list: l10 level1 lfo9; text-align: justify;"><span style="font-family: "Book Antiqua",serif;">Consider a pre-IME medical
records review to address any medical causation issues.<o:p></o:p></span></li>
</ol>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: "Book Antiqua",serif;">The
City of Allentown decision highlights the unpredictable nature of litigation.
The Employer presented medical expert evidence which addressed the causation
issues … but the WCJ did not find that evidence to be credible. <o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left: 0.75in; text-align: justify;"><span style="font-family: "Book Antiqua",serif;"><o:p> </o:p></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-73709587102492161592021-02-28T23:38:00.001-05:002021-03-05T12:28:03.266-05:00Best Practices for Utilization Review when a Provider "supervises" adjunctive medical treatment modalities. <p><b><span style="font-family: arial;">A Utilization Review Request is a valuable and necessary remedy for Employers and Insurers in the handling of Pennsylvania work injury claims. </span></b></p><p><span style="font-family: arial;">Proper UR filing requires proper identification of the "Provider under Review".</span></p><p><span style="font-family: arial;">When multiple medical treatment regimens are provided - the identification of the "provider" may become confusing. A recent appellate decision addressed this issue and provided valuable guidance. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">Daisy Rodriguez, M.D. v. WCAB (First Group America) No.
520 CD 2020 Memorandum Opinion (opinion not reported) filed February 10, 2021.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial;"><span style="letter-spacing: 0.1pt;">Daisy Rodriguez, M.D. (provider) filed a Petition for Review to
the <st1:address w:st="on"><st1:street w:st="on">Commonwealth Court</st1:street></st1:address>
from an adverse ruling by the Workers’ Compensation Appeal Board (WCAB). The WCAB affirmed
the Decision of the Workers’ Compensation Judge, which held that certain medical treatments
to Claimant for his work-related back injury were </span><span style="letter-spacing: 0.133333px;">were not reasonable or necessary </span><span style="letter-spacing: 0.1pt;">after January 2, 2018. </span><span style="letter-spacing: 0.1pt;">On appeal, the </span><st1:address style="letter-spacing: 0.1pt;" w:st="on"><st1:street w:st="on">Commonwealth Court</st1:street></st1:address><span style="letter-spacing: 0.1pt;"> rejected the Provider’s argument that First Group America (Employer) did not meet its burden
of proof.</span></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">Claimant was involved in a motor vehicle accident in his
position as a bus driver on September 22, 2017.<span style="mso-spacerun: yes;">
</span>Shortly thereafter, he commenced treatment with the Provider.<span style="mso-spacerun: yes;"> </span>The Employer issued an amended Notice of
Temporary Compensation Payable (NTCP) describing the work injury as “a low back
sprain or tear”.<span style="mso-spacerun: yes;"> </span>A Subsequent NTCP
described the work injury as “low back inflammation”.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The Employer requested a Utilization Review of “any and
all treatment including but not limited to acupuncture, cupping, moxibustion,
and crunches " provided to Claimant from January 2, 2018 and thereafter, under
the provider’s prescription and supervision. <o:p></o:p></span></p><p class="MsoNormal" style="text-align: justify;"><i><span style="font-family: arial;"><span style="letter-spacing: 0.133333px;">NOTE</span><span style="letter-spacing: 0.133333px;">: moxibustion is a form of acupuncture where a small intense heat source is placed on certain acupuncture meridians in order to stimulate the flow of “chi life energy”.</span><span style="letter-spacing: 0.133333px;"> </span><span style="letter-spacing: 0.133333px;">Cupping is a procedure used to drain excess fluids and toxins.</span></span></i></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The Utilization Review Organization Report of review of Claimant’s
treatment was authored by Dr. James Wasson on April 3, 2018. <span style="mso-spacerun: yes;"> </span>Dr. Wasson concluded that the Provider’s
medications and monthly evaluations of claimant were reasonable and necessary
as of January 2, 2018 and for six months thereafter. <span style="mso-spacerun: yes;"> </span>However, Dr. Wasson concluded that
acupuncture, chiropractic care and physiatric care provided to Claimant were
not reasonable and necessary as of January 2, 2018. <span style="mso-spacerun: yes;"> </span>Dr. Wasson explained that Claimant received 62
separate acupuncture treatments and frequent physical therapy and chiropractic
treatments, all of which “had limited, if any, long-term benefit”.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial;"><span style="letter-spacing: 0.1pt;">Provider filed a timely Utilization Review petition and
the WCJ conducted a <i>de novo</i> hearing.<span style="mso-spacerun: yes;">
</span>Employer has the burden of proof in this proceeding. <span style="mso-spacerun: yes;"> </span>Employer submitted the Utilization Review
report of Dr. Wasson. Also, Employer submitted the independent medical evaluation report of Dr. Christopher Selgrath,
D.O., dated July 12, 2018. <span style="mso-spacerun: yes;"> </span>Dr. Selgrath found that Claimant had full range of motion in his cervical and lumbar spine. Examination of both upper extremities was normal.<span style="mso-spacerun: yes;"> </span></span><span style="letter-spacing: 0.1pt;">Dr. Selgrath opined Claimant had fully
recovered from the work-related injury and required no further treatment.</span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">Employer submitted Provider’s physical
capacities evaluation, which released Claimant to sedentary work with
restrictions as of December 7, 2017. </span><span style="letter-spacing: 0.1pt;"> </span></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">In support of the Utilization Review petition, Provider
presented testimony and documentary evidence. Claimant testified he began treating with the Provider within a week of the injury. He
received the aforementioned treatment modalities, together with massage therapy and stretching exercises. He said he found these treatments to be helpful, explaining
they reduced his pain. When asked about
the acupuncture, he responded it helped his low back a lot and his neck and the
pain was a lot lighter, milder by January.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;"><span style="background-color: white;">Provider </span>issued a narrative report which reviewed her treatment plan for chronic pain management and
functional maintenance. She did not
believe a cure or even significant improvement in function were reasonable
expectations - given the severity of Claimant’s condition. She opined the medications and therapies at
issue were reasonable and necessary for control of Claimant’s moderate-to-severe
pain. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The WCJ denied Provider’s Utilization Review petition and credited Dr. Wasson’s opinion that Claimant’s chiropractic,
acupuncture and physiatric care were not reasonable and necessary after January
2, 2018. The WCJ found that Dr. Wasson’s
opinion was confirmed by the fact that Claimant ended these treatments. The WCJ also credited Dr. Selgrath’s opinion
that claimant did not need any further treatment as of July 12, 2018 (the date
of the IME). The WCJ did not credit the
testimony of Claimant where it differed from the opinions of Dr. Wasson and Dr.
Selgrath. The WCJ noted that Claimant returned to work on a
full-time basis on November 6, 2017 and he did not testify as to any difficulties
performing his job duties, notwithstanding his Provider’s work
restrictions. The WCJ did not credit Provider’s opinion, noting she recommended continued treatment even though Claimant had discontinued her recommended course of treatment on his own.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">In Provider’s appeal to the WCAB, she argued that Dr.
Wasson’s opinion was legally defective and in part invalid. She argued it was improper for Dr. Wasson to
conclude prescription medications and monthly evaluations would become unreasonable
at a point six months into the future. <u>She<span style="mso-spacerun: yes;"> </span>also argued that Dr.
Wasson opined on treatment rendered by providers whose services were not under
review and who have licensure and qualifications not held by Dr. Wasson.</u><u> </u> </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The WCAB affirmed the WCJ and
explained that the issue of reasonableness and necessity of treatment six
months after January 2, 2018 was now moot as Claimant discontinued treatment
with the provider at the end of April of 2018.
<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">Regarding Provider’s argument that Dr. Wasson’s review of
treatment by professionals not named in the Utilization Review request - the WCAB noted that provider had prescribed these therapies and they were
administered at her office. further, the Provider had certified
that these prescribed treatments were reasonable and necessary. <u>The WCAB reasoned that if Provider was competent
to prescribe and supervise acupuncture, moxibustion, cupping, and chiropractic treatment,
then Dr. Wasson was competent to review that treatment and determine whether it
was reasonable and necessary</u>. The WCAB concluded
that the opinions of Dr. Wasson were substantial competent evidence that
supported the WCJ Decision to deny the Provider’s petition for review of the
utilization review determination.<o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">On Provider’s appeal to the <st1:address w:st="on"><st1:street w:st="on">Commonwealth Court</st1:street></st1:address>, Provider raised three
issues.<span style="mso-spacerun: yes;"> </span>First, she argued that Employer’s utilization review petition failed to identify the separately
licensed acupuncturists and chiropractors as required by 34 <st1:place w:st="on"><st1:state w:st="on">Pa.</st1:state></st1:place> Code § 127.452(d).<span style="mso-spacerun: yes;"> </span>Second, she argued that the WCJ erred in
relying on Dr. Wasson’s report, because he was not a licensed acupuncturist or chiropractor.<span style="mso-spacerun: yes;"> </span>Third, Provider argued that the WCAB exceeded
its scope of review by introducing issues not before it.<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The <st1:address w:st="on"><st1:street w:st="on">Commonwealth
Court</st1:street></st1:address> affirmed the Decision of the WCAB and
WCJ.<span style="mso-spacerun: yes;"> </span>The Court reviewed Section 306(f.1)(6) of the Workers’ Compensation Act that
establishes the procedure for resolving disputes about whether treatment of a
work injury is reasonable and necessary.<span style="mso-spacerun: yes;">
</span>Subparagraph 306(f.1)(6)(i) includes the requirement:</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;"> <i>“utilization review
of all treatment rendered by a healthcare provider shall be performed by a
provider licensed in the same profession and having the same or similar
specialty as that of the provider of the treatment under review”.<span style="mso-spacerun: yes;"> </span></i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The <st1:address w:st="on"><st1:street w:st="on">Commonwealth
Court</st1:street></st1:address> referenced the regulations adopted by the
Bureau of Workers’ Compensation regarding Utilization Review.<span style="mso-spacerun: yes;"> Regulation </span>Section 127.452(d) states that:</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;"><i>“the request for <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place>
shall identify the provider under review.<span style="mso-spacerun: yes;">
</span>Except as specified in subsection (e), the provider under review shall
be the provider who rendered the treatment or service which is the subject of
the <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place>
request".<span style="mso-spacerun: yes;"> </span></i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">Subsection (e) reads as follows:<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;"><i>"when the treatment or service requested to be
reviewed is anesthesia, incident to surgical procedures, diagnostic tests,
prescriptions or durable medical equipment,<u> the request for <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place> shall identify the provider who made the
referral, ordered or prescribed the treatment or service as the provider under
review</u>".</i><span style="mso-spacerun: yes;"> (emphasis supplied) </span>See: 34 <st1:place w:st="on"><st1:state w:st="on">Pa.</st1:state></st1:place> Code § 127.452(e).<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">Provider argued that § 127.452(d) required the Employer to
identify the separately licensed acupuncturists and chiropractors as the "provider" under review in its <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place>
request. She offered this argument as she did not administer
those treatments.<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">In response to this
argument, the <st1:address w:st="on"><st1:street w:st="on">Commonwealth Court</st1:street></st1:address>
cited its decision in <i><u>MV Transportation v. WCAB (Harrington)</u>, 990 A.2d
118 (Pa. Cmwlth. 2010).</i><span style="mso-spacerun: yes;"> In that case, that </span>employer
requested a Utilization Review of a claimant’s physical therapy and
identified one licensed physical therapist as the provider under review. The
Court held this wass proper as the employer did not need to identify each individual physical
therapist as a separate provider when seeking review of a course of physical
therapy treatment.<span style="mso-spacerun: yes;"> </span><i>“… it made little
sense to request a separate review of each therapist providing treatment under
the direction of the same physician”</i>.<span style="mso-spacerun: yes;">
</span>(page 122-123).<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial;"><span style="letter-spacing: 0.1pt;">The </span><i style="letter-spacing: 0.133333px;"><u>MV Transportation </u></i><st1:address style="letter-spacing: 0.1pt;" w:st="on"><st1:street w:st="on">decision</st1:street></st1:address><span style="letter-spacing: 0.1pt;"> reversed
the underlying WCJ Decision and concluded that when making a </span><st1:place style="letter-spacing: 0.1pt;" w:st="on"><st1:city w:st="on">UR</st1:city></st1:place><span style="letter-spacing: 0.1pt;"> request for physical therapy prescribed by
a doctor and administered in that doctor’s facility under his or her
supervision, <u>the employer must name the doctor prescribing the physical therapy
and the facility where the claimant receives that treatment.</u></span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial;"><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">The Court analogized the </span><u style="letter-spacing: 0.1pt;"><i>MV Transportation</i></u><span style="letter-spacing: 0.1pt;"><i>
</i>case to the present situation where the challenged course of treatment was
carried out by acupuncturists and chiropractors <u>acting under the provider’s
supervision in her office</u>.</span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">In her
report, the Provider stated that she examined Claimant on a monthly basis to
determine if she needed to change any of his treatment. </span><span style="letter-spacing: 0.1pt;"><u>Provider stated that Claimant required
supervised therapies to assure compliance with her prescription for palliative
care.</u></span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">Although the </span><u style="letter-spacing: 0.1pt;"><i>MV Transportation</i></u><span style="letter-spacing: 0.1pt;">
case dealt with one type of treatment - physical therapy - and where the present
case deals with a variety of treatments - nevertheless, the logic of </span><u style="letter-spacing: 0.1pt;"><i>MV Transportation</i></u><span style="letter-spacing: 0.1pt;">
applies.</span><span style="letter-spacing: 0.1pt;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial;"><span style="letter-spacing: 0.1pt;">The Court held that the Employer does not need to
name each chiropractor and each acupuncturist as the “provider” must seek a review
of the claimant’s course of care.</span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">The
Court found this to be consistent with § 127.452(e) which does not require each
provider to be named in a </span><st1:place style="letter-spacing: 0.1pt;" w:st="on"><st1:city w:st="on">UR</st1:city></st1:place><span style="letter-spacing: 0.1pt;">
request where a “prescription” for treatment or services under review.</span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;"><u>In the present case, the Provider under review, not only
prescribed but also supervised the Claimant’s entire treatment regimen.</u></span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">Stated otherwise, the provider arguably “rendered”
the “service” which was the subject of the utilization review request.</span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">As the Provider supervised Claimant’s entire treatment
regimen, it was not necessary for the Employer to file </span><st1:place style="letter-spacing: 0.1pt;" w:st="on"><st1:city w:st="on">UR</st1:city></st1:place><span style="letter-spacing: 0.1pt;"> requests for each provider of
treatment.</span><span style="letter-spacing: 0.1pt;"> </span><span style="letter-spacing: 0.1pt;">By filing a </span><st1:place style="letter-spacing: 0.1pt;" w:st="on"><st1:city w:st="on">UR</st1:city></st1:place><span style="letter-spacing: 0.1pt;"> request identifying a provider as a "provider under review" rendering the challenged treatments, this Employer satisfied the
requirements of § 127.452(d).</span><span style="letter-spacing: 0.1pt;"> </span></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">The <st1:address w:st="on"><st1:street w:st="on">Commonwealth
Court</st1:street></st1:address> rejected the Provider’s second argument that
the WCJ erred in relying upon Dr. Wasson’s <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place> report because he did not have qualifications
to render an opinion on treatment provided by licensed chiropractors and
acupuncturists.<span style="mso-spacerun: yes;"> </span>The Commonwealth Court
referenced its prior decision in <i><u>Leca v. WCAB (Philadelphia School District)</u>,
39 A.3d 631 (Pa. Cmwlth. 2012)</i> where the employer filed a UR request with
respect to a claimant’s ongoing chiropractic care and the employer offered
the opinion of an orthopedic surgeon who concluded that chiropractic care six
times per week could not be justified given the lack of improvement in
claimant.<span style="mso-spacerun: yes;"> </span>This <st1:address w:st="on"><st1:street w:st="on">Commonwealth Court</st1:street></st1:address> decision affirmed the Decision
of that WCJ, relying upon the general rule that a physician is competent to
testify in specialized areas of medicine even though the physician is neither a
specialist nor certified in those fields.<span style="mso-spacerun: yes;">
</span>It was not an error for the WCJ to consider the opinion of an orthopedic
surgeon when considering a challenge to the reasonableness and necessity of chiropractic
treatment.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: arial; letter-spacing: 0.1pt;">In the case <i>sub judice</i>, Dr. Wasson is a medical doctor licensed
in internal medicine - as is the Provider.<span style="mso-spacerun: yes;">
</span>The Court noted that in the review of a Utilization Review Determination
pursuant to § 306(f.1), the Workers’ Compensation Judge is obligated to
consider the UR report as evidence but is not bound by the report.<span style="mso-spacerun: yes;"> </span>Thus, the WCJ is authorized to consider the
opinions of Dr. Wasson. The weight and credibility to be assigned by the WCJ
to Dr. Wasson’s <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place>
report - as with any other evidence - is for the factfinder. <span style="mso-spacerun: yes;"> </span>Issues as to the weight and credibility of
evidence belongs to the Workers’ Compensation Judge.<span style="mso-spacerun: yes;"> </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;">Here, the Employer met its burden of proof in the
instant Utilization Review as the WCJ credited the opinions of Dr. Wasson and
Dr. Selgrath, concluding that the challenged treatment was not reasonable and
necessary. </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;">The third argument of Provider was that the WCAB
improperly introduced an issue into this appeal - as the WCJ decision did not address the Provider's challenge to the validity of the determination of Dr. Wasson - so the Board
erred in addressing that issue. The Court
noted that Provider challenged the validity of the <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place> determination, the fact that the WCJ did
not specifically address the legal argument regarding separately licensed
professionals, did not preclude the Board from addressing that same argument on
appeal, as the Provider raised that argument. </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;">The Court held the WCJ made the<span style="background-color: white;"> <span style="background-attachment: initial; background-clip: initial; background-image: initial; background-origin: initial; background-position: initial; background-repeat: initial; background-size: initial;">credibility determinations</span> </span>necessary to his
conclusion that the course of treatment prescribed by the Provider to
treat Claimant’s work injury was not reasonable and necessary. On this basis, the WCAB did not exceed its
scope of review by addressing the Provider’s arguments about the invalidity of
the <st1:place w:st="on"><st1:city w:st="on">UR</st1:city></st1:place>
determination.</span><span style="font-family: Book Antiqua, serif;"><o:p></o:p></span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;"><b>Recommendations:</b></span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;">When filing a UR Request, carefully review the medical treatment records and billing statements to identify the prescribing healthcare provider. Is the prescribing provider also providing or supervising the care? </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;">Or is the treatment referral to an independent healthcare provider? The identification of the provider may change the "provider under review". </span></span></p><p class="MsoNormal" style="text-align: justify;"><span style="letter-spacing: 0.1pt;"><span style="font-family: arial;">When in doubt, review this issue.</span></span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-78669769845021209802021-02-01T00:09:00.000-05:002021-02-01T00:09:31.318-05:00An Employee is required to give "timely" notice of a work injury to the Employer<p>An Employee is required to give "timely" notice of a work injury to the Employer </p><p>The Employee notice of the occurrence of a work-related injury is an essential element of one's burden of proving a compensable claim.</p><p>Section 311 of the Act provides " no compensation shall be due until such notice be given and unless such notice be given within 120 days after the occurrence of the injury, no compensation shall be allowed.</p><p>Recently a question arose as to the calculation of the 120 day time period for proper notice of injury to the employer. In <u>Holy Redeemer Hosp. Systems v. WCAB (Figueroa),</u> Pa. Cmwlth. No. 372 C.D. 2020, December 31, 2020, the Commonwealth Court affirmed the decision of the WCAB. The WCAB affirmed the decision of the WCJ that Claimant sustained her burden of proof of all of the elements of her claim petition, but the WCB reveresed the conclusion of the WCJ that Claimant failed to provided timely notice of a work injury to the Employer.</p><p>The pertinent facts reflect the Claimant worked on July 25, 2015, as an emergency room nurse. She experienced significant pain in her leg, which increased over the course of her work shift. She took off her next scheduled work day and visited her physician . He took Claimant off work. On Monday November 23, 2015, Claimant notified the Employer that she sustained a work injury on July 25, 2015. </p><p>She gave notice of her work injury on the 121<sup>st</sup> day after her work injury, which was a Monday. The Employer issued a NTCP, followed by a Notice Stopping an a Notice of Denial.</p><p>This legal issue arose as Monday July 25, 2015 was the 121st day after her alleged work injury. The 120th day fell on a Sunday. Why was Claimant's notice of a work injury on Monday considered "timely" ? Section 1908 of the Statutory Construction Act of 1972, provides the correct answer to this question. which states as follows:</p><p class="MsoNormal"><o:p></o:p></p><p class="MsoNormal"><u><o:p> "</o:p>When any period of time is referred to in any statute</u>, such period in all cases, except as otherwise provided in section 1909 of this title (relating to publication for successive weeks) and section 1910 of this title (relating to computation of months) <u>shall be so computed as to exclude the first and include the last day of such period. Whenever the last day of any such period shall fall on Saturday or Sunday, or any day made a legal holiday by the laws of this Commonwealth or of the United States, such day shall be omitted from the computation.</u></p>
<p class="MsoNormal">In the case <i>sub judice,</i> when the 120<sup>th</sup> day to give notice of her work injury under Section 311 of the Act falls on a Sunday, her notice of injury on Monday was timely. Employer's appeal was limited to the notice issue. The Court rejected the Employer argument that the language of Section 311 is not ambiguous, therefore the WCAB erred by applying the Statutory Construction Act. </p><p class="MsoNormal"><br /></p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<br />
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><br /></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-29900311080821198862020-12-14T10:59:00.000-05:002020-12-14T10:59:09.035-05:002021 Pennsylvania Workers' Compensation AWW, Max TTD indemnity rate and Medical Expense percentage increase. <h2 style="text-align: left;"><br /></h2><p class="MsoNormal">NOTE: This information will be published in the December 26, 2020 Pennsylvania Bulletin:<o:p></o:p></p>
<p class="MsoNormal">For injuries occurring on or after <b>January 1, 2021,</b> <b>the statewide Average
Weekly Wage (AWW) will be $1,130</b> <b>.00. </b> This is an increase from the 2020 rate of $1,081.00.</p><p class="MsoNormal">For medical treatment rendered on or after January 1, 2021, the increase in fee
schedule-tied payments will be 4.6%, up from 3.1%.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">The 2021 Statewide Average Weekly Wage Workers’ Compensation
Rate Schedule has been approved by the Secretary of Labor and Industry and it
will be published in the PA Bulletin on December 26, 2020. We offer advance
notice of the schedule at this time so that our stakeholders may initiate any
updates to their operating systems that rely on this calculation. A comparison
with last year’s table is included for reference. The following notice has been
prepared for our Press Office to update the L&I website when the wage and
rate schedule has been published in the PA Bulletin:</p>
<p class="MsoNormal"><i>Pursuant to the Workers’ Compensation Act, Section 105.1,
the Department of Labor & Industry has determined the statewide average
weekly wage for injuries occurring on and after January 1, 2021, shall be
$1,130.00 per week. For purposes of calculating the update to payments for
medical treatment rendered on and after January 1, 2021, the percentage
increase in the statewide average weekly wage is 4.6 percent.</i></p>
<p class="MsoNormal"><i>The maximum weekly rate as of January 1, 2021 will
be $1,130.00.</i><o:p></o:p></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0tag:blogger.com,1999:blog-6571536666411484932.post-17770847454006558052020-08-31T20:00:00.002-04:002020-08-31T20:03:40.924-04:00Continuing Challenges to the Employer Right to an Impairment Rating Evaluation of an Injured Employee<p> <span style="font-size: medium;">The Impairment Rating Evaluation remedy in the Pennsylvania Workers Compensation Act</span></p><p>In 1996, Pennsylvania Employers and Insurers were provided a remedy to limit the duration of total disability benefits via an Impairment Rating Evaluation (IRE). This 1996 Amendment to the <span style="font-family: inherit;">Pennsylvania Workers Compensation Act was declared to be an unconstitutional delegation of legislative authority by the 2017 PA Supreme Court decision at <u><i>Protz.</i></u></span></p><p><span style="font-family: inherit;">The PA General Assembly enacted Act 111 on October 24, 2018 , to replace the unconstitutional provisions with nearly identical language at section 306(a.3), which was effective immediately. A significant difference was that an IRE must be conducted utilizing a specific edition of the AMA Guides, the 6th edition, second printing April 2009. (Eliminating the flawed <i>"most recent edition" </i>language)</span></p><p><span style="font-family: inherit;">However ... challenges to the "new" IRE provisions continue ... including a challenge to the constitutionality of the new language.</span></p><p><span style="font-family: inherit;">These legal challenges often result in claimant legal counsel advising the Employer/Insurer that their client will not attend a scheduled IRE appointment. Their response results in the filing of an Employer petition to Compel an Expert Evaluation. When assigned to a Workers' </span>Compensation<span style="font-family: inherit;"> Judge, at the time of hearing, an injured worker is often ordered to attend an IRE appointment. Most frequently this is accomplished via a final order.</span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">In an unpublished Memorandum opinion, the
Commonwealth Court addressed a Workers’ Compensation Judge’s Order to Compel an
injured worker to attend an Impairment Rating Evaluation, in <u><i>Cantonese v. WCAB (RTA Services Company
Inc.)</i></u>, 1739 C.D. 2019, Memorandum Opinion by Judge Covey filed June 12, 2020.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">The basis facts are not disputed. Employee
was injured on December 11, 2013 in a work-related injury.<span style="mso-spacerun: yes;"> </span>He received workers’ compensation benefits
pursuant to a Notice of Compensation Payable. </span><span style="font-family: inherit;">On January 31, 2019, Employer filed a petition seeking to compel
claimant’s attendance at an impairment rating evaluation (IRE).</span><span style="font-family: inherit;"> </span><span style="font-family: inherit;">Employer alleged that employee failed to
attended an IRE that was scheduled for January 28, 2019.</span><span style="font-family: inherit;"> </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">The
Workers’ Compensation Judge granted the Employer petition on May 3,
2019.<span style="mso-spacerun: yes;"> </span>Employee appealed that decision to
the WCAB, arguing that the Workers’ Compensation Judge erred by ordering him to
appear at an IRE because Act 111 of 2008 was unconstitutional.<span style="mso-spacerun: yes;"> </span>On November 5, 2019, the WCAB quashed
employee’s appeal as interlocutory.<span style="mso-spacerun: yes;">
</span>Employee appealed to the Commonwealth Court.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">In the decision to affirm the WCAB, the
Commonwealth Court cited the well-established principle that “where an order
does not dispose of all claims or all parties, it is interlocutory and not
appealable to this court”.<span style="mso-spacerun: yes;"> </span>Citing:
<i>Swartz v. WCAB (Cheltenham York Road), 869 A.2d 35 (Pa.Cmwlth. 2005).</i><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">“Furthermore,
this court has held that an order directing a claimant to submit to a medical
examination is interlocutory.”<span style="mso-spacerun: yes;"> </span><i><u>Groller
v. WCAB (Alstrom Energy Sys.)</u>, 873 A.2d 787 (Pa.Cmwlth. 2005).</i><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">In
<i>Groller</i>, the Court explained<span style="background: yellow; mso-highlight: yellow;">:“</span>Because the IRE order
merely stated that the claimant was required to participate in the IRE and
neither affected the claimant’s benefits nor affected the employer’s obligation
to pay benefits, the IRE order was a non-appealable, interlocutory order.<span style="mso-spacerun: yes;"> </span>Because the IRE order is interlocutory, it is
not a final order …. “<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">In
the instant case, as the order on review before the WCAB was the Workers’ Compensation
Judge’s order directing employee to appear for an IRE, the WCAB
correctly concluded that employee’s appeal was interlocutory and it properly
quashed employee’s appeal. For these reasons, the Commonwealth Court affirmed the decision. </span></p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: inherit;">This is not a new, ground-breaking ruling. Rather this result follows the similar reasoning in <i>Watson v WCAB (Hillsberg)</i> April 15, 2020. However, these decisions are offered as a reflection of the trend in rulings by WCJ's, the WCAB and Commonwealth Court.</span></p>pawcdefensehttp://www.blogger.com/profile/04445985108335757087noreply@blogger.com0