Worker's Compensation/Disability Flashcards
Ryans v. Lowell (1984)
Ryans had been receiving benefits; required to be examined by Dr. Lowell after he requested more benefits; he was asked to do a variety of things (get records, sign releases) and never got back to the Commission so benefits were terminated
He sued saying Dr. made an improper diagnosis and that he made recommendations to the Commission which subsequently terminated his benefits
TC found in favor of Commission/Lowell and he appealed
Can the commission listen to the recommendations of experts when considering benefits and program requirements?
Yes, including outside consultants 1.) Nothing prohibits an institution from retaining consultants to obtain information and guidance to determine if a client should get benefits and/or course of tx or if tx is necessary or when to terminate benefits 2.) Psychiatrist owed no duty of care to the claimant but only to the client (rehab commission) who was not suing them 3.) Physicians can be sued for malpractice if the party that employs them is injured by the
Ervin v. American Guardian Life Assurance Co (1988)
Filed suit on behalf of her husband (EKG guardian performed showed abnormalities) and the Dr. was negligent by not discovering them and/or reporting them to her husband (he died a month later); she claimed he was owed a duty under physician/patient relationship
TC found in favor of American noting there was no relationship b/c he was acting as a contractual agent of American to determine terms of life insurance; she appealed
Is a professional physician/pt relationship a legal prerequisite to basing a cause of action in professional malpractice against physician? Does the physician, who at the request of insurance company who employed him, owed a duty to the applicant to discover and disclose heart abnormalities?
Yes/No. TC ruling affirmed
1.) No duty was owed to the decedent by the doctor because he was employed by American to determine life insurance (not employed to make a diagnosis or treat the applicant) so there was an absence of physician/pt relationship 2.) Had a contractual obligation to American but not to decedent
When conducting an evaluation for a 3rd party, and report results to 3rd party, there is not a pt/physician relationship with the examinee
MA Mutual LIfe Insurance Co v. Ouellette (1992)
Ouellette was an optometrist who had disability insurance with Mutual; he was convicted of lewd behavior with a minor and incarcerated- part of plea was to sell his practice and surrender his license
Filed for total disability citing he had “atypical paraphilia and primary pedophilia”- court said undisputed he had this but never sought therapy until his incarceration
Mutual denied his requests noting his inability to perform the duties of his profession was due to legal involvement and incarceration and not illness or disease
TC agreed with Mutual and he appealed
Can antisocial behavior, due to an impulse control disorder, be considered grounds for disability payments?
No. 1.) Court said mental disorder did not preclude him from engaging in substantial gainful activity- conversely, record showed that his disorder had not affected his ability to work in 10 years before conviction. 2.) His incarceration interrupted work activities, not a mental disorder
Disability policies provide coverage for factual disabilities, not legal disabilities
Damascus v. Provident Life & Accident Insurance (1996)
1980- signed up for Provident Accident/life insurance; in 1990 complaint with board of dentistry was filed due to MI and inappropriate care of clients; 1991 placed on five years probation where he was supervised and in therapy
Several days later another accusation was filed with the board noting repeated negligent and unprofessional acts (MI was not mentioned)
1995 his license was revoked due to negligent, unprofessional bx and excessive prescribing of drugs; he filed request with Provident saying board found he was MI which prevented him from practicing and later filed suit against Provident; Provident said his license revocation was not due to MI but negligence and was legally disabled due to actions of state dentistry board
TC granted for insurance company
When both MH and unprofessional conduct are alleged, can a provider be owed disability payments?
COA reversed. There was a dispute in this case about if he was mentally competent to practice after the loss of his license
1.) Presence of legal or social impediments does not negate the possibility of future disability
1.) Need to determine what the cause of the disability is (misconduct/negligence or MI) to determine if legally or medically disabled
Cleveland v. Policy Management Systems Corp (1999)
Cleveland had a stroke while working for PMS, lost her job and got SSDI due to disability from stroke; later improved and went back to work, which she reported to SSA and they then denied her SSDI application; she was fired a few days later; eventually re-awarded SSDI benefits because couldn’t work due to her condition
Week before SSDI award, she challenged her termination from PMS (via ADA) noting they terminated her w/o accommodating her disability; DC found in favor of PMS noting that by applying for/receiving SSDI she conceded she was totally disabled which did not allow her to prove an essential element of ADA (she could perform essential job duties with reasonable accommodation); COA affirmed; SCOTUS granted cert
Does application for and receipt of SSDI bar alleged victims of discrimination from simultaneously pursing a claim against their former employers under ADA?
No. SSDI and ADA claims do not conflict in such a way to bar anyone from raising them jointly
1.) SSDI and ADA both help ppl with disabilities but in different ways- SSDI provides monetary benefits to those who can’t work due to a disability (can’t do their work or any other kind of substantial gainful work); ADA seeks to eliminate unwarranted discrimination against disabled individuals to guarantee equal opportunity and provide nation with increased productivity 2.) When considering SSDI eligibility, ADA question (if could have been capable of doing the job with reasonable accommodations) is not considered; thus, the “reasonable accommodation” issue is left open for resolution in an ADA claim
Even when there appears to be a contradiction, still must have opportunity to present their cases (don’t want to put a per se bar on it because there are situations where they could exist together)
Black and Decker Disability Plan v. Nord (2003)
Nord was an employee in a sedentary position and dx by doctor with degenerative disc disease, pain meds not working so doctor recommended he cease work and consult with orthopedist; he filed claim which was denied; he appealed and during appeals, an independent neurologist agreed with his diagnosis and pain but said he could still work, so Black and Decker again denied his claim
Federal DC ruled against him; 9th COA reversed and found in favor of Nord,citing “treating physician rule”
Black & Decker appealed to SCOTUS
Should special weight be given to a patient/employee’s treating physician in disability claims?
No. SCOTUS vacated and remanded. Employee Retirement Income Security Act (EIRSA) does not require plan administrators to accord special deference to the opinions of treating physicians.
1.) Don’t need to give special deference or have a heightened burden of explanation when they reject a treating physician’s opinion 2.) BUT cannot refuse to consider claimant’s reliable evidence, including opinion of treating physician
Biestek v. Berryhill (2019)
Biestek worked as carpenter/construction but stopped in 2005 due to degenerative disc disease, Hep C and depression; applied for benefits but SSA and Administrative Law Judge (ALJ) denied his application
6th Circuit affirmed DC decision noting substantial evidence that he did not meet back pain related impairment requirement and the ALJ properly evaluated testimony of medical and vocational experts
Vocational experts: determine which jobs if any they can perform, typically labor economists and ALJ asks them questions about if the claimant could find work
Vocational expert in this case said he could do two jobs that existed in substantial numbers
Biestek’s lawyer wanted to see the data underlying the opinion but they declined which was supported by ALJ
He appealed-SCOTUS finally agreed to review- He argued failure to produce underlying data upon request renders an expert’s opinion in adequate under all circumstances to support a finding of no disability
During a SSI or SSDI application, does a vocational expert’s testimony count as “substantial evidence” of “other work” if the expert doesn’t provide underlying data on which testimony is premised? Does substantial evidence standard required in SSDI require experts to share data used to deny benefits claims?
No. SCOTUS said refusal of expert to share underlying data during SSDI benefits hearing does not categorically preclude the testimony as counting as “substantial evidence”
If testimony amounts to “substantial evidence” requires a case by case determination and cannot be subject to categorical rule as Biestek proposed (expert could be highly credible and refuse to produce underlying data)
Mere addition of a request for data does not render an expert’s testimony as categorically inadequate
