In an effort to combat opioid addiction, the Wolf Administration recently rolled out a set of opioid prescribing guidelines to assist health care providers treating workers’ compensation patients. Highlighting the need for reform, Governor Wolf stated: “[i]n 2017, there were more than 174,216 workers’ compensation claims made in Pennsylvania, and our state ranks third highest in the nation in the percentage of injured workers who become long-term opioid users.” The Administration reported that workers who received longer-term opioid prescriptions for work-related lower back injuries had a substantially longer duration of temporary disability.

Accordingly, it is no surprise that the average lost time claim for injured workers, prescribed with opioids, is 900% higher than injured workers who were not prescribed the drug. To improve these numbers, the Administration identified the following objectives for the guidelines:

  • To promote the delivery of safe, quality health care to injured workers;
  • To ensure patient pain relief and functional improvement;
  • To be used in conjunction with other treatment guidelines, not in lieu of other recommended treatment;
  • To prevent and reduce the number of complication caused by prescription medication, including addiction; and
  • To recommend opioid prescribing practices that promote functional restoration.

The guidelines include recommendations for the treatment of acute, sub acute, post-operative pain, and chronic pain. The Wolf Administration released a detailed seven-page instruction on how health care providers should approach treatment for such conditions. Generally, under the guidelines, opioid prescription should be done in combination with other treatment options, at the lowest dose, and for the shortest length of time possible.

While the Administration’s newly issued guidelines are an important step toward fighting opioid addiction in the Commonwealth, it is important to remember that they are just that—guidelines. They are not legally binding and are intended only to supplement, not replace clinical judgment. By following these guidelines, however, health care providers will play a significant role in promoting safe and effective treatment for injured workers so that they may return to work as soon and as safely as possible.

Should you have a question regarding this article, please feel free to reach out to a member of our Labor and Employment Group.

 

The Commonwealth Court issued several interesting “unreported memorandum opinions” in the past several weeks.  The Court revised its Internal Operating Rule 414 several years ago, allowing unreported or unpublished opinions to be cited and relied upon by counsel, for persuasive value, but not as binding precedent in future cases.  Thus, it is sometimes important to pay attention to unreported cases, which the Court has chosen not to circulate more broadly, to advance arguments and defenses in pending cases.

In McKee v. WCAB (Geisinger Medical Center), the employee, a nursing assistant, sustained an admitted right knee meniscus tear, while moving a patient from a wheelchair to a stretcher.  She underwent an arthroscopic surgery two months later, followed by a total knee replacement, another three months after that.  The employer refused to accept the total knee replacement, and the employee sought to amend the injury description to include “aggravation of pre-existing osteoarthritis.”  Her medical records revealed a lengthy history of knee complaints, which included as part of the work injury, at least two prior surgeries.

The employer offered medical evidence, found credible by the WC Judge, that the work incident, despite causing a discrete meniscal tear, did not cause or materially worsen the underlying arthritic condition. In legal terminology, the work incident was not a “substantial contributing factor” in her needing a knee replacement.  Specifically, Claimant’s medical expert could not provide a credible explanation of any “biomechanical, biochemical, tissue or cellular changes in the knee” that would demonstrate an aggravation of the knee osteoarthritis, which necessitated the joint replacement surgery.

In a second unreported case, Kozlowski v. WCAB (Lehigh Valley Imaging), the Court found that a medical secretary who works in a seated position while scheduling and checking in patients, answering phone calls, filing and faxing, did not sustain a work injury, when she spontaneously experienced a sudden onset of low back pain while scheduling patients at work.  The employee had injured her low back several years prior (but could not recall how that injury occurred).  The medical evidence she submitted to support her claim, reflected only the history that “her chair is very uncomfortable and is the cause of her pain.”  Her physician also noted that her radiating low back pain was “related to repetitive activity” and “prolonged sitting” at work.

The employer’s expert diagnosed a non-work related, non-specific low back pain with leg pain and numbness, and pre-existing symptomatic mild lumbar disc degeneration.  He felt that there was no precipitating event, trauma or repetitive activity to suggest that Claimant suffered a work-related lumbar spinal injury.  The Court found no error in the Judge’s acceptance of the employer’s evidence because Claimant failed to meet her burden of proof by presenting unequivocal medical testimony establishing a causal connection between her injury and the alleged work-related cause.  Such evidence was necessary, because there was no obvious connection and no “act requiring force or strain” that had caused her pain.

The above fact patterns are fairly typical in today’s aging workforce and the holdings in these cases, may be helpful in defending against various non-work-related conditions or circumstances.

Should you wish to discuss a particular workers’ compensation case or issue, please do not hesitate to contact Paul Clouser, Denise Elliott or Micah Saul, in our Lancaster office.

In a recent case, decided on June 19, the Supreme Court of Pennsylvania granted appeal to clarify the scope of subrogation reimbursement under the Pennsylvania Workers Compensation Act (the “Act”).

By way of background, the Act makes an employer liable for paying disability benefits and medical expenses of an employee who sustains an injury in the course of his/her employment, regardless of whether the employer was negligent. Under Section 319 of the Act, however, employers are entitled to reimbursement for certain expenses where a third party caused the employee’s injury. Specifically, an employer (or its insurance carrier) has the absolute right to collect the workers’ compensation benefits it paid if the employee recovers from the third party who caused the injury. This is known as subrogation.

The Supreme Court in its recent decision addressed the scope of the reimbursement under Section 319 of the Act. Section 319 states, in pertinent part:

Where the compensable injury is caused in whole or in part by the act or omission of a third party, the employer shall be subrogated to the right the employe…against such third to party to the extent of the compensation payable under this article by the employer; reasonable attorney’s fees and other proper disbursements incurred in obtaining a recovery or in effecting a compromise settlement shall be prorated between the employer and employe…Any recovery against such third person in excess of the compensation theretofore paid by the employer shall be paid forthwith to the employe…and shall be treated as an advance payment by the employer on account of any future instalments of compensation.

The critical question the Court addressed was whether the term “future instalments of compensation” encompasses both future disability benefits and payment of future medical expenses. In other words, the Court addressed whether an employer can credit the excess third part recovery against both future disability and future medical payments.

The Commonwealth Court, our intermediate appellate court, concluded that the term “instalments of compensation” encompasses both disability and medical expenses. The Commonwealth Court reasoned that since the objective of subrogation is to protect the presumably innocent employer from ultimate liability, the credit should apply to both medical expenses and disability benefits.

In its June 19th ruling, the Supreme Court disagreed. The Court’s assessment of the issue was in some ways quite straightforward, but it requires an understanding of how an employer must pay disability and medical expenses. The long and short of it is that disability benefits are required to be paid in installments, while medical expenses are not. Accordingly, the Court found that the term “instalments of compensation” under Section 319 spoke for itself and meant “compensation that is paid in installments” which can only include disability benefits, not medical expenses.

In a nutshell, the Court found that when a workers’ compensation claimant recovers proceeds from a third-party settlement under Section 319, the employer (or the insurance carrier) is limited to drawing down against that recovery only to the extent that future disability benefits are payable to the claimant.

What does this mean in plain language?

If the third-party recovery exceeds the employer’s accrued subrogation lien (workers’ compensation payments made prior to resolution of the third-party claim), the employer can treat the excess recovery (which will be paid to the employee) as a credit against future workers’ compensation payments. However, the credit may only be taken against future disability (aka wage loss or indemnity) benefits. There may be no credit taken against future medical benefits.

For this reason, employers looking to settle with an employee who has sustained a serious work injury that was caused by the negligence of a third party should proceed with caution! This is especially true when only the wage loss portion of the claim is resolved in the settlement and the medical portion is left open (either indefinitely or for some set time in the future). When resolving a claim in this way, employers must remember that no excess recovery credit can be taken against future medical benefits. This new reality should be factored into the valuation of the case.

If you need any assistance with subrogation rights or have any questions regarding this Article, please feel free to reach out to any member of our Labor and Employment group for assistance.

The first cases addressing the impact of Pennsylvania’s Construction Workplace Misclassification Act (“CWMA”) in the context of the Pennsylvania’s Workers’ Compensation Act, have finally reached the Appellate Courts. The CWMA, which became effective on February 10, 2011, imposes criminal and administrative penalties for the misclassification of employees as “independent contractors” at commercial and residential construction sites in Pennsylvania. “Construction” is broadly defined to include “erection, reconstruction, demolition, alteration, modification, custom fabrication, building assembly, site prep and repair work,” at both residential and commercial sites.

The CWMA details a multi-prong test for determining whether a worker is an “employee” or “independent contractor” for purposes of the Act:

  1. The individual must have written contract to perform such services;
  2. The individual must be free from control or direction over the performance of such services, both by contract and in fact;
  3. The individual must be customarily engaged in an independently established trade, occupation, profession or business, with a business location separate from the location of the person for whom services are being performed; and
  4. The individual must maintain liability insurance during the term of the contract of at least $50,000.

What had been unclear for some time, was whether the formal requirements of the CWMA would supplant the common law definition of “employee” under the Pennsylvania Workers’ Compensation Act, which had focused primarily on a traditional “direction and control test” for distinguishing between independent contractors and employees. This issue was recently addressed in D & R Construction v WCAB. The Commonwealth Court in D & R Construction ruled that, for injuries occurring at construction sites on or after February 10, 2011, the injured worker will be deemed an employee, unless all of the mandatory criteria are in place for a finding of independent contractor status, pursuant to the CWMA. Additionally, all criteria should be given equal weight by the WC Judge, and if any one is absent, the injured worker will be deemed to be an “employee” of the business entity requesting the services.

In light of this ruling and pending clarification by the Pennsylvania Supreme Court, it is critically important that employers utilizing subcontractors at Pennsylvania residential and commercial project sites, make sure that such subcontractors and their employees meet the definition of “independent contractors” under the CWMA and are properly insured for both liability and workers’ compensation. Contractual indemnification language may also be advantageous, in the event of an unexpected construction site injury or claim.

For further information on construction site injuries or guidance, please contact Micah Saul, Denise Elliott, or Paul Clouser in the Lancaster office.

What should a Pennsylvania employer do when an employee seeks workers’ compensation benefits after injuring himself by engaging in risky behavior at work?  Companies may be tempted to take the position that workers’ compensation isn’t available to workers who hurt themselves by intentionally doing dangerous things on the job.  Recently, however, the Commonwealth Court found that Pennsylvania’s Workers’ Compensation Act requires a more nuanced analysis.

In Wilgro Services, Inc. v. WCAB, the claimant was employed as an HVAC technician.  He was assigned to work on air conditioning equipment located on a customer’s roof.  Several co-workers were performing other jobs on the customer’s roof at the same time.  Unfortunately for the claimant, they finished their work before he finished his.  Not realizing that claimant was still working, the other employees removed the ladder that was used to access the roof and left the job site.

The claimant was left stranded on the roof, with no apparent way down.  Eventually, he decided that his best option was to jump to the ground 20 feet below.  His flight of fancy did not end well.  The claimant sustained severe injuries to his feet and back.

The employer denied the claimant’s application for workers’ compensation benefits.  It reasoned that by jumping from the roof, he abandoned his employment.  The employer argued that such conduct was not among the claimant’s job duties and his leap from the roof did nothing to further the company’s interests.  The case eventually made its way to the Commonwealth Court on appeal.

The Commonwealth Court ultimately disagreed with the company’s arguments.  Instead, it determined that leaving the work site was a necessary element of any job, including the claimant’s.  Since a ladder was not readily available and because claimant jumped from the roof in a legitimate (but perhaps foolish) attempt to leave work, the Court found that his actions were not so far removed from his usual employment as to constitute departure from his job duties.  Thus, he was entitled to workers’ compensation benefits.

In reaching its decision, the Commonwealth Court analyzed a similar case that resulted in a different outcome.  In Penn State University v. WCAB, an employee was on his lunch break when he decided to jump down a flight of stairs on a whim for his own amusement.  He too was injured.  Unlike the Wilgro claimant, however, this employee was not entitled to workers’ compensation benefits.

The Commonwealth Court determined that although work injuries that occur during an employee’s on-premises lunch break are generally compensable unless they’re engaged in activity wholly foreign to the employer’s business.  Jumping down a flight of stairs on a lark, the Court held, was an extreme, high-risk action that sufficiently removed the employee from the course and scope of his employment.

So, if an employee is injured when intentionally engaging in high-risk conduct that is not overtly work-related, employers should assess all the facts and circumstances at hand before deciding whether to accept the claim.  In cases where an employee had some work-related reason to perform the dangerous act, they could be entitled to workers’ compensation benefits.

An ever-increasing number of employers are sponsoring wellness incentives as a means of encouraging employees to developing healthy habits. In turn, employers gain healthier, more productive work forces.  Wellness incentive programs aren’t without their risks, however.  In this podcast, Denise Elliott discusses whether employees are covered by workers’ compensation benefits for injuries sustained while participating in an employer-sponsored wellness program.

Picture this.  You have just settled a problem workers’ compensation case and you or your carrier have disbursed settlement checks totaling $100,000 in exchange for a full and complete compromise and release of “any and all past, present and/or future benefits, including but not limited to, wage loss benefits, disfigurement benefits, medical benefits, or any other monies of any kind including, but not limited to, interest, costs, attorney’s fee and or penalties for or in connection with the alleged 08/12/2015 work injury claims Employee may have with or against Employer…”

Several months later, the same employee sues your company in Federal Court for violating his FMLA rights, retaliation for exercising FMLA rights, and for wrongful discharge based upon unlawful retaliation for filing a workers’ compensation claim in violation of Pennsylvania common law.

“What on Earth,” you say.  “But we just paid out a $100,000 settlement!” Unfortunately, the employee may pursue these additional claims because they were not properly released at the time of the workers’ compensation settlement.  The United States Court of Appeals for the Third Circuit recently held that a Compromise and Release Agreement under the Pennsylvania Workers’ Compensation Act, covers only those matters which “may fairly be said to have been within the contemplation of the parties when the release was given.”  Zuber v. Boscov’s, No. 16-3217 (United States Court of Appeals for the Third Circuit, opinion filed September 11, 2017).  In Zuber, the agreement referenced only work injury claims and as such, the settlement document was only read to prevent the employee from seeking additional money related to an alleged work injury claim.  Likewise, the employee certification page of the subject agreement specifically stated that the employee “understands that the Compromise and Release is a settlement of his workers’ compensation claim only” and thus, the document was “unambiguously” a specific and limited release rather than a general release.

The above problems could have been avoided, of course, by utilizing separate release documents, coupled with a properly worded letter of resignation, to make it clear that the employee was indeed consenting to and bargaining for a global resolution of all employment issues, including a full compromise and release of his workers’ compensation rights, and a settlement and release of other potential employment claims under other laws and statutes including the FMLA, ADA, ADEA and wrongful discharge.

Often times defense counsel assigned by an insurance carrier in workers’ compensation matters will proceed to settlement without proper consideration of other ancillary employment matters and exposures.  Accordingly, employers must be vigilant in making sure that their interests are properly protected and that employees who accept workers’ compensation settlements do not return to court seeking other costly benefits or remedies. Fully insured employers should insist that the carrier appointed attorney consult with employment law counsel on the settlement. Employers who are self-insured or have large deductible plans, who have more leeway in selecting defense counsel should insist on hiring workers’ compensation defense counsel who are familiar with employment laws and statutes, to avoid the result in the Zuber case.

For further information, on this subject, please feel free to contact Denise Elliott, Micah Saul or Paul Clouser, in our Lancaster office.

Prior to June 20, 2017, a powerful tool was available to employers and workers’ compensation carriers to cap exposure on long term workers’ compensation claims.  That tool, provided by the Act 44 amendments in 1996, was called an impairment rating evaluation (IRE) and generally worked like this: once a claimant had received 104 weeks of total disability benefits and had reached maximum medical improvement, the employer could request an IRE.  A doctor was assigned to perform the evaluation and was required by statute to consult the most recent version of the American Medical Association’s guidelines.  If, under those guidelines, the IRE doctor determined that the claimant’s injury caused less than 50% whole body impairment, the employee’s workers’ compensation benefits could be modified from total to partial disability status, with a corresponding time limitation on future indemnity benefits.  The process was helpful in resolving serious injury cases, where the employee was too disabled to work but had reached a medical plateau.

Pennsylvania workers’ compensation law places no cap on the length of time in which a claimant can receive total disability benefits.  Partial disability benefits, however, are capped at 500 weeks.  Thus, via the IRE process, it was possible to prevent a claimant from receiving total disability benefits indefinitely by modifying their status to a maximum of 500 weeks of partial disability benefits.

On June 20, 2017, the Pennsylvania Supreme Court changed all of this with its decision in Protz v. Workers’ Compensation Appeal Board.  In that case, the Court held that the IRE process was unconstitutional because the legislature is not permitted to delegate its authority to issue impairment rating guidelines to a non-legislative body (i.e. the American Medical Association).  Since the IRE provisions are legislated to be applied under the most current version of the American Medical Association guidelines (which are frequently updated), the Supreme Court struck down the IRE provisions of Pennsylvania’s Workers’ Compensation Act as an unconstitutional delegation of legislative authority.

The immediate impact of Protz on future claims is clear – unless the Pennsylvania Supreme Court reconsiders and reverses its decision, the IRE process is no longer available to employers and workers’ compensation insurance carriers.  This means that it will be considerably more difficult to cap exposure on workers’ compensation claims where an employee has received 104 weeks of temporary total disability benefits and has reached maximum medical improvement.  Indeed, a reversion to the use of vocational experts to establish job availability is likely, where light duty work at the time-of-injury employer is not available.  For claims where the IRE process was used prior to the court’s decision in Protz, outcomes are less clear.

Employers who are litigating a modification of benefits based on an IRE would do well to withdraw the modification petition.  Now that the IRE process has been deemed unconstitutional by the Pennsylvania Supreme Court, an IRE can no longer serve as a valid basis for future modification of benefits.  Without a valid basis to litigate a modification petition, employers who continue to rely on an IRE in litigation are exposed to penalties and unreasonable contest fees.

Likewise, employers who are actively seeking to obtain an IRE should refrain from doing so.  Again, the evaluation cannot provide a valid basis for modification of benefits, and the Bureau of Workers’ Compensation has also indicated that it will no longer assign IRE physicians in the wake of Protz.

So what about claims where benefits have been modified or a claimant’s status has been changed as the result of a past IRE where the claimant failed to appeal?  Employers likely have no affirmative obligation to restore the pre-IRE, pre-modification status quo, but claimants may file petitions seeking to do just that.  While Pennsylvania law typically prevents the retroactive application of judicial decisions to matters that have been fully and finally determined, it is unclear how workers’ compensation judges, the Appeal Board, and Pennsylvania Courts will approach the issue. In cases where an employer obtained a modification of benefits because of an IRE and the claimant did not appeal, the doctrine of res judicata may serve to prevent re-litigation of the case.

We will continue to monitor the status and impact of Protz; additional developments will be reported here on our blog.

Employers often shy away from discharging employees for disciplinary reasons when those employees are receiving workers’ compensation benefits, such as in instances where the employee is working a modified duty assignment.  However, such employees can and should be held to the same standards as other employees, including compliance with applicable policies and procedures.  Additionally, so long as the discharge is found to be related to the disciplinary violation, any subsequent loss of earnings will be deemed to be unrelated to the work injury, thus rendering the discharged employee ineligible for reinstatement of workers’ compensation wage loss benefits.

In a recent unreported Commonwealth court case, (Waugh v. WCAB, No. 702 C.D. 2016), the Claimant was employed as a certified nursing assistant (CNA) at a medical center.  She had sustained an accepted work injury to her right arm, when a patient grabbed and twisted her arm in the course and scope of her employment.  She underwent two surgeries and eventually returned to work in a modified duty capacity.

While working modified duty, Claimant was reprimanded for acting outside the scope of her employment for administering medication to a patient.  Several months later, there was a similar incident, in which Claimant applied a tourniquet to a patient while assisting a phlebotomist, who was attempting to draw blood.  Employer’s policy in the event a phlebotomist cannot locate a vein, is to call a specialized IV team to insert the needle and draw blood.  Claimant was terminated for this second instance of acting outside the scope of her employment.  Despite her protests that she was “only trying to help,” the termination was held to be proper, as was the workers’ compensation determination denying reinstatement of benefits.

The Court reaffirmed the longstanding rule that a lack of “good faith” on the part of the claimant, is sufficient to deny reinstatement of workers’ compensation wage loss benefits.  This is so, even where unemployment benefits are awarded, on the basis that the employer had not established a case of willful misconduct under the Pennsylvania Unemployment Compensation Act.

The determination of good faith or bad faith is obviously “fact sensitive,” but in situations where the employer would discharge the employee absent a workers’ compensation backdrop, this factor alone should not discourage the employer from taking the appropriate disciplinary action, including discharge.

For further information, on this subject, please feel free to contact Denise Elliott, Micah Saul or Paul Clouser, in our Lancaster office.

As a general rule, an employee who is injured while commuting to or from work is not entitled to workers’ compensation benefits, as the injuries are not deemed to be “in the course and scope of employment” by virtue of the longstanding “going and coming rule.”  There are exceptions to the rule, including: (1) situations where there is no fixed place of employment and the employee is therefore deemed to be a “traveling,” as opposed to “stationary” employee; (2) the employee is on a special assignment for the employer; (3) the employment contract includes transportation to and from work; or (4) special circumstances exist, such that the employee was furthering the interests of the employer when injured.

In an interesting recent case, the Commonwealth Court awarded compensation under the special circumstances exception, despite the fact that Claimant was commuting to work at the time of his motor vehicle accident.

The employee, Miller, was a salaried director of maintenance services, exempt from the overtime requirements of the Fair Labor Standards Act. His regular work hours were from 7:00 a.m. to 3:30 p.m., Monday through Friday.  The employer maintained a four building campus as a facility for senior residents.  The campus had a system of security cameras, whose maintenance was an important priority for the employer.

Miller testified that in addition to his regular hours, he would be called in while off-site two to three times monthly.  In such instances, he received “comp time,” in lieu of additional pay.  The comp time accrued from the time he answered the phone, until he arrived back at home.  On the morning in question, Miller was “feeling very poor and weak.”  He stayed home past his usual 7:00 a.m. start time, with the intention of taking a sick day.  However, the employer called and requested that he stop in to reset the security cameras, after which he could return home for the rest of the day.  En route to the facility, Miller became nauseous and veered off the road, hitting a telephone pole.  He sustained multiple injuries, including a broken eye socket, broken pelvis, ruptured bladder and multiple scars and disfigurements.

The key issue before the WC Judge was whether Miller was commuting to a fixed place of employment, such that the “going and coming rule” barred his claim, or whether special circumstances existed, such that an exception to the rule applied.

Since “but for” the security camera emergency, Miller would not have made the trip to work, the Judge, and subsequently the Commonwealth Court, concluded that this factor brought the case within the “special circumstances” exception to the going and coming rule, and awarded benefits.

The key takeaway is that commuting cases are often fact sensitive and need to be analyzed carefully, to determine whether workers’ compensation benefits are appropriate.  For example, construction workers who might at first glance appear to be “traveling” as opposed to “stationary” employees, are frequently deemed to be “stationary,” if they are working at only one job site at a time.  As such, the “going and coming” rule might preclude compensation in such cases, absent special circumstances.

Please contact Paul Clouser, Denise Elliott or Micah Saul, if you have questions about situations in which your employees may or may not be deemed to be “in the course and scope” of their employment, pursuant to the Pennsylvania Workers’ Compensation Act.