12. Relevant Case Law 1 Flashcards
What is the employer’s obligation upon submitting required material to the independent medical review organization?
The employer is required to promptly issue a notification to the employee that lists the documents submitted to the independent medical review organization. This notification must also include copies of any material that had not previously been provided to the employee or the employee’s designee.
What should a claims administrator do if there is a change in the claims administrator responsible for a claim?
The claims administrator who issued the utilization review decision in dispute must notify the independent medical review organization of the change in the claims administrator. This notice must be given within five working days of the change taking effect.
What is the significance of the WCAB vs. Escobedo case?
The WCAB vs. Escobedo case is a significant en banc decision that established key principles for the apportionment of permanent disability under Labor Code section 4663 following the reforms enacted by SB 899 in 2004.
What does Labor Code section 4663 pertain to?
Labor Code section 4663 pertains to the apportionment of permanent disability specifically addressing how disability from multiple causes should be attributed.
What reforms were introduced by SB 899 in 2004?
SB 899 introduced reforms to the California Workers’ Compensation system including changes to the rating system for permanent disabilities and clarifications on how such disabilities should be apportioned among multiple causes or conditions.
Who was Marlene Escobedo in relation to the Escobedo case?
Marlene Escobedo is the individual involved in the significant case which served to clarify laws regarding the apportionment of permanent disability within the workers’ compensation framework.
What happened to the individual on October 28 2002?
The individual sustained an industrial injury to her left knee while working as a sales associate at Marshalls.
What was the consequence of the left knee injury?
The individual developed right knee problems as a compensable consequence of the left knee injury.
What preexisting condition did the individual have before the injury?
The individual had preexisting degenerative arthritis in both knees though it was asymptomatic before the injury.
What percentage of permanent disability did QME Dr. Ovadia apportion to the preexisting arthritis?
Dr. Ovadia apportioned 50% of her permanent disability to the preexisting arthritis.
What is the key holding regarding apportionment under section 4663?
Apportionment under section 4663 must be based on causation of permanent disability not causation of injury.
What must a reporting physician determine regarding disability?
A reporting physician must determine: 1) What percentage of disability was directly caused by the industrial injury and 2) What percentage was caused by other factors including pathology and asymptomatic conditions.
What criteria must medical evidence meet to constitute substantial evidence on apportionment?
For medical evidence to constitute substantial evidence on apportionment it must: 1) Be based on reasonable medical probability; 2) Not be speculative; 3) Be based on pertinent facts and adequate examination; 4) Explain the reasoning behind conclusions; and 5) Explain how and why the conditions were assessed.
What is the distinction between causation of injury and causation of permanent disability according to the key holdings?
The distinction is that apportionment must focus on the impact of the injury on the individual’s permanent disability rather than the injury itself.
Define ‘reasonable medical probability’ in the context of medical evidence for apportionment.
Reasonable medical probability refers to a level of certainty in medical opinion that indicates a conclusion is more likely than not to be true as opposed to speculation or conjecture.
Why must medical conclusions be explained clearly?
Medical conclusions must be explained clearly to ensure they are based on a thorough understanding of the patient’s condition and the reasoning is transparent allowing for better evaluation of credibility and reliability.
What role does an adequate examination play in apportionment assessments?
An adequate examination is critical as it ensures that the reporting physician has comprehensively evaluated the patient’s condition and history providing a solid basis for determining the extent of permanent disability attributable to the industrial injury versus preexisting conditions.
What does the burden of proof refer to in the context of disability claims due to industrial injury?
In disability claims due to industrial injury the burden of proof is divided between the employee and the employer. The employee must prove the percentage of disability that is directly caused by the industrial injury while the employer must prove the percentage of the disability caused by other factors.
What was the outcome of the WCAB’s decision regarding apportionment in the case referenced?
The WCAB upheld the Workers’ Compensation Judge’s (WCJ) decision of a 50% apportionment based on Dr. Ovadia’s findings.
What criteria did Dr. Ovadia’s report meet to support the 50% apportionment?
Dr. Ovadia’s report met the following criteria: it was based on an adequate examination it explained his reasoning it stated opinions to reasonable medical probability it properly assessed causation percentages and adequately explained the basis for the 50% apportionment to preexisting arthritis.
What framework did the decision establish for analyzing apportionment of permanent disability under section 4663?
The decision established a framework that allows for apportionment of permanent disability to asymptomatic preexisting conditions and pathology provided that this apportionment is adequately supported by substantial medical evidence explaining the causal relationship between preexisting conditions and permanent disability.
What significant legal precedent does the Kite v. EBMUD case set regarding apportionment?
The Kite v. EBMUD case sets a significant legal precedent by allowing apportionment of disability to asymptomatic preexisting conditions if there is substantial medical evidence adequately explaining the causal relationship to the permanent disability.
Who was Richard Kite and what was his role in the Kite v. EBMUD case?
Richard Kite was the claimant in the case Kite v. East Bay Municipal Utility District where he sought workers’ compensation benefits concerning his disability due to an industrial injury.
What are the relevant dates regarding the surgeries and injuries of the forklift driver?
The forklift driver sustained injuries to both hips by August 14 2007. He underwent right hip replacement surgery in August 2007 and left hip replacement surgery in August 2009.
What diagnosis was made by Dr. Cheng QME regarding the forklift driver’s condition?
Dr. Cheng found that the forklift driver had bilateral osteoarthritis that was permanent and stationary.
What was the rating assigned to each hip by Dr. Cheng?
Dr. Cheng rated each hip at 20% Whole Person Impairment (WPI).
Which method did Dr. Cheng choose to combine the impairments and what is the significance of this choice?
Dr. Cheng chose to combine the impairments through simple addition rather than using the Combined Values Chart. This choice is significant because it reflects the physician’s discretion in determining the most appropriate method based on the specific case.
What was the employer’s action in November 2010 related to the forklift driver’s employment?
In November 2010 the employer sent a return-to-work offer after the forklift driver had already returned to work.
What are the key issues presented in this case?
The key issues are: 1. Whether bilateral hip impairments should be combined using simple addition vs. the Combined Values Chart and 2. Whether a late return-to-work offer triggers increased permanent disability (PD) benefits when the employee has already returned to work.
Summarize the key holdings regarding the combining of impairments. What does the AMA Guides state?
- On combining impairments: The AMA Guides do not mandate the use of the Combined Values Chart. Doctors have the discretion to choose the appropriate combination method. Dr. Cheng’s use of simple addition was deemed proper due to the synergistic effect of bilateral hip injuries.
What was the key holding regarding the late return-to-work offer?
The text does not provide the full key holding regarding the late return-to-work offer. Additional context is required to complete this answer.
Explain the term ‘synergistic effect’ as used in the context of bilateral hip injuries.
The term ‘synergistic effect’ refers to the interaction of multiple impairments that produces a combined effect greater than the sum of their individual effects. In this context the bilateral hip injuries may lead to compounded limitations and impairments that justify the choice of simple addition for rating purposes.
What is the requirement for a late return-to-work offer according to the statute?
The statute must be interpreted literally requiring the return-to-work offer to be made within 60 days of the Permanent Disability (PD) status.
Is an employee entitled to increased PD benefits if they return to work before Permanent Disability status is determined?
Yes an employee who returns to work before the Permanent Disability status is still entitled to the 15% increase in PD benefits if no timely offer is made.
