December 23, 2009

Injuries Must Arise Out of AND In the Course of Employment ...

On November 9, 2009 the Georgia Court of Appeals underscored a fundamental point in workers’ compensation cases. For an on-the-job injury to be compensable, the injury must not only occur during one's employment, but it must "arise out of" and directly result from the performance of an employee's work duties. St. Joseph’s Hospital, et al., v. Ward, No. A09A1398 (Nov. 9, 2009). Ward worked as a nurse for St. Joseph’s Hospital and asserted workers’ compensation claims for several injuries: left knee (12/19/2003); right knee (6/23/2005); right knee (7/7/2005); and both knees (9/16/2005). Following a hearing the administrative law judge (ALJ) found that the employee sustained a compensable accident on 6/23/2005 when she turned around to get a patient a cup of water and twisted her right knee. She unsuccessfully attempted to return to work on 7/7/2005, then remained out of work until 8/15/2005 when she was offered light duty work. She worked light duty until 9/16/2005 when she went out for right knee replacement surgery. The ALJ found 9/16/2005 to be a fictional date of accident due to a gradual worsening of her condition.

St. Joseph’s appealed and the State Board Appellate Division concluded that, based on the 2004 Court of Appeals decision in Chaparral Boats v. Heath, 269 Ga. App. 339, 606 S.E.2d 567 (2004), the claimant’s right knee injury was not compensable because she was not exposed to any risk unique to her employment by standing and turning, and that, in turning, she did not come into contact with any object or hazard of employment. In Chaparral Boats the Court readdressed the positional risk doctrine and determined that if an employee’s injury was caused by a risk to which they would have been "equally exposed" apart from their employment, and the injury was not related to or caused by any peculiar condition of the employment, the injury was not compensable because there was no causal connection. In other words, the injury did not arise out of the employment. Ward appealed the Appellate Division ruling and the superior court reversed. The Superior Court concluded the Appellate Division misconstrued Chaparral Boats because the employee’s injury “directly resulted from the performance of her work duties of assisting a patient to get the patient a cup of water.”

St. Joseph’s appealed, and the Court of Appeals found that the superior court exceeded its authority when it rejected the Appellate Division’s application of Chaparral Boats. The Court stated, “the Board’s appellate division is authorized to review the evidence adduced before the ALJ, weigh that evidence, and assess witness credibility.” Moreover, “when reviewing awards in workers’ compensation cases, ‘both the appellate court and the superior court must construe the evidence in the light most favorable to the party prevailing before the appellate division of the State Board of Workers’ Compensation. It is axiomatic that the findings of the State Board, when supported by any evidence, are conclusive and binding.’” Quoting Ray Bell Constr. Co. v. King, 281 Ga. 853, 854, 642 S.E.2d 841 (2007).

Thus, the Appellate Division was justified in concluding that Ward was not exposed to any risk unique to her employment by standing and turning. Both the Court of Appeals and the superior court were required to defer to this finding. However, this is the most recent decision in a line of cases addressing the positional risk doctrine. While this represents a shift back to the Court’s position in Chaparral Boats, it remains to be seen whether the Supreme Court of Georgia will grant certiorari and review this case.

David W. Willis, Esq.
Melissa B. Whitman, Esq.
David & Rosetti, LLP
229 Peachtree Street
International Tower, Suite 950
Atlanta, Georgia 30303
Main: (404) 446-4488
Fax: (404) 446-4499

December 15, 2009

Workers' Compensation Subject to Federal Racketeering Law?

In a recent article published in Business Insurance it was announced that the U.S. Supreme Court declined to review a Court of Appeals decision which allowed workers compensation claimants to sue an employer and its third-party administrator (TPA) under federal racketeering law. In October 2009 the 6th Circuit Court of Appeals held in Paul Brown vs. Cassens Transport Co. that several employees could pursue a claim for mail and wire fraud violations of RICO (Racketeer Influenced and Corrupt Organizations Act) against their employer and its third-party administrator.

Their allegations were based upon denials of their workers' compensation claims by the employer/self-insurer and third party administrator. Specifically, the plaintiffs alleged that Cassens Transport and its TPA used "unqualified doctors" to give fraudulent medical opinions in support of a denial of their workers compensation claims. The workers also alleged the company, the TPA and doctors committed mail and wire fraud in their communications about the claims.

As expected, employer groups have severely criticized the decision. The case has been remanded back to the trial court level, but if it stands this provides a precedent for federal courts to rule on workers comp claims. Equally as significant is what this may signal for the future. Will this mean communications between employers/insurers and medical providers fall under closer scrutiny, or become barred altogether? Will workers' compensation administrative law judges look closer at doctors providing medical care? Who is to determine whether a doctor is qualified or unqualified, and isn't that what independent medical evaluations (IMEs) and second opinions are for? If an employer and/or claims adjuster cannot effectively communicate with medical providers won't this be detrimental for the overall administration of workers' compensation claims?

The decision bears close watching as all states may be impacted by this decision. Stay tuned for more details.

David W. Willis, Esq.