Articles Posted in Workers’ Compensation

Massachusetts General Laws c. 152, § 11A(2) of the Workers’ Compensation Act states that an impartial medical examiner is to be used whenever there is a dispute within a claim or a complaint over medical issues that is the subject of an appeal. In order to offset the cost of the medical examination, the injured worker must submit a fee equal to her or his average weekly wage in the Commonwealth at the time of the appeal. A failure to do so can quash the appeal, as seen in the Reviewing Board decision of Saini v. Jeffco Fibers, Inc. (Board No. 044894-91).

In this case, the employee had a work injury in 1991 and settled four years later for $145,000. Eleven years after the settlement, the injured worker filed a claim for the payment of medical bills, which was denied by the ALJ. A timely appeal was filed but was not accompanied by the appeal fee. Notice was sent to the claimant’s attorney, but the fee remained unpaid. A month after the notice of the overdue fee was sent, the case was withdrawn. The injured employee’s attorney complained after the withdrawal, but the ALJ kept it in place, pointing out that the impartial medical examination was not waived by the insurer. A second and third claim were filed but were also withdrawn. Eventually, at another hearing, an ALJ formally denied and dismissed the claim for medical benefits, tying it back to the original submission and pointing out that the failure to pay the fee amounted to an acceptance of the order under General Laws c. 152, § 10A(3).

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During the course of a career, the employing company may re-organize different aspects of its business, including its workers’ compensation insurer. Workers’ compensation law provides for this situation, in the event that a long-term worker suffers an ongoing injury with another injury. The successive insurer rule requires an insurer to pay for the compensation of all of the injuries that a worker suffers, even if it was not the insurer when the original incident or ongoing injury occurred. As long as the recent injury has a causal relation to the disability claimed, the insurer must cover the risk. The insurer must take the employee “in the condition in which he finds him,” so the provision of benefits is streamlined and expedited.

In Linton v. G.P.C. International (Bd. No. 035380-10), the second insurer appealed a decision granting medical benefits for a repetitive injury to an employee’s right shoulder. The employee worked for the employer since 1996, performing repetitive, heavy lifting of 75 to 100 pounds as a paper processor and machine operator.  He began having pain in 2003 in his right arm, which resulted in physical therapy. Seven years later, the worker returned for shoulder pain care and could not work for two months. During this period, he received weekly workers’ compensation benefits. The first insurer paid for medical expenses, including physical therapy and a TENS unit he still uses.

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As one nears retirement, many decisions await from family to financial matters. A recent federal appellate decision, O’Shea v. UPS Retirement Plan (No. 15-1923), reveals the importance of careful estate planning alongside serious illnesses or retirement. In this case, an employee, diagnosed with cancer, died one week before his official retirement date but after his final day of work. Following a diagnosis in the previous year, the employee originally planned to retire at the end of the calendar year. The employee met with a human resources supervisor, who advised him to take his accrued time, which pushed back his official retirement date. This advice given was standard practice, and the HR supervisor had no knowledge that he was terminally ill.

Following the submission of his retirement application, the employee was told that his annuity start date would be March 1, 2010 after his official retirement on February 28, 2010. The employee chose the Single Life Annuity with 120-Month Guarantee and named his children as the beneficiaries. The Guarantee allowed him to receive payments of over $4,000 each month for 10 years. If he died during this term, his listed beneficiaries would receive the payments. Neither the HR supervisor nor the retirement benefits applications made it clear that he needed to live until the annuity start date on March 10, 2010 for the guarantee to be realized. The employee was unaware that he risked forfeiting his payments by delaying the retirement date.

While the retirement application did not explicitly lay out the requirements in the body of the application, it did note that the benefits plan designations are subject to the terms of the Plan. The Plan states that payments can be made to the beneficiaries if the participant dies before the first payment but after the annuity starting date. The only exception listed is for a spouse or domestic partner, who would be entitled to receive a pre-retirement survivor annuity. In addition to the annuity plan, the employee also participated in the Special Restructuring Program, which provided a year’s compensation in exchange for signing a release of claims and retiring. The employee accepted this with his attorney on February 12, 2010 for a single pre-tax payment of $98,800. The release included his employer and “all related companies,” which included the benefit programs, as well as any claims of which he might not know.

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When you work at a physically intensive workplace for a long time, minor to moderate individual injuries that occur over several years can become a sustained injury. A recent Reviewing Board Decision, Breire v. Lowell General Hospital (BOARD NO. 036471-11), highlights considerations made by deciding authorities in Massachusetts’ workers’ compensation system. In this case, the injured employee worked for nearly 40 years as a certified nurse’s assistant (CNA). Throughout this time, she incurred several injuries, some from the workplace and some from her personal life.  Those of note included a workplace injury in which she hurt her back lifting a 350-pound man into a car, as well as car accidents outside work in which she hurt her back and neck. The injured CNA also sustained multiple injuries while working for the employer in this case, hurting her back, hip, and neck on different occasions over 10 years.

The injury that led to this litigated claim occurred when she helped her co-workers lift a 400-pound patient. The CNA suffered hand, neck, and back injuries. On the date of the injuries, she finished her shift, and she returned to work the next day but eventually sought a leave of absence from her job. The injured worker advised her employer that she could no longer perform her duties, due to the combination of injuries suffered. The employee sought temporary total disability benefits, among others. The insurer filed a denial, arguing that the injury suffered was not a workplace injury. After a conference and a hearing, the Administrative Law Judge (ALJ) awarded the injured CNA § 34A (total permanent disability benefits), finding that the last injury was the major cause of her disability.

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The Massachusetts Workers’ Compensation Act, under G. L. c. 152, § 31, provides benefits to the spouse of a deceased worker whose fatal injuries were caused by the workplace. The statute allows unmarried widows or widowers to receive 2/3 of the deceased’s average weekly wage. This benefit was designed to help living spouses who were not able to support themselves, and it can be reviewed at any time for cost-of-living increases, reductions, or termination.  In Freedman vs. Suffolk County Sheriff’s Office (Bd No. 012354-97), the wife of a deceased worker appealed the termination of her spousal benefits after an Administrative Law Judge (ALJ) ruled that she was fully self-supporting.

To determine whether or not the wife was self-supporting, the ALJ conducted an in-depth review of her living expenses. The ALJ found that her qualified weekly expenses were $768.50, which were more than covered by her salary of $894.97 a week. The woman had been receiving $751.04 from the § 31 benefit, and she appealed the ALJ’s finding, arguing that she was not fully self-supporting because she was putting her daughter through college.

The Board determined that the judge’s method of calculations was correct to determine what was “necessary and reasonable.” However, while the Board emphasized there is generally a high amount of deference to ALJ findings, it did not agree with the exclusion of college expenses. While there is not a “redline” for determining reasonable and necessary expenses, consideration is given to accustomed standards of living. The Board went on to hold that college tuition must be factored into a determination of whether a widow or widower is fully self-supporting.

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As an injured Massachusetts worker, you want to ensure that all your benefits get paid by the entity or entities responsible for paying them. The Reviewing Board decision published this month, John Pastore v. Polaroid Corp., Inc. (Bd. Nos. 004718-89, 029283-13, 012201-13), dissects an agreement between a self-insured employer and an excess insurance carrier regarding the § 34A benefits and § 34B cost of living adjustments (COLA) of an injured employee. The worker in this case was injured in an industrial accident in 1983. His employer was a licensed self-insurer, obligated to follow the statutory requirements that come with being its own workers’ compensation insurance carrier. These included purchasing extra insurance as back up to help meet their workers’ compensation obligations through a “reinsurer.”

After the injury, the employer agreed to accept the claim and pay the weekly benefit, eventually agreeing to pay for the permanent and total incapacity (§ 34A) benefits at around $297.85 a week. The reinsurance company had a $250,000 policy, which the employer tried to utilize. The reinsurer initially denied the claim, since the employer voluntarily placed the employee on the § 34A benefits. Eventually, the employer and the re-insurer agreed to a settlement of $155,000 to reimburse the employer’s obligation to the injured worker. Neither the employee nor the Dept. of Industrial Accidents was made aware that this settlement occurred in 1998. Both became aware of this agreement after the employer’s bankruptcy action and exhaustion of bond set aside for benefits payment. The employee then filed suit for payment to resume.

At the hearing, the Administrative Law Judge (ALJ) held that the employee was now “uninsured” and that the Workers’ Compensation Trust Fund (WCTF) was obligated to pay the benefits. The WCTF, on appeal, disagreed with the assessment, arguing that the reinsurer was the entity obligated to pay the benefits to the injured employee. The Reviewing Board agreed, reversing the prior decision and directing the re-insurer to pay the benefits. In its analysis, the Board first pointed out that the WCTF was not created until after the worker was injured, and the injured worker would not be considered to be “uninsured” because the employer was a self-insurer. The Board then pointed out the difference between standard insurance agreements for settlement and the obligations of workers’ compensation insurers under Massachusetts law. Self-insurers are regulated by the Department of Industrial Accidents, rather than the Commissioner of Insurance. Workers’ compensation insurers are all beholden to the intent of the Workers’ Compensation Act, which was designed to protect injured workers. The Board found that the agreement reached between the now-bankrupt employer and the re-insurer was valid and that the re-insurer was responsible for both the § 34A and the COLA benefits.
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When an injury occurs in a Massachusetts workplace, an injured employee can receive payment for the medical treatment of the injury as long as it was related to the workplace accident. In Thomas A. Novack’s Case (15-P-1090), a nursing home employee sustained a lower back injury while on the job. He eventually received a lump-sum payment with an agreement that the insurer would keep paying for medical treatment that was adequate, reasonable, and stemming from the workplace injury. The injured employee received treatment from various providers after the settlement, and those costs were paid by the insurer for the next five years. The insurer then ceased payment, and Medicare began paying for all of the medical treatment received thereafter.

The employee filed for reimbursement from the Department of Industrial Accidents for the treatment paid for by Medicare. The Administrative Law Judge (ALJ) pondered whether the injured employee could even seek reimbursement when a third party made the payment, but the ALJ ultimately stopped at the finding that the treatment was not adequate, reasonable, or causally related to the workplace injury. The ALJ also noted in the decision that there was a lack of proof that bills were submitted to the insurer before they were given to Medicare. The request for reimbursement was denied, and the injured employee appealed.

The Appeals Court looked at the conclusions of the ALJ to see if the evidence supported the findings. The ALJ did not find the treating physician’s letters persuasive in their attempt to show the connection from the back treatment to the workplace accident. The appellate court felt the ALJ documented sufficient evidence to rule against the injured employee. The ALJ’s ruling in favor of the insurer was affirmed.
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Many types of employment involve repetitive motions. Over the course of time, these repeated movements can lead to an injury that is compensable under Massachusetts’ workers’ compensation laws. A recent Board Decision in Aguilar v. Old Republic Insurance (Bd No. 029539-12) reviewed a decision that awarded a limited amount of temporary total incapacity benefits, an ongoing award of partial incapacity benefits, and medical benefits for a total replacement for the injured worker’s right knee. In this case, the injured employee worked as a certified nursing assistant (CNA), which required her to move, feed, dress, and bathe patients. During the proceedings, the injured CNA testified that she felt pain in her knees, especially the right one. The nurse stated that she fell to the floor in 2011, landing on the right knee while bringing a tray to a patient.

The employee stopped working in the year following the fall, and she had the knee replacement procedure. The injured CNA then applied for short-term disability benefits, followed by workers’ compensation benefits. Following the filing of this claim, the CNA was seen by an impartial medical examiner, who agreed with her treating physician that her employment was the major cause of her knee injury. The judge adopted these opinions, ruling out the pre-existing condition defense raised by the insurer. The judge found the injured CNA’s testimony regarding her multiple falls was credible, based on the hospital visit that followed a fall and a report to a supervisor. The judge also felt that she should be credited for all the multiple, documented complaints she made throughout the years preceding the knee replacement to her supervisor.

In addition to arguing the injured employee’s knee was the result of a pre-existing condition, the insurer also argued that the CNA did not prove she fell and struck something during the last reported fall, nor did she prove the rest of the falls described arose out of her employment. The insurer pointed to the employee’s non-work-related diagnosis of vertigo and dizziness as the cause of the falls. While the Reviewing Board agreed that the judge did not make findings about the falls or the nature of the falls, the judge felt that those falls were not really relevant to whether or not the injured CNA suffered a workplace injury. The board found that the focus of these proceedings was the repetitive movements the employee had to make while performing her duties. The board felt that there was plenty of evidence and testimony for the judge to find a workplace injury did occur, and to award all of the temporary, partial, and medical benefits.
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In Massachusetts workers’ compensation claims, an award of partial incapacity benefits rather than total incapacity benefits can make all the difference to a worker and his or her family. It can be the difference between financial strain and an existence that resembles life before the accident. Massachusetts workers’ compensation law Ch. 152 §1(7A) allows compensation for workplace injuries that exacerbate pre-existing conditions, as long as there is a determination of whether or not the compensable injury remains a major cause of the disability or need for treatment. The workplace injury does not have to be the predominant cause of the disability. In Herrera vs. Mediate Management, Inc. (Bd. No. 010696-10), the Reviewing Board chose to return the case to the Administrative Law Judge for additional findings of fact regarding whether or not the compensable injury was a major cause of the disability. The board did so because it felt there was insufficient analysis in the determination of whether or not the janitor’s current medical condition entitled him to receive total incapacity benefits instead of partial incapacity benefits.

In this case, the janitor tore his medial meniscus and underwent physical therapy and arthroscopic knee surgery. The janitor testified that his pain did not abate, and he was unable to work in the same occupation due to this injury. The ALJ, in his findings, wrote that he agreed with the medical opinion of the insurer’s expert witness, which concluded he had a pre-existing condition that was unrelated to the injury and progressive in nature. However, he also wrote that he agreed with the janitor’s medical expert, who placed restrictions on the employee’s movement and opined that the work-related injury remained a major contributing factor to his need for treatment. The ALJ then concluded, based on the testimony of the impartial physician (which was not formally adopted), that the arthritis and continuing degeneration were not caused by the workplace injury. The judge went on to rule that the janitor could work light duty and qualified for partial incapacity benefits, but not total incapacity benefits.
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In Robert Amaral’s Case (15-P-860), the Appeals Court of Massachusetts reviewed whether or not it was appropriate for an administrative hearing judge to terminate a worker’s total weekly incapacity benefits. The worker injured his shoulder and lower back while helping restrain two juveniles at the Department of Youth Services. He originally received both total and partial incapacity benefits, but his employer, a self-insurer, filed to discontinue the total incapacity benefits.

The employer argued that the injured worker was no longer entitled to weekly benefits because the injury sustained at work was not a major cause of his continued disability. The administrative judge relied upon the employer’s medical expert witness, who opined that his disability mostly stemmed from his pre-existing spinal degeneration and obesity.

In all workers’ compensation cases, the judge is allowed to weigh the medical evidence presented in order to determine whether the injuries sustained by the worker were actually from the workplace and not aggravated by conditions preceding the accident or aggravated by circumstances outside of and unrelated to work. In this case, the injured worker appealed the judge’s ruling and the affirmation of the Reviewing Board, arguing that the judge had abused her discretion by adopting the medical opinion of the employer’s expert.
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