Compensability

Question 1

What are the four basic conditions that must be met for a workers’ compensation claim to be established?

Answer 1

1. There must be an “injury” (physiological or psychological harm)
2. There must be an employment relationship
3. The injury must have been caused by the employment (AOE)
4. The injury must occur in the course of the employment (COE)

Question 2

What is the definition of an “injury” according to the Labor Code?

Answer 2

• Any injury or disease arising out of employment
• Any “derivative” injury caused by the treatment of an injury arising out of employment
• Any reaction to or side effect from preventive health care the employer provides to healthcare workers

Example: A worker develops a skin rash from using a chemical provided by the employer for cleaning purposes.

Question 3

What is the difference between a specific injury and a cumulative injury?

Answer 3

• Specific injury: Occurs as the result of a single incident or exposure
• Cumulative injury: Results from repetitive trauma (mental or physical) over a period of time

Question 4

What is considered “first aid” in workers’ compensation?

Answer 4

Any one-time treatment and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require medical care

Question 5

What is an “occupational disease” in California workers’ compensation?

Answer 5

A disease that in whole or in part was caused by work, including diseases that may have occurred without a relationship to work under other circumstances

Question 6

What are the seven types of injuries specifically excluded from compensation by the Labor Code?

SSSAFRP

Answer 6

1. Injuries caused by alcohol or illegal controlled substances
2. Intentionally self-inflicted injuries
3. Suicide
4. Injuries from altercations where the injured employee is the initial aggressor
5. Injuries from commission of a felony
6. Injuries from off-duty recreational activities
7. Certain psychiatric injuries claimed after notice of termination/layoff

Question 7

What is an “aggravation” of a pre-existing non-industrial condition?

DMC

Answer 7

When a worker suffers an on-the-job aggravation of a non-industrial pre-existing disease or underlying condition, causing a temporary or permanent increase in disability, creating a new need for medical treatment, or requiring a change in the existing course of treatment

Question 8

How is the “date of injury” (DOI) determined for a specific injury vs. a cumulative injury?

Answer 8

• Specific injury: The date on which the incident or exposure occurred
• Cumulative injury: The date when the employee first suffered disability from the exposure, and either knew, or should have known, that the disability was caused by present or previous employment

Question 9

What does “arising out of employment” (AOE) mean?

Answer 9

The injury must have been caused by the employment

Question 10

What does “occurring in the course of employment” (COE) mean?

Answer 10

At the time of the injury, the employee must have been performing a service that grew out of and was incidental to the employment

Question 11

What are the five major types of causation?

DCAPA

Answer 11

1. Direct Causation
2. Contributing Cause
3. Acceleration
4. Precipitation
5. Aggravation

Question 12

What principle applies when considering pre-existing conditions or risk factors?

Answer 12

The employer “takes employees as they find them” - they cannot avoid liability by claiming the injury wouldn’t have happened if the worker had been in a different physical or emotional condition

Question 13

What factors should be considered when assessing causation for occupational diseases?

Answer 13

• Kind of exposure involved
• Level, frequency, and duration of exposure
• Presenting signs or symptoms consistent with the exposure and disease
• Medical literature indicating association between the disease and exposure

Question 14

What are “presumptions” in workers’ compensation for certain groups of employees?

Answer 14

Specific conditions (e.g., hernias, pneumonia, tuberculosis, heart disease, cancer) are presumed to be work-related for certain employees like firefighters, peace officers, and correctional employees

Question 15

What is the threshold for causation in psychiatric injuries?

Answer 15

The employee must demonstrate that the events of employment were the “predominant cause” (more than 50%) among all combined causes of the psychiatric injury

Question 16

What is the employment duration requirement for psychiatric injury claims?

Answer 16

The employee must have been employed by the employer for at least six months (need not be continuous) unless the injury was caused by a sudden and extraordinary employment condition

Question 17

What is the “substantial cause” requirement for psychiatric injuries resulting from violent acts?

Answer 17

The actual events of employment must have contributed at least 35% of the causation from all sources combined

Question 18

What types of psychiatric injury claims are prohibited?

Answer 18

• Claims substantially caused by lawful, non-discriminatory, good faith personnel actions
• Claims filed after notification of termination or layoff (with some exceptions)

Question 19

What additional information should be gathered when evaluating psychiatric injury claims?

Answer 19

• Developmental history
• Personal problems
• Job satisfaction
• Performance reviews
• Reasons for leaving other positions
• Level of functioning in home, academic, and social settings

Question 20

Under what conditions can a psychiatric injury claim filed after notice of termination or layoff be compensable?

Question 21

What additional information should be gathered when evaluating psychiatric injury claims?

Answer 21

• Developmental history
• Personal problems
• Job satisfaction
• Performance reviews
• Reasons for leaving other positions
• Level of functioning in home, academic, and social settings

This information is crucial for assessing the factors contributing to the psychiatric injury claim.

Question 22

Under what conditions can a psychiatric injury claim filed after notice of termination or layoff be compensable?

Answer 22

• The injury was the result of sudden and extraordinary events of employment
• The employer had notice of the injury before the notice of termination or layoff
• Medical records before the notice contain evidence of treatment of the psychiatric injury
• A trier of fact has found sexual or racial harassment
• Evidence that the DOI is after the notice but before the effective date of termination

These conditions must be met for a psychiatric injury claim to be compensable after notice of termination or layoff.