Legal Corner

Workers Compensation
Policy exclusion means carrier avoids comp benefits - Georgia

In Harco National Insurance Co. v. Eric Knowles Inc., a logging worker was leaving the work area on a dirt road to get lunch when he encountered an operating skidder. He put his vehicle in park to allow the work to finish and the driver accidentally drove the skidder into his vehicle. While he initially received benefits from general liability and auto insurance policies, the insurance company requested a finding that the worker was acting within the scope of his employment at the time he was injured and that his injuries are compensable under the Workers'Compensation Act, which was excluded from the other policies.

The appeals court ruled that an ordinary midday lunch break on the employer's premises is still considered to be "in the course of" employment. It was undisputed that his injury was caused by heavy equipment returning from a task that was part of the timber harvest operation. Traversing to and from the work area for lunch "arises out of" employment when the causative danger is incidental to the character of the work.

Tort suit for birth defects in children of employees revived - Illinois

An appellate court reversed a summary judgment order in favor of Motorola Solutions in multiple negligence suits after determining questions of material fact remained whether birth defects in children were the result of their parents' workplace exposure to reproductively toxic chemicals at semiconductor manufacturing facilities in Arizona and Texas. The court rejected the company's argument the exclusive remedy applied since it applies to injuries suffered by an employee and in some cases as in Texas, to their heirs who suffered emotional or economic harm, but not physical injury.

School district has sovereign immunity in wrongful termination case - Nebraska

In Simpson V. Lincoln Public Schools, a worker suffered a compensable injury, but a workers' compensation case management nurse noticed discrepancies in her records, which led to a background check and allegations that she had failed to disclose a criminal charge and used different middle initials and birth dates. Although her employment application had been destroyed in a fire and she had positive performance appraisals, the school terminated her. She filed a wrongful termination lawsuit.

The case made its way to the Supreme Court, which found that sovereign immunity protects the state and its political subdivisions from suits unless the Legislature, by law, has provided otherwise. A two-part analysis determines whether the discretionary function exemption applies. The first step is determining whether the action is a matter of choice for the acting political subdivision or employee, and the second is determining whether that judgment is of the kind that the discretionary function exemption was designed to shield.

The court noted that the decision to terminate her employment was not dictated or required by any policy of the school and was discretionary. Therefore, the school has sovereign immunity.

Several decisions on compensability of psychological injury related to COVID-19 exposure - New York

In Anderson v City of Yonkers, the Workers' Compensation Board (WCB) denied benefits for a second-grade school teacher with a past medical history of asthma and bronchitis, who claimed anxiety due to COVID-19 exposure in the workplace. The WCB found "the conditions that . . . claimant is claiming are the result of the stress that was no greater than that which occurred in the normal work environment." Upon appeal, the court said the WCB "improperly applies a disparate burden to claimants seeking benefits for contracting the virus as compared to those seeking benefits for psychological injuries stemming from exposure to COVID-19 in the workplace." The case was remanded to determine whether the teacher had demonstrated "either a specific exposure to COVID-19 or the prevalence of COVID-19 in her work environment so as to present an elevated risk of exposure constituting an extraordinary event" and, if so, whether a causal connection exists between the alleged injury and the workplace.

Similar rulings were issued in Sheldon Matthew vs New York City Transit Authority involving a train conductor, in Bolot Djanuzakov vs Manhattan & Bronx Surface, Transit Operating Authority involving a bus driver, and in Kimberly McLaurin vs New York City Transit Authority involving a train operator.

Bariatric surgery needed before knee operation not compensable - North Carolina

In Kluttz-Ellison v. Noah's Playloft Preschool, a worker filed two workers compensation claims at the preschool for injuries she suffered after falling off a ladder and tripping over a sleeping cot. For years she had struggled with weight issues and her physicians determined she needed knee surgery but would have to lose weight first and recommended bariatric surgery.

The Industrial Commission found that her knee surgery was compensable, but initially denied coverage for the gastric bypass, finding the weight loss treatment was not medically necessitated by her compensable injuries. The worker sought reconsideration and the Commission agreed the surgery was needed to achieve a BMI of less than 40 as a prerequisite to the knee revision surgery. While an appeals court affirmed, in a split decision the Supreme Court overturned. It referenced the "directly related" test where there must be a sufficiently strong causal relationship between the condition that requires treatment and the workplace injury. "Medical compensation will be limited to conditions directly related to the workplace injury and will not "convert our compensation law into a system of compulsory general health insurance."

Attorneys can receive 20 percent of medical bills - Pennsylvania

In Williams v. City of Philadelphia, the Commonwealth Court overturned a ruling by a WCJ and the Workers' Compensation Appeal Board (WCAB) that refused to grant a 20 percent attorney's fee on the medical benefits, despite a request from the attorney and agreed upon by the injured worker. The standard fee agreement in workers' compensation is 20 percent of the benefits obtained or awarded to an injured worker, but it typically only applies to indemnity (wage loss) benefits.

Although the Commonwealth Court ruled in a 2020 case, Neves v. Workers' Compensation Appeal Board (American Airlines), that an attorney for the injured worker could obtain 20 percent of the medical bills, as well as 20 percent of the wage loss benefits, it was unclear if the injured employee could be held responsible for payment from the medical provider and many attorneys did not adopt the practice. In the Williams ruling, the Commonwealth Court found that the 20 percent fee on the medical benefits should have been granted. Importantly, it added that a healthcare provider cannot bill an injured worker for the 20 percent deducted as a fee.

Fall after shift compensable - Tennessee

In Raymond Pridgen v. Texas Roadhouse Holdings LLC, et al, a worker was in a designated break area outside the restaurant waiting for his ride home after his shift when an opossum ran from behind a dumpster and startled him, causing him to fall and sustain significant injuries to his shoulder and back. The employer argued that the injuries did not arise "primarily out of or in the course and scope of his employment." A trial court disagreed and concluded the worker was permanently and totally disabled.

Upon appeal, the employer maintained the injuries were not compensable and questioned the disability finding. The appeals court used Supreme Court case law noting, "'course of employment' includes not only the time for which the employee is actually paid but also a reasonable time during which the employee is necessarily on the employer's premises while passing to or from the place where the work is actually done." It also noted the worker had made unsuccessful attempts to return to work and his testimony regarding his physical limitations was competent.

Direct and Natural Consequence Rule determines compensability of later injury - Tennessee

In Hudgins v. Global Personnel Solutions Inc., a worker injured her knee after tripping over a pallet at work and received medical benefits, including authorization for a partial knee replacement. Later, she experienced back pain and the employer contested the compensability of the employee's spinal conditions, but a trial court and the Appeals Board disagreed.

Upon appeal, the Supreme Court noted the direct and natural consequence rule contemplates that certain injuries may be compensable even if they do not occur while the employee is at work, so long as they are the direct and natural consequence of a compensable injury. It requires a finding by a preponderance of the evidence that the employment contributed more than fifty percent to such consequential injuries for them to be compensable. According to the court, the employee met this standard.

Employer can't argue an absence of causation and unauthorized treatment for psychological injury - Virginia

In Andrew Stephenson V. Dan Bar Investments Inc., a worker was awarded medical and disability benefits for a back injury sustained in a motor vehicle accident. He later sought coverage for psychological injuries he contended developed from the accident and sought payment for treatment he received from a psychologist. The employer asserted that the injury was unrelated to the workplace accident and argued that the psychologist's visits were unauthorized. However, a deputy commissioner advised they could not do both. If the employer contests authorization, it admits causation and if the employer challenges causation, the question of authorization of treatment is moot.

Therefore, the employer withdrew the causation defense and proceeded by contending the claimant sought unauthorized medical care. The injured worker argued that the employer did not provide a panel of at least three physicians to choose from as required by statute and the deputy commission agreed. Upon appeal, the employer argued that the deputy commissioner erred in compelling them to choose between causation and authorization of treatment. The Workers' Compensation Commission (VWCC) disagreed noting an employer's challenge to an injury's causal relationship to a compensable accident is manifestly a denial of responsibility for the cost of treatment for that injury. The VWCC also found that the evidence established that the psychological injuries were related to the industrial accident.