Articles Posted in Workers’ Compensation

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A Massachusetts workers’ compensation reviewing board decision earlier this year looked at whether subsequent insurers should be responsible for helping to pay the benefits awarded to a roofer injured over the course of 30+ years of work. The roofer installed duct work and metal roofing since 1970. He carried aluminum weighing up to 60 pounds and kneeled often. He experienced his first knee injury in 1981 and was given workers’ compensation in that state. He underwent arthroscopic surgery and returned to work without any further injuries until 1998.

Roof shingles
In 1998, his knee began locking and eventually “popped” while working on a roof, causing excruciating pain. A second arthroscopic surgery was needed, and he received workers’ compensation benefits for three to four months and returned to full duty work once again. No additional medical treatment was needed after his return to work for an additional 10 years. In 2008, he was diagnosed with arthritis in his left knee.

The injured employee kept working but experienced pain when he had to climb or kneel. He later described his pain as the same whether it was “climbing ladders at work or climbing stairs at home.” To relieve the pain, he received three cortisone shots to his left knee. The injured employee testified that they did not help much, and he kept working without additional treatment until three years later. Shots were tried again but eventually discontinued due to the employee’s allergy to the injections. The employee kept working until he was laid off, but he did not pursue any other work, since he had to undergo total knee replacement surgery.

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The state allows employees to receive Massachusetts workers’ compensation benefits for both physical and psychological injuries. An employee is considered to be injured if the disability was predominantly caused by an accident that occurred while performing tasks for the employer. An injured employee can also recover for aggravated mental injuries that preceded the workplace accident if the workplace accident is a major, but not necessarily predominant, cause of the disability or need for treatment. In this instance, the injured employee does not have to provide as much medical proof to show she or he qualifies for benefits.

A recent Reviewing Board decision (Board No. 020182-15) looks at the difference between the burdens of proof. The self-insurer/employer sought to reverse a ruling awarding the employee total incapacity benefits. The employer argued several errors were made by the administrative judge. Under StrainThe board declined to dismiss the employee’s claim but did recommit the case for additional findings of fact.

In its decision, the board felt the nature of the dispute required a deeper scrutiny of the facts. The employee was a chaplain working at a hospital when a resident lunged from his wheelchair and hit the chaplain in the face. The employee maintained he sought workers’ compensation for his physical injury sustained from the incident as well as benefits for his pre-existing mental health issues. On appeal, the employer argued the employee was only attempting to seek benefits for a pure mental or emotional injury. The record indicated otherwise. The board noted the judge seemed to view the case as the injured employee presented it – a physical injury resulting in emotional sequela, or an aggravation of his previous injury. The employer felt it was deprived of due process by the judge’s treatment of the claim by allowing the lower burden of proof to prevail. The injured employee countered that there was no stipulation to the heightened standard of medical proof regarding causation.

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Massachusetts workers’ compensation offers benefits for both physical and psychological injuries an employee suffers after an accident. By their nature, physical injuries are easier to connect to a workplace accident. Detailed proof and testimony must be offered by an injured person to show the workplace accident was the major factor in the psychological injury. A recent Massachusetts workers’ compensation action (Bd. No. 031456-05) offers a glimpse into which proof can be offered in a successful bid for workers’ compensation for a psychiatric injury.

In this lawsuit, the Reviewing Board assessed whether or not an employee should have been awarded both §§ 34 and 34A benefits. The employee suffered multiple fractures in her left foot after she slipped and fell in an industrial accident. Her employer agreed the foot injury was caused by a workplace accident and agreed to cover the initial costs related to her psychiatric issues stemming from the injury. Metal StairThe employee exhausted her § 35 and § 34 benefits after a fusion in 2006, followed by another in 2012 and a third in 2013. The second surgery seemed to provide some relief to her condition but did not resolve her pain or her difficulties walking on uneven surfaces. The third surgery did not do much to alleviate pain in her heel or the pain that had since developed in her knee. Since the accident, the injured person could not leave the house on cold days because it took her foot hours to feel warm, which then resulted in additional psychological tension. Because of the constant pain and inability to perform typical daily functions, the employee often felt sad, cried, and had fits of anger.

At the hearing, the administrative judge found the employee was permanently and totally disabled due to both the orthopedic and the psychological conditions. The employee was awarded § 34 and § 34A permanent and total incapacity benefits. The employer/self-insurer appealed the ruling, alleging the psychiatric disability should not have been tried at the hearing, since the issue had not been raised at the pre-trial conference. The Reviewing Board disagreed, pointing to the submissions and transcript of discussions before the hearing.

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In a recent Massachusetts workers’ compensation case, the Reviewing Board analyzed an appeal by an insurer dissatisfied with a hearing decision. The insurer alleged the judge incorrectly used the wage amount of $1,726.37 to calculate the weekly wage paid to the injured carpenter. The insurer argued the employee was not entitled to the award, since there was no appeal of the conference order.  carpenter's tableThe insurer felt the employee could only use the maximum amount of $1,490.33 to calculate his entitled average weekly wage.

The injured carpenter was hurt in an industrial accident while moving a piece of machinery. The machinery began to tip, he grabbed it, and he caught his ring on the machine. The employer didn’t dispute liability and agreed to initially pay an average weekly wage of $800 a week. The injured employee eventually sought an adjustment, which was at the center of this action. The carpenter initially asked for an average wage of $1,505.09 a week, and he submitted an IRS Form 1099 for checks from his employer, payable to him for 35 out of 52 weeks prior to the injury, as proof. The claim was then withdrawn in October 2012.

In November 2012, the injured man refiled a claim for an adjustment, this time requesting an average weekly wage of $1,490.22 per week. As proof, the employee submitted the same 35 weeks’ worth of checks. This claim was also withdrawn, but he eventually refiled a year later. This third attempt at a readjustment claim was for the same amount, and this was accompanied by medical reports and a 2011 tax return. This amount was sent to a conference. After the conference, the administrative judge ordered $1,490.33 to be used as the weekly wage amount. The insurer appealed, but the employee did not.

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Injured Massachusetts employees may be surprised to learn that workers’ compensation includes benefits for psychiatric injuries. Compensable psychiatric injuries can be caused by hostile supervisors, bullying by coworkers, or traumatic events. Anxiety and depression stemming from a physical injury can also be compensated. Claims for psychiatric benefits are discussed in a recently issued Reviewing Board decision (Bd No. 0061111-12), which looked at whether or not the administrative judge erred by ceasing all claims for benefits after May 2013.Padlocked fence  The injured worker was a court officer whose duties included transporting prisoners and providing security in the courtroom. In 2012, the employee was injured by a prisoner and taken to the hospital to care for harm to his ribs, right arm, and wrist. The officer also experienced headaches and vertigo months after the incident.

The self-insurer accepted liability for the physical injuries. Benefits for those were resolved in 2013. At this conference, the employee added claims for psychiatric counseling, PTSD, and further indemnity benefits. The insurer objected, disputing the liability for the neurological injury and PTSD claim. The insurer asserted there was no causal relationship between the psychiatric injury and the workplace.

In his decision and denial of benefits, the administrative judge adopted the expert testimony opinion the employee did not have an objective neurological impairment related to the inmate altercation in 2012, as well as the opinion of another expert who determined the injured employee did not have a psychiatric condition limiting his ability to work. The judge found that the employee’s physical injuries had resolved by May 2, 2013 and that he was able to perform the full range of activities consistent with employment.

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Many types of Massachusetts workers’ compensation benefits are directly paid after proof of treatment or travel is provided to the employer’s insurer. Some, like lost wages, require the application of a formula found in Massachusetts’ General Laws. This formula takes a percentage of the highest wage paid over a period of time and divides it by the number of weeks in this period to find what the injured employee’s Average Weekly Wage payout will be. A miscalculation can cause the employee to be underpaid or overpaid for a long period of time before correction. Fragile IceMany workers’ compensation awards go before the Reviewing Board or an appellate body to see if an employee has been overpaid benefits.

This can be seen in a recent Board decision (Bd. No. 00294-13). In this case, a medical health assistant was injured after she slipped on black ice at her workplace. This accident caused an injury to her back that was treated with injections, physical therapy, and diagnostic testing. This treatment occurred over two years, beginning with care performed by a nurse practitioner and eventually leading to a consultation with an orthopedic surgeon. During this period, she performed modified work at her original position, part-time bartending, and baby-sitting. Over a year after the accident, the injured worker went to an Independent Medical Examiner, who agreed with her treating physician that she had a lumbar spine strain with a small central disc protrusion. He also agreed that the workplace injury was the major contributing cause of her disability and need for treatment. The IME opined that she could still work a 40-hour work week with no repetitive stooping and bending, along with lifting and carrying restrictions.

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Determining if an injured employee is eligible for workers’ compensation benefits is straightforward if the accident occurs at the work site. It is not as clear if the worker is injured while traveling to and from locations. Workers’ compensation benefits are awarded to those injured while performing acts for the employer in the ordinary course of business. Thus, if a position requires an employee to travel, and the employee is injured while traveling for the employer, the employee is eligible for workers’ compensation. However, a worker is barred from receiving compensation if the “going and coming” rule applies.  Book stackThis rule blocks injured workers from receiving compensation if an injury occurs while an employee travels to and from a lone, static place of employment.

Traveling employees are different, though, and this is illustrated in a recent Reviewing Board decision (Board No. 015466-13). In this case, the insurer appealed a decision by an administrative judge that awarded payment of §§ 13 and 30 medical benefits to a nurse seriously injured in a car accident. The injured worker was a psychiatric nurse who was assigned to work in Brattleboro, Vermont. The employee traveled from her home in Massachusetts to work five days a week on the night shift. The injured nurse was provided expenses for a hotel stay and meals for five days of the week. The nurse advised she did not put in for additional travel reimbursement from the employer, nor did she tell her employer whether she traveled home to Massachusetts on her off-days. The injured nurse did not think she was required to go home on those days, nor did she believe she was obligated to tell her employer any time she went home.

The senior market manager for the injured nurse’s company testified at the hearing. The manager stated she provides all traveling employees with a seven-day per diem each week unless she was told they were traveling back to the “permanent tax home.” The manager testified that while she did not assume the contracted medical staff traveled, she did provide additional per diem payments to employees who notified her they were going home to pick up clothes or traveling for a personal event.

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In Massachusetts, an injured worker can receive workers’ compensation benefits for a work-related injury that aggravated a pre-existing condition as long as the injury is a major cause of the disability. This differs from the requirements for psychiatric injuries under G. L. c. 152, § 1(7A), which place a higher burden on the injured person to show the workplace injury was the predominant contributing cause. To determine whether or not the work-related injury rises to this standard, the Administrative Judge (AJ) hears from medical experts who have either examined the worker or looked at the injured person’s records. An award of benefits hinges on whether or not there is sufficient evidence to support the claim of psychiatric disability.

In a recent case (16-P-837), the Appeals Court reviewed an appeal of a decision of the Department of Industrial Accidents (DIA) reviewing board, which reversed an AJ’s decision in favor of the injured worker.  Moving crowdThe board determined the injured woman did not show the employment-related event was the predominant contributing cause. The injured worker appealed, arguing the decision should have been affirmed, or in the alternative, recommitted to the AJ for additional findings. The claim originated from the worker’s repeated encounters with clients through the Department of Transitional Assistance (DTA) who were verbally hostile and threatening. The woman sought psychiatric treatment in 1997 after working there for several years, but she had a stressful incident in 2013 when she was threatened by a client during an interview. The worker sought help from a supervisor but received no support. Paralyzed by anxiety, the injured worker did not return to work.

Prior to her employment, the woman suffered physical and emotional abuse from her mother. The woman did not have any family support, nor any mental health treatment during this period. During the hearing with the AJ, the independent medical examiner testified that her childhood experiences and experiences at work contributed to her diagnosed mental health disorders. The doctor affirmed that she was medically disabled and that the cause of this disability stemmed from the combined experiences. The doctor testified that after several years of traumatic incidents, the threatening client at work in 2013 was the “proverbial straw that broke the camel’s back.” In its review, the board concluded this was not enough to show the work-related incidents were the predominant cause of her disability.

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Injured employees may receive compensation beyond the emergency room bill and calculated wages under the Workers’ Compensation Act. They may also receive payments for prescriptions and therapies for persistent medical conditions. In Magraf’s Case (16-P-364), the appellate court reviewed an award of prescription drug coverage and reimbursement for medical appointments under G. L. c. 152, §§ 13(1) and 30 following a lump sum settlement for an injury. Prescription PillsThe insurer raised an affirmative defense that the employee had a pre-existing condition, but the Administrative Law Judge chose to order payment anyway, citing the opinions provided by the Independent Medical Examiner (IME). The Reviewing Board upheld the ALJ’s determination, and the following appeal ensued.

The existence of a pre-existing condition does not prevent compensation for a work injury. Massachusetts’ General Laws allow for the compensation of an injury as long as the work injury was a major cause of the disability. It does not have to be the predominant cause of the disability. An employer or insurer may raise a pre-existing condition as an affirmative defense to the payment of benefits, but they bear the burden of showing the pre-existing condition is not covered. When assessing the Reviewing Board’s decision, the Appeals Court looks at whether or not the decision was supported by substantial evidence, whether or not the Board made an error of law, or whether the Board issued a decision that was arbitrary and capricious.

The insurer argued that the ALJ failed to make findings regarding the nature of the injured worker’s pre-existing condition. The ALJ felt the issue of causation had been fully litigated and satisfied by the lump sum agreement. To avoid re-litigating causation, the court ruled the insurer must meet a new burden of production. The Board agreed with the judge’s assessment, determining that the judge rightfully adopted the IME’s opinion that the work injury was still a major cause of the injured worker’s disability and need for treatment.

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After a workplace injury, a worker is entitled to receive a weekly wage that’s calculated by plugging the worker’s earnings into a formula under Massachusetts G. L. c. 152, § 35D. A partially incapacitated worker may receive 60% of the difference between the average weekly wage before the injury and the weekly wage the worker is capable of earning after the injury. This is not to exceed 75% of the amount she or he would receive if deemed totally incapacitated. A recent Appeals Court case, Lavalley’s Case (16-P-46), assessed an earning capacity calculation for a worker suffering from bilateral carpal tunnel syndrome.

In this lawsuit, the administrative law judge (ALJ) initially ordered the insurer to pay $235.43 a week in partial benefits. keyboard typingHowever, the order did not include the calculation under G. L. c. 152, § 35D, and both parties appealed to the Reviewing Board. After the Reviewing Board remanded the lawsuit down to the ALJ for further findings of fact, the ALJ found that the insurer was only required to pay $121.91 from the day the injury began on June 1, 2011 to December 31, 2014. The insurer was then required to pay $97.91 from January 1, 2015 forward. The worker appealed this order to the Reviewing Board, which affirmed the ALJ’s calculation. The injured worker then appealed the Reviewing Board’s decision.

In its review, the Appeals Court first established that the decisions of the Reviewing Board are not overturned unless there was no evidence supporting the ruling, or the decision was tainted by errors of law. At the initial hearing, the ALJ made a finding that the injured worker could perform light work and granted her the maximum amount of weekly wage under the law. However, the ALJ did not attach the corresponding calculation with this finding. On remand, the judge used the same evidence that was presented at the first hearing but came to a different conclusion and ordered the lesser amount. The injured worker argued that the second order went against the first and that the ALJ was obligated to hear new evidence.

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