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H&W New York Workers' Compensation Defense Newsletter
Vol. 3, Issue 3

Court of Appeals Corrects Standard for Permanent Total Disability

On 9/6/18, New York State’s highest Appellate Court, the New York Court of Appeals, decidedWohlfeil v. Sharel Ventures.  This decision unanimously reverses an 11/16/17 Appellate Division decision which held that a claimant is permanently totally disabled unless he or she can engage in “gainful employment, not some undefined type of limited sedentary work.”  This decision by the Court of Appeals returns the standard for determining permanent total disabilities to what we believe is the correct standard, where a claimant is not permanently totally disabled if there is any form of work in the labor market he or she can physically perform.  (This standard is separate from and should not be confused with the standard for statutory permanent total disabilities.)

Appellate Division Allows Credit of SLU Assigned to Ankle Against Knee SLU

On 9/6/18, the Appellate Division, Third Department, decided Genduso v. New York City Department of Education.  This decision is notable primarily for what we believe to be an error by the Court in describing how schedule loss of use awards are assessed for ankle injuries. 

Claimant had a few claims involving injuries to his right leg: one for the ankle and two for the knee.  He received multiple schedule loss of use awards for the right leg over the years.  In 2013, claimant injured his right knee again and filed a third knee claim.  Claimant’s treating physician opined a 40% schedule loss of use award for the right leg based on the right knee injury in that case.  The Board awarded a 40% loss of use for the right leg, but deducted the previous 20% and 12.5% schedule loss of use awards from the claimant’s other two claims, resulting in a net 7.5% increased loss of use to the right leg. 

Claimant appealed to the Appellate Division, arguing that one of the previous loss of use awards was for a right ankle injury, separate from the right knee involved with his current case.  Based on this, claimant argued that only the previous schedule loss of use awards attributable to right knee injuries should be deducted from his 40% SLU attributable to the right knee.  The Court disagreed, stating that, “Neither the statute nor the Board’s guidelines list the ankle or the knee as body parts lending themselves to separate SLU awards.”  The Court reasoned that a schedule loss of use award for the leg is a schedule loss of use award for the leg regardless of what particular part of the leg is injured. 

We believe the Court’s statement that “Neither the statute nor the Board’s guidelines list the ankle or knee as body parts lending themselves to separate SLU awards” is incorrect because the schedule loss of use guidelines (all three versions) provide separate schedule loss of use calculations for injuries involving knees and feet.  Ankle injuries are generally analyzed as foot schedule loss of use awards rather than leg awards.  As such, the Court’s statement here seems to reflect a misreading of the Board’s schedule loss of use guidelines.  Additionally, the Court’s decision appears inconsistent with the New York Court of Appeals holding inZimmerman v. Akron Falls Park, 29 N.Y.2d 815 (1971).  The Zimmerman decision, issued by New York’s highest Appellate Court, states that a claimant can receive multiple schedule loss of use awards for a limb totaling greater than 100% as long as each award involves separate injury sites which have no impact on each other.  The facts in that case involved a loss of use award to the left arm based on a shoulder injury, and a separate loss of use for a previous amputation to the left forearm.   There appears to be no material distinction between these two cases.

Appellate Division Reminds Board that Excusal of Late Notice is Discretionary

On 9/6/18, the Appellate Division, Third Department, decided Taylor v. Little Angels Head Start.  This case involved a carrier’s defense against a claim based on untimely notice.  It is well known that there are many reasons the Board may invoke to excuse a claimant’s failure to provide timely notice, and the Board regularly does so.  Nonetheless, the Court here highlighted the fact that excusing untimely notice is discretionary.  The Court stated, “The Board is not required to excuse a claimant’s failure to give timely written notice even if [a ground for excusal] is proven; the matter rests within the Board’s discretion.”  As such, even when the record contains evidence allowing for excusal of untimely notice, an argument can be made in appropriate cases that the Board should decline to exercise its discretion to do so.

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Buffalo, NY 14202
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Rochester, NY 14614
585-262-6390
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Full Board Reverses Panel Decision That Provided Exception toDelta Airlines Attachment Decision

 

One year ago we reported on the Board Panel decision in Barbella Environmental Tech, which provided an exception to theDelta Airlines ruling on labor market attachment. The ruling deemed claimants who were still employed by the employer of record to be attached to the labor market without the need to produce proof of same as required by theAmerican Axle decision. The Barbella Board Panel decision narrowed the ruling in cases like Delta Airlines, finding that only in cases where there is objective medical evidence that the claimant could return to work with the employer of record and where the claimant has a realistic expectation to return to work with the employer is the claimant relieved of the need to prove labor market attachment.

The Full Board reviewed the Barbella decision earlier this year and reversed the Board Panel decision inBarbella. The Full Board decided not to adopt the two-pronged test created by theBarbella panel’s majority and unfortunately affirmed the rule that a claimant has not voluntarily withdrawn from the labor market where the claimant continues to be employed by the employer and the medical evidence in the record establishes that a claimant is unable to return to work.This decision will make it more difficult to defend against indemnity benefits in claims where a claimant remains “on the books” with the employer of record.

 

Still No Word on Pharmacy Formulary

 

At the end of last year, the Board announced draft regulations for a proposed New York State Pharmacy Formulary. WCL §13-p, which became law in April 2017, required the Board to "establish a comprehensive prescription drug formulary on or before" 12/31/17. To date, we have only seen a draft formulary and the proposed rules published in December 2017.In February 2018, we published an extensive white paper with our summary and analysis of the proposed formulary and regulations. Among other things, we believed that the proposed pharmacy formulary would result in lower costs for employers and carriers.

The proposed formulary was supposed to become effective 7/1/18, but our review of the State Register shows that the proposed regulations were never finalized. The Board has been silent regarding the formulary and seemingly is violating its statutory requirement to “establish a comprehensive prescription drug formulary on or before” 12/31/17. WCL §13-p.

 

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Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
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Hamberger & Weiss - Rochester Office
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Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

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H&W New York Workers' Compensation Defense Newsletter
Vol. 3, Issue 1

Board Announces Initiative to Replace C-4 Family of Forms with CMS-1500

The Board announced earlier this month that it will replace the C–4 family of forms (with the exception of the C-4.3 permanency evaluation form) with theCMS–1500 form.Board Subject Number 046-1079 describes technical specifications for the rollout and states that it will occur in 3 phases, the first of which will commence on 1/1/19. On that date, providers may begin voluntary transmission of CMS –1500 bills through an approved Board electronic clearinghouse and payers will also be expected to accept electronic receipt of same. On or about 1/1/20, the Board willrequire use of the electronic CMS–1500 billing form through its clearinghouse. Because the CMS-1500 form does not have the space on it for providers to write a history, opinion on causal relationship, or opinion on degree of disability, the Board will require providers to attach a narrative that includes this detail. The Board has provided a website outlining the CMS–1500 initiative which discusses the requirements it expects providers to adhere to in compiling narratives to attach to their billing forms in order to assist in the management and adjudication of claims.
 
In addition to the expected requirements of a history of the injury, a diagnosis, and an opinion on causal relationship, the Board also demands detail from the health provider concerning the specific functional work activities or activities of daily living that the patient cannot perform as a result of the injury or illness. This is another example of the Board’s continued emphasis on function as a significant factor in assessing impairment. We hope that the Board will enforce these requirements by supporting payer bill denials for inadequate narrative descriptions. We recommend that our clients carefully review the narrative submissions from providers and deny those bills with narratives that fail to adhere to the standard when the program goes live next year.
 
Providers can no longer simply “check the box” in order to provide an opinion on causal relationship. In addition to stating whether the incident described by the patient was the competent medical cause of the injury or illness, the provider must also indicate whether the complaints are consistent with the history provided and whether the history is consistent with the objective findings noted on examination. Of note, the Board’s recently revised C-4.3 Form will not be eliminated by the CMS-1500 initiative. Providers will still be expected to fully complete the C-4.3 Form to render a valid opinion on permanency.
 
There is a potential loophole for providers that wish to avoid the Board’s narrative attachment requirements. The CMS-1500 requirements website states that physicians can include page 2 of the Doctor’s Progress Report (Form C-4.2) “as an optional attachment with the CMS-1500 and medical narrative to provide concise information on the Doctor's Opinion and Return to Work.” It is unclear to us whether this means page 2 of the Form C-4.2 can be submitted in lieu of the required narrative or in addition to the required narrative. If it is the former, then physicians can avoid many of the new narrative requirements by simply attaching the form.
 
Given prior complaints from providers concerning the Boards suite of medical forms, it is unsurprising that the Board is moving forward with this initiative. In 2010,the Board went so far as to declare a provider shortage in the greater Rochester area, noted the burden on providers created by the Board’s forms requirement, and at that time authorized use of the CMS–1500 form with an attached narrative in lieu of completion of the required C-4 family of forms.

Board Eliminates Need to File C-8.1A with C-4AUTH Denial

In a welcome change, the Board has announced that Form C-8.1A will no longer need to be filed in cases where a carrier denies a request for authorization of a special service with Form C-4AUTH. In the past, a carrier’s denial of treatment requested by an attending physician on a C-4AUTH form required completion of 2 forms, as well as a conflicting medical opinion, resulting in the perverse and uniquely New York requirement of requiring 3 documents from the carrier to deny one request from the provider. The Board announcement is a step in the right direction, reducing the paperwork burden on carriers and eliminating a redundant form.
 
The Board’s announcement appears to be a policy statement following a decision inMatter of J&A Concrete Corporation, 2017 NY Work. Comp. G1078502 (filed 9/5/17), which held that the filing of a C-8.1A would be “redundant and unnecessary” where the carrier has already filed a C-4AUTH denial coupled with the filing of a contrary supporting medical opinion. This change is effective immediately.
 

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Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

H&W New York Workers' Compensation Defense Newsletter

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H&W New York Workers' Compensation Defense Newsletter
Vol. 2, Issue 11

 

Happy Independence Day from H&W!

 

We have a short issue this month; the Board has been relatively quiet after over a year of activity following the 2017 reforms. We report today only about a case from the Appellate Division which appears to upend some long-held assumptions about the interplay of PPD and SLU benefits in New York.

We hope that our readers have a happy, relaxing, and safe Fourth of July holiday next week!

 

Appellate Division Allows SLU Award after Classification with PPD

 

On 6/14/18, the Appellate Division, Third Department, decided Taher v. Yiota Taxi, Inc.  This decision appears to allow a claimant classified with a permanent partial disability to receive a schedule loss of use award in the same claim as long as no permanent partial disability payments have been paid. 
 
This case involved a claimant who had injuries to his neck, back, right knee, and right shoulder.  The doctors examining him produced both schedule loss of use award opinions and permanent partial disability opinions.  Claimant argued that he should be both classified and also given a schedule loss of use award because he had returned to work with no reduced earnings.  The Board rejected this argument, and claimant appealed to the Appellate Division.  The Court reversed the Board’s decision, in part, stating that, “In the unique circumstance where no initial award is made based on a non-schedule permanent partial disability classification, a claimant is entitled to an SLU award.”  In support of this holding, the Court citedGallman v. Walt’s Tree Service, 43 A.D. 2d 419 (3d Dep't. 1974).  The Gallman case cited by the Court states that a claimant classified with a permanent partial disability may also receive a facial disfigurement award in the same claim as long as no lost time awards have been made based on the PPD classification. 
 
Some have questioned whether the Court truly means that a claimant can receive both a schedule loss of use award and a PPD classification in the same case or if this decision is an anomaly with limited precedential value.  Because the Court directly cited the Gallman decision for the proposition that a classified claimant can also receive a facial disfigurement award in the same case when no PPD awards have been paid, we believe the correct reading of this case is that a claimant can receive a schedule loss of use award payment and classification in the same case, but where no PPD payments have previously been made. This decision may have implications for the value of future settlements in cases having both PPD classification and SLU potential. 

 

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Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

Copyright © 2018, Hamberger & Weiss, All rights reserved.
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1 South Washington Street       
Suite 500                               
Rochester, NY 14614

Hamberger & Weiss
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350 Main Street
Buffalo, NY 14202
         
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Board Continues “New” SLU Guidelines Rollout with New Forms, Training

 

The Board continues its implementation of its 2018 Impairment Guidelines with Subject No. 046-1067, in which the Board provides new forms that both attending physicians and Independent Medical Examiners are required to use effective immediately in providing opinions on schedule loss of use (SLU). We believe that the required forms continue the Board’s tradition of legislating through forms, but with respect to the SLU issue are generally favorable to the employer and carrier community because they force examiners to perform some actions suggested in the 2018 Guidelines, such as measuring the contralateral extremity.
 
The employer and carrier community should take careful note of the Board’s new requirements for IME forms. According to Subject No. 046-1067, an IME evaluator must fill out not only the IME form cover sheet, but provide the appropriate listed attachments for either an SLU evaluation or a non-schedule PPD evaluation along with the evaluator’s narrative report. All three elements (IME-4, permanency attachment, and narrative) are required for a complete IME report. The IME-4 attachments (“A” for SLU evaluation,“B” for classification evaluation) essentially mirror their attending physician counterparts, discussed below.
 
TheIME-4 form also has been changed to require the evaluator to indicate the start time of the patient’s examination, the end time of the examination, and the total time spent by the evaluator reviewing records. The IME evaluator should take care to make sure that all sections of the IME form and any appropriate attachments are filled out when completing an IME report. An IME-4 cover sheet with narrative is no longer sufficient.
 
Thenew C-4.3 form now has two required attachments. The first, Attachment A, is to be completed by an attending physician conducting an SLU evaluation. Of note, the attachment indicates that the examining physician should provide three measurements for range of motion, compare range of motion to the contralateral extremity, and requires specific notation of the applicable special consideration, if any.
 
Attachment B of the new C-4.3 form is relevant to non-schedule classifiable cases and is largely unchanged from Section F of the old C–4.3 form. The new attachment does, however, contain additional space for describing the claimant’s work status, and more detail in consideration of the claimant’s functional capabilities and exertional abilities.
 
Earlier this month, the Board offered training on the new SLU guidelines and the new forms required. Although the webinar series is over, a recording is available and parties can review theBoard’s PowerPoint presentation on the Board’s website here.

 

Board Clarifies §15(8) Reimbursement Process Following Board Panel Decisions inExpress Solutions and Southco

 

Our readers will recall our article last month discussing the Express Solutions and Southco Board Panel decisions which not only established the Board’s jurisdiction for determining §15(8) reimbursement issues, but also set out the appropriate procedure for payors to follow in obtaining reimbursement for qualifying expenses under §15(8). The Board has clarified the procedure discussed inExpress Solutions and provided new forms for requesting reimbursement inSubject No. 046-1063, issued earlier this month.
 
Beginning 6/1/18, employers and carriers (payors) must use the new forms to seek reimbursement under WCL §15(8). They are:
 

 
The Subject Number also clarifies some ambiguities in the procedure detailed in theExpress Solutions decision. Specifically, it notes that an employer or carrier disputing a reduction in a reimbursement request can submit a request for reconsideration on the C-251.6 form via email toSpecialFunds@wcb.ny.gov within 60 days of the date marked on the Special Funds Group’s response (Form C-251R or C-251.1R). At that point, “senior SFG staff not integral to the original review” will review the reimbursement request and any additional documentation submitted and then email a response to the employer or carrier with the “final determination” of the SFG regarding the reimbursement request.
 
If the employer or carrier disputes the reconsideration made by SFG, it may file an RFA–2 within 30 days of the date marked on the reconsideration form. The SFG response must be attached to the RFA–2. For now, until the Board modifies Form RFA-2, employers and carriers are instructed to use the box marked “other” and state that the purpose of the request is “Desk review of SFG Decision Form C-251.6R”). Clearly, the Board is trying to avoid hearings before a WCLJ for consideration of these review requests.
 
Subject No. 046-1063 also details a new procedure for formalizing the establishment of §15(8) liability in cases where a §15(8) claim is pending but has not yet been found to apply. We suspect that there are not many cases left in the system where this new procedure will be applicable, given the closure of the §15(8) fund to new claims nearly 10 years ago. Nevertheless, in such cases, the Board requires the requesting carrier to email a document of no greater than one page specifying eCase Document ID numbers for all documents in the Board eCase file submitted prior to 7/1/2010 that support the carrier’s request for §15(8) relief, along with a “no more than one sentence description” of how each document cited from the electronic Case folder meets each essential element of §15(8) relief (e.g., “Timely Submitted Form C-250”; “M&S Statement”; etc.).
 
Upon receipt of the document, the SFG will either advise the payor of its voluntary acceptance of §15(8) liability or request a hearing.
 

 

Board Virtual Hearings Live in Multiple Districts; Major Changes for Parties Requesting Hearing Record

 

The rollout process for the Board’s new virtual hearing system continues.  Virtual hearings are live in the Capital, Binghamton, Brooklyn, Syracuse, and Rochester Districts of the Board as of mid-April, and will come to the Buffalo District on 6/13/18.  The virtual hearing system has had its share of growing pains. We expect future tweaks and improvements as the rollout continues. As our attorneys and clients become accustomed to this new hearing process, we offer the following tips:
 

  1. Hearing transcripts can no longer be requested or obtained directly from Board employed court reporters because virtual hearings are audio recorded without a live reporter.  In appropriate cases our office will arrange to have the recordings transcribed by an outside reporter for use in preparing legal briefs or ongoing litigation.  These transcripts will not be official hearing records, but are useful nonetheless in cases involving testimony or complicated legal issues for, among other things, preparation of Memoranda of Law requested by WCLJs and cross-examination of witnesses at later trial hearings.
  2. The virtual hearing process makes “picking up” a hearing without notice from the carrier/employer difficult because our attorneys no longer have access to the Board’s master list of hearings on calendar for a given day.  As such, extra care must be taken to ensure our office receives timely notice of any hearings that clients wish for us to handle.

 

Contact Us

 

Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

Copyright © 2018, Hamberger & Weiss, All rights reserved.
You are receiving this email because you are a valued client of Hamberger & Weiss
Our mailing addresses are:

Hamberger & Weiss                   
1 South Washington Street       
Suite 500                               
Rochester, NY 14614

Hamberger & Weiss
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
         
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H&W New York Workers' Compensation Defense Newsletter

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Board Announces Proposals to Improve Medical Care for Injured Workers

 

On 4/17/18, the Board issued Subject No. 046-1058, which included a number of proposals the Board purports will improve medical care for injured workers.  The proposals include a planned June 2018 regulatory proposal to raise provider fees for services provided on or after 10/1/18. The Board also plans to eliminate the current Board treatment forms (C-4 and C-4.2) and replace them with the use of theCMS-1500 form commonly used by medical providers to bill health insurers.
 
The Board claims that this change is based on complaints from health providers that use of the C-4 and C-4.2 forms create significant additional administrative costs.  The Board plans to implement use of the CMS-1500 form by 1/1/19.
 
We believe that use of the CMS-1500 form will make it more difficult for self-insured employers, carriers, and third-party administrators to determine the appropriate payment rate as well as whether the treatment is casually related if a physician fails to attach a narrative report to the form. The CMS-1500 form does not provide any space to indicate a history of the injury, degree of disability, or indicate causal relationship to a date of injury or specific incident. Additionally, there is no space for a narrative. We recommend that our clients contact the Board and object to this proposed change because it will make it more difficult to administer claims and accurately pay injured workers.
 
The Board also announced that the first phase of the medical portal, one of the Board's Business Process Re-engineering (BPR) initiatives, will be rolled out later in 2018. An electronic medical portal allegedly will allow medical providers to “quickly and easily” determine whether their course of treatment is consistent with the Board’s Medical Treatment Guidelines. This is the first step in the Board’s transition to a paperless system.
 
Finally, the Board said that it and the Governor's Office are exploring options, including new legislation that will allow injured workers access to other provider types outside of physicians, chiropractors, podiatrists, and psychologists.  Proposed legislation would amend the Workers’ Compensation Law to allow nurse practitioners, physician’s assistants, licensed clinical social workers, and other providers to treat injured workers. We believe that although this proposed change may increase access to care for injured workers, it will come at the cost of a decline in quality of care.  We would object to the proposed legislation if it empowered such providers to render opinions on causal relationship upon which the Board could establish claims and make awards.
 

 

Two Board Panel Decisions Establish Board Jurisdiction for Determining §15(8) Reimbursement and Right of Payers to Obtain Reimbursement for Qualifying Expenses Paid More Than One Year Prior to the Reimbursement Request on Newly Established §15(8) Claims

 

For some time, the Special Funds Group (“SFG”) has argued that the Workers’ Compensation Board did not have jurisdiction to resolve disputes concerning reimbursement to carriers on established WCL §15(8) claims. SFG was able to obtain a Board Panel decision supporting their position and this has frustrated the efforts of carriers seeking reimbursement under §15(8) withheld by SFG.See, Corning, Inc., 2017 N.Y. Work. Comp. 90203937 (9/15/2017). TheCorning decision held that the Board did not have administrative jurisdiction over the WCL §15(8) reimbursement process. This left carriers without a forum to resolve disputes concerning §15(8) reimbursement.
 
On 1/11/18, a Board Panel, upon remand from the Full Board, issued a decision in Express Solutions, 2018 WL 1560704 (WCB #70106478; 1/11/18) in which it disavowed the prior holding inCorning, Inc., 2017 NY Work. Comp. 90203937 and established that the Board has jurisdiction over the reimbursement process as well as the right to adjudicate disputes concerning same. With the decision inExpress Solutions, carriers can seek relief from the Board in these matters, subject to the process laid out in that decision.
 
The Board Panel ruled that once WCL §15(8) liability is established by the Board, the carrier and SFG must follow the following process:
 
1) File a timely request for reimbursement with the SFG using the appropriate form including all necessary information and documentation;
 
2) The SFG screens the request for any incomplete or improper entries, issues confirmation of receipt, and reviews the request to determine if each item is eligible for reimbursement and was paid in accordance with all appropriate laws, regulations, fee schedules, and other appropriate considerations;
 
3) The SFG issues a response to the carrier indicating the dollar amount approved for each indemnity payment along with an explanation for reductions from the amount requested (if any). If the total amount of the medical reimbursement requests was not produced, SFG will not respond to the request, and will process for payment;
 
4) The carrier may request reconsideration of a response from SFG in which the reimbursement amount requested was reduced;
 
5) A senior staff person in SFG shall review the reconsideration request and issue its final determination; and
 
6) The carrier may seek review of SFG’s final determination by filing a timely request for further action, subject to WCL §23.
 
Although this process seems (and probably will be) cumbersome, the upshot is that there is now a process that the SFG must follow concerning §15(8) reimbursement requests. SFG’s failure to follow the process can be held to task before a WCLJ who has the power to direct reimbursement to the carrier. Additionally, this decision puts to rest the argument from SFG that the Board lacks the jurisdiction to resolve disputes concerning §15(8) reimbursement.
 
Express Solutionswas cited in a more recent Board Panel decision, Southco, 2018 N.Y. Work. Comp. 70107367 (4/10/18), which affirmed the Board’s repudiation of theCorning, Inc. decision.  The Southco decision also affirmed the rule, opposed by SFG, announced by the Board in Subject Number 046-223R dated December 12, 2008.  That Subject Number provided that as long as request for reimbursement is filed within one year of the date the Board establishes §15(8) applicability, the carrier is entitled to reimbursement of all qualifying expenses (indemnity and medical benefits paid beyond the 104 or 260 week retention period) even if such expenses were paid more than one year before the request for reimbursement.
 
InSouthco, the date of accident was 2/21/2001.  A timely claim for §15(8) relief was filed in 2002, but the Board did not find that §15(8) applied until 8/12/2016.   The carrier filed its requests for reimbursement from Special Funds in May and July 2017 (within one year).  Thus, the carrier would be entitled to reimbursement of medical and indemnity benefits paid beyond the 260 week retention period, not just those made within one year that reimbursement request.

 

New Court Decision Reminds Primary Payers to Rely on Medicare Final Demand Letter in Determining Amount of Conditional Payments

 

As Medicare primary payers, carriers and self-insured employers should be aware of the Trial Order issued by the Supreme Court of New York, New York County on 3/15/18 inMayo v. NYU Langone Medical Center, 2018 WL1335262 (N.Y. Sup.) (3/15/18). The Order vacated a settlement on the basis of mutual mistake of the parties because they relied on a Conditional Payment Letter for the amount of a conditional payment lien, rather than a final demand from Medicare. The difference between the amount of conditional payment reimbursement requested in the Letter and the final demand was $142,939.58!

The Plaintiff's estate inMayo moved for an order declaring a medical malpractice settlement null and void on the basis that relying on a Conditional Payment Letter requesting $2,824.50 in reimbursement rather than a final demand in the amount of $145,764.08 was a mutual mistake of the parties. The Defendant liability carrier argued that the mistake was not mutual, but a unilateral error on the part of the Plaintiff as Medicare beneficiary.  The liability carrier took the position that the Plaintiff failed to ensure that the conditional payment lien amount was correct. The court disagreed, finding that the mistake was mutual.

The significance of this decision is two-fold for primary payers. First, primary payers cannot rely on the total amount of the conditional payment lien stated in the Conditional Payment Letter at the time of settlement. Payers must obtain a final demand from the Centers for Medicare and Medicaid Services. This illustrates the importance of being vigilant in conditional payment research and response at every stage of the conditional payment recovery process.

Second, the Court refused to agree that the Plaintiff, as Medicare beneficiary, is solely responsible for conducting conditional payment research and resolving conditional payment demands. The Court specifically referenced, “the defendant’s potential liability with respect to Medicare liens,” as evidence supporting the argument that the error was mutual. Like the liability carrier in theMayo Order, workers’ compensation carriers and self-insured employers are potentially liable for conditional payment reimbursement. Thus, they must research conditional payments and resolve reimbursement claims when settling claims with Medicare beneficiaries.

Conditional payment research has been part of the Hamberger & Weiss WCMSA process since inception. In addition, our Settlement Team has been actively engaged in resolving conditional payment reimbursement claims since the advent of CMS’ Commercial Repayment Center. To date, we have successfully challenged over $750,000 in conditional payment claims. For any questions concerning the Medicare conditional payment process, please contact our partner,Nicole Graci.

 

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Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

Copyright © 2018, Hamberger & Weiss, All rights reserved.
You are receiving this email because you are a valued client of Hamberger & Weiss
Our mailing addresses are:

Hamberger & Weiss                   
1 South Washington Street       
Suite 500                               
Rochester, NY 14614

Hamberger & Weiss
700 Main Place Tower
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Buffalo, NY 14202
         
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Hamberger & Weiss Seminars Are Here!

 

Our annual workers’ compensation seminars are scheduled for 4/10/18 in Buffalo at Samuel’s Grande Manor and 4/24/18 in Syracuse at the Holiday Inn – Syracuse/Liverpool. This year, we will discuss: 

  • The practical effects of the 2017 workers' compensation reforms on permanent partial disability cases  
  • Defenses to the Board’s payor compliance program  
  • The “new” SLU guidelines  
  • The Board’s new pharmacy formulary and medical marijuana  
  • The Medicare conditional payment recovery process  
  • Major court decisions over the past year. 

If you have not yet registered, please contact Heidi Mahoney at hmahoney@hwcomp.com to do so. We look forward to seeing you! 

 

Board Begins IME Study

 

The Workers’ Compensation Board is beginning its study of IME’s mandated by the 2017 legislation, which requires the Board to study IME utilization and submit a report to the Advisory Committee by early 2019. As a result, the Board is reaching out to stakeholders seeking input on concerns regarding IME exams, including quality, cost, potential fraud, as well as alternative methods for utilization/assignment of IME’s and practices followed in other states. Our partner, Susan R. Duffy, was invited by the Workers’ Compensation Board as the New York State Bar Association Defense Attorney Representative, along with claimant’s counsel, William Crossett, to participate in the information gathering phase. Susan participated in a conference call with Board participants on March 21, 2018 to discuss concerns from the defense perspective and will be submitting expanded written comments. Preserving the rights of employers and carriers in the selection and utilization of IME’s, and limiting Board involvement, is critically important in protecting your rights in defending claims, so we are appreciative of the opportunity to provide our input and expertise.

Please do not hesitate to contact Susan at sduffy@hwcomp.com with any comments or questions about the IME study.

 

Board Panel Allows Consideration of Apportionment Between Two Work Related Injuries Before Permanency

 

For several years, the Board has generally refused to consider apportionment during the period of temporary disability, even between two work related injuries. In 2010, the Full Board stated in Byram Hills CSD, 2010 N.Y.Work.Comp. G0070823 (12/31/10) that "there is no basis for apportionment of a temporary disability, and the issue of apportionment should be deferred until a finding of permanency has been made." Since that decision, Board Panels and Law Judges have generally deferred consideration of apportionment until permanency. 
 

In a 3/23/18 decision, Hamburg Central School, 2018 N.Y.Work.Comp. G1342161 (3/23/18), a Board Panel stepped away from this rule, finding that "apportionment does not need to wait for a finding of MMI" between two work related injuries. In that case, the claimant had two compensable right knee injuries. The first one occurred on 3/8/04 and the claimant was eventually awarded a schedule loss of use on that file. His doctor eventually found that he had no impairment and he returned to work full time, full duty.  
 

The claimant suffered a second injury on 10/8/15 and the new carrier argued that the second injury was merely an aggravation of the prior injury and that following a brief period of temporary disability, there should have been a finding of no further causally related disability against the new file. In the alternative, the new carrier argued that apportionment applied and that no more than 10% of liability should be assessed against it. The claimant and the earlier carrier argued that the injury of 10/8/15 was a new injury and that consideration of apportionment was premature until permanency. The Law Judge agreed and assessed awards solely against the new carrier. The Board Panel reversed, noting the power given to it by the Courts to resolve the factual issue of apportionment. It returned the case to the Law Judge for development of the record on the issue of apportionment.  
 

The precedential value of this case is limited because it is a Board Panel decision but it may prove useful for employers and carrier in negotiating or litigating reduced liability through apportionment to an earlier work-related injury.  
 

Congratulations to our partner Melanie Wojcik, who litigated the case before the Law Judge and wrote the successful Application for Board Review.

 

Contact Us

 

Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

H&W New York Workers' Compensation Defense Newsletter

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Susan R. Duffy Receives Workers’ Compensation Award

 

We are pleased to announce that our partner, Susan R. Duffy, received the Mary M. Russo-John Sciortino Award from the Torts, Insurance and Compensation Law Section of the New York State Bar Association at its Annual Dinner in New York City. The award is given to a lawyer in recognition of outstanding contribution to the practice of law in the field of Workers’ Compensation. Congratulations Susan!

 

CRC Announces New Contractor for Conditional Payment Recovery

 

As many of you know, we perform conditional payment searches and handle conditional payment recovery demands for our clients as part of our Medicare Secondary Payer practice. As of2/12/18 the Commercial Repayment Center (CRC) will have a new CRC contractor, Performant Recovery Inc. There will be a “dark days” transition period from 2/9/18 to 2/12/18, sowe would ask that any conditional payment reimbursement requests (CPN, CPD, NOI, Referrals to Dept. of Treasury) that are due from 2/9/18 to 2/12/18 be referred to us for handling in advance of 2/9/18 so that we can be sure they are timely filed.

The contractor will have a new address and fax as of 2/12/18:

Medicare Commercial Repayment Center – NGHP ORM
PO Box 269003
Oklahoma City, OK 73216-9003
FAX  (844) 315-7627

The call center number will remain the same (855) 798-2627.

The CMS conditional payment recovery process will remain the same, as the processes (Section 111 reporting, letters of authority, deadlines, etc.) are dictated by CMS, not the contractor in place at a given time.

Cases that are pending with CGI Federal (the current contractor) will be transferred to Performant Recovery.

Should you have any questions, please do not hesitate to contactNicole Graci at ngraci@hwcomp.com or 716-852-5200.

 

Appellate Division Issues Two Important SLU Decisions in January

 

As befits the adoption of the Board’s just-barely revised SLU Guidelines on January 1st, the Appellate Division also has had SLUs on the mind, issuing two decisions concerning same in January 2018.

In the first,Parody v. Old Dominion Freight, the Court held that the Board is not bound by the medical opinions of schedule loss of use (SLU) in the record and may fashion its own SLU assessment based on the medical evidence and the impairment guidelines if the ultimate result is supported by the record, even if the percentage loss of use awarded has not been given by any medical expert in the record.

This opens additional avenues for compromising as well as litigating SLU awards because the parties need not assume that the Board will be forced to choose the SLU opinion of one of the medical experts. The Board is permitted to selectively adopt and reject portions of expert opinion and testimony, and thus could make a different finding on percentage loss of use, using the medical evidence in the record, than that reached by the medical experts.

The second case,Maloney v. Wende Correctional Facility, holds (as we have long argued) that a medical expert may not add both the values for deficits in anterior (or forward) flexion and abduction in determining percentage SLU of the arm because the combined value of same could exceed 80%, which is the SLU percentage applicable to ankylosis under the Board’s Impairment Guidelines. This decision provides authority from the Appellate Division to support the Board’s own line of cases followingNFTA Metro that considering loss of range of motion in both abduction and forward flexion would be duplicative and improper. Of note, the Board’s new2018 SLU Impairment Guidelines also clarify that the two values should not be duplicated.

Also of note inMaloney was the Court’s rejection of the claimant’s argument that the employer waived its defenses to the attending physician’s SLU opinion because it failed to file a pre-hearing conference statement. The Court noted that the filing of a pre-hearing conference statement is contemplated where the claim for workers’ compensation benefits is controverted. The Court said that inMaloney, the employer did not controvert the claim and that the Board admitted error in directing the employer to file a pre-hearing conference statement. The Court’s statement concerning pre-hearing conference statements being filed in contemplation of controversy may allow an argument to avoid the Board’s attempt to preclude issues where it directs a pre-hearing conference statement in an established or accepted claim.

 

Appellate Division Requires Board to Obtain Medical Evidence of Effect of Injury on Claimant’s Functional Abilities in Determining LWEC

 

On 12/14/17, the Appellate Division, Third Department, decided King v. Riccelli Enterprises,  which held that when assessing a claimant’s loss of wage earning capacity (LWEC), the record must contain medical evidence of how the work injury impacts claimant’s functional capabilities. The record in King contained permanent partial disability rankings under the 2012 Guidelines, and a generic 15 lb. lifting restriction.  The Court held that this, by itself, was insufficient, and that the physicians needed to explain how the claimant’s permanent medical impairment impacted his ability to perform relevant physical tasks. 

This decision serves as a reminder for medical professionals of the level of detail necessary for a competent medical report on permanency. LWEC findings by the Board where the record lacks a detailed description of claimant’s physical capabilities will be vulnerable to attack. Doctors must fill out the C-4.3 form completely, including the part requesting information on specific physical task capabilities. If the doctors on record have not provided this information, the parties may need to obtain it by deposition testimony or risk having a LWEC finding reversed or remanded on appeal.

 

Claimants Trying to Prove Re-Attachment to Labor Market Must Show Connection Between Unsuccessful Job Search and Work Injury

 

On 12/14/17, the Appellate Division, Third Department, decided Pontillo v. Consolidated Edison of New York.  The Court held that when a claimant voluntarily retires and tries to claim re-attachment to the labor market, mere production of evidence of an unsuccessful job search by itself is insufficient. The claimant must also prove that his or her “earning capacity and …ability to find comparable employment has been adversely affected by his or her disability,” and that “…other factors totally unrelated to [the] disability did not cause the adverse effect on his or her earning capacity.”  (internal quote omitted).

InPontillo, the claimant had an established claim for pulmonary fibrosis. The employer provided a light-duty job, which claimant worked at for two days before retiring. He later claimed re-attachment to the labor market. He was never classified with a permanent disability. Claimant produced evidence of an unsuccessful job search, and the WCLJ made awards, finding him re-attached to the labor market. The employer appealed, arguing that claimant failed to prove his unsuccessful job search was causally related to his work injury. The Board Panel affirmed, and the employer appealed to the Appellate Division. 

The Court reversed, holding that the Board failed to address the employer’s burden of proof argument, and remanded for further proceedings. Based on this holding, merely producing proof of an unsuccessful job search after voluntary removal from the labor market is insufficient. The claimant must also affirmatively prove a causal nexus between his or her work injury and the unsuccessful job search to re-attach to the labor market.

 

Contact Us

 

Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

Copyright © 2017, Hamberger & Weiss, All rights reserved.
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Hamberger & Weiss                   
1 South Washington Street       
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Rochester, NY 14614

Hamberger & Weiss
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350 Main Street
Buffalo, NY 14202
         
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Hamberger & Weiss Elects Stephen P. Wyder, Jr. to Partnership

 

We are pleased to announce that Stephen P. Wyder, Jr. has been elected as a partner in the firm, effective January 1, 2018. Mr. Wyder has been practicing workers’ compensation defense since joining the firm in 2010. Prior to that, he was an Assistant District Attorney with the Sullivan County District Attorney’s Office where he handled both jury and bench trials in felony and misdemeanor criminal cases.  

Mr. Wyder has developed a sub-specialty in appellate practice and has argued cases before the Appellate Division and worked on cases presented to the Court of Appeals. He is expert in trial practice and litigation before the Workers’ Compensation Board, having handled a wide range of claims ranging from slip-and-falls, repetitive stress claims, fraud, discrimination and other claims under the Workers’ Compensation, Volunteer Firefighters, and Volunteer Ambulance Workers’ Benefits Law.  

He is a member of the Monroe County Bar Association and resident in our Rochester office.  

 

Board Announces Draft Pharmacy Formulary and Finalizes SLU Guidelines

 

On 12/28/17, the Board announced draft regulations for a proposed New York State Pharmacy Formulary and finalized the new Permanent Impairment Guidelines for Schedule Loss of Use (SLU) evaluations.
 

WCL §13-p, which became law in April 2017, required the Board to "establish a comprehensive prescription drug formulary on or before" 12/31/17. The Board has apparently interpreted the "shall establish" language in WCL §13-p to only mean "publish proposed regulations for comment." The proposed formulary provides a list of preferred and non-preferred medications for treatment of common workers' compensation injuries. Medications on the preferred list do not require pre-authorization from the carrier but those on the non-preferred list do. Of note, not a single opioid medication is on the preferred list. We will review the formulary as well as the proposed regulations in detail and publish a detailed analysis of same in the coming weeks. The public comment period for the proposed regulations is open until 2/26/18.
 

The Board also finalized and adopted the new Permanent Impairment Guidelines for SLU evaluations. They appear to be substantially unchanged with only minor clarifications to the Proposed Guidelines the Board issued on 11/22/17 for public comment that we discussed in last month's issue. The primary consideration in determining SLU under these new guidelines is loss of range of motion. The new guidelines take effect for all claims, regardless of date of injury, on 1/1/18. The only exception to this is if the claimant had at least one SLU exam conducted under prior Guidelines before 1/1/18. In such cases, the Board will determine the claimant's SLU using the 2012 Guidelines.

 

Terranova Court of Appeals Decision Reminds Board to Not Miss the (Equitable Apportionment) Forest for the (Kelly Decision) Tree

 

In a decision released on 12/19/17, the Court of Appeals (New York State’s highest court) ruled that the Board erred in allowing a carrier to take full credit for a schedule loss of use awarded after the settlement of a claimant’s third-party action without any further contribution to litigation costs for use of that credit.  

WCL Section 29 provides that for a carrier to obtain a lien recovery and future offset rights against a third-party settlement, the carrier must pay its fair share of litigation costs as outlined in KellyBurns, and other decisions. Nevertheless, in Terranova v. Lehr Construction Co., 139 A.D.3d 1309 (3d Dep’t 2016), the Appellate Division affirmed a Board decision allowing a carrier to take full credit on an SLU awarded after the settlement of the claimant’s third-party action but without any further contribution to litigation costs for use of that credit. The claimant appealed this decision to the Court of Appeals, which reversed the Appellate Division in the 12/19/17 decision.

 

In Terranova, the carrier paid $21,495.99 in past benefits at the time of settlement. The claimant also had a 10% SLU opinion from his doctor, but it hadn’t been awarded. The consent letter provided that the carrier would reduce its lien from $21,495.99 to $14,018.75. This reduction represented the carrier’s proportional contribution to the cost of litigation associated with obtaining the third-party settlement under Kelly v. State Insurance Fund. There was no further reduction of the lien to account for the carrier’s future credit rights. Rather, the consent to settle letter said that “any future workers’ compensation benefits [would] be subject to” Burns v. Varriale payments. After the settlement, the Board awarded the claimant a 10% SLU, which totaled $17,280.00. The Board also found that the third-party settlement exceeded the SLU award and that despite the language in the consent letter, the carrier could take full credit of the SLU award against the third-party settlement without any further contribution for litigation costs.

 

On appeal, the Appellate Division affirmed and focused its attention on the consent letter. Even though the consent letter noted that the carrier was subject to Burns payments on future awards, the Appellate Division ruled that the carrier did not need to make a Burns payment for the SLU award. Instead, the Appellate Division relied on the language in the consent letter that specified that the carrier’s initial reduction in the lien was in satisfaction of its Kelly obligation.

 

Last summer, we questioned the rationale of the Appellate Division’s decision as contrary to statute and precedent because the Kelly decision required not only a reduction in the carrier’s lien at the time of settlement to account for litigation costs, but also a further reduction to account for the present value of the carrier’s future obligation that was extinguished because of the third-party settlement. That further reduction was missing from the analysis of Terranova by both the Board and Appellate Division.

 

The Court of Appeals has corrected this, noting that the overriding principle in third-party action cases is the “certainty” of the award at the time a third-party matter is resolved. In Terranova, the Court found that because the present value of the loss of use was not finalized at the time of the claimant’s third-party recovery, the carrier was obligated to pay its fair share of litigation expenses at the time the present value was determined. The Board’s original decision allowed the carrier to take credit for the SLU without paying its fair share for use of that credit.

 

A Reminder Regarding Medical Treatment Denials and Expedited Hearings

 

As we reported in our March 2017 issue, we have noticed WCLJs strictly enforcing the requirement on Board Notices of Hearing regarding the scheduling of depositions in cases involving medical treatment issues. Specifically, WCLJs are precluding employers and carriers from scheduling depositions on these treatment issues when no attempts have been made to complete the deposition prior to the initial expedited hearing on the issue. Any denial of a C-4AUTH will result in an expedited hearing.  A review request of an MG-2 will generally result in an expedited hearing, unless the claimant and carrier both request that the Board’s medical arbitrator review the denial.
 
If you receive a Notice of Expedited Hearing on a medical treatment issue, that Notice will usually contain language directing the parties to complete depositions prior to the hearing. If that is the case, we strongly recommend that you contact defense counsel to review the file to determine if a deposition should be scheduled. Often we do not recommend deposition testimony, particularly if the treatment at issue involves physical therapy or chiropractic care or where the attending physician didn’t meet his or her burden of proof in making the treatment request. But in those cases involving surgery requests or other expensive forms of treatment, it may be advisable to depose the treating physician.

 

A PH-16.2 should be filed in advance of any expedited hearing, even if the claim is not controverted. Under 12 NYCRR 300.34, a PH-16.2 must be filed within twenty days of the file being transferred to the expedited hearing process. However, 300.34 also requires the PH-16.2 be filed in accordance with 300.33, which requires the PH-16.2 be filed ten days before any pre-hearing conference. 12 NYCRR 300.33. Prior Board Decisions have held that failure to file a PH-16.2 prior to an expedited hearing scheduled to address a treatment denial issue will result in a waiver of the right to cross-examine any medical witnesses. In addition, if the deposition cannot occur prior to the expedited hearing, a written affirmation must be submitted. However, in no circumstances may an adjournment be granted more than thirty days after the pre-hearing conference.

 

Happy Holidays and Happy New Year from Hamberger & Weiss

 

We would like to thank our clients, colleagues, and friends for your continued trust in us. We sincerely hope that you have had a wonderful holiday season and we wish all of you peace, happiness, and prosperity throughout the new year!

 

Contact Us

 

Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

H&W New York Workers' Compensation Defense Newsletter

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Everything Old is New Again: Board Releases “Revised” SLU Impairment Guidelines on 11/22/17 for Public Comment

 

On 11/22/17, hours before the start of the Thanksgiving holiday, the Board issued itsrevised Impairment Guidelines for schedule loss of use and proposed regulations viaSubject Number 046-1005. In a complete departure from the draft proposed guidelines that the Board issued on 9/1/17 (to which the Board has removed access to from its website), as well as the statutory mandate contained in WCL §15(3)(x), the new revised guidelines are nothing more than the current guidelines that have been in place since 1996 in a new package with a few minor tweaks that will do little to control schedule loss of use (SLU) costs. The regulations that the Board proposed on 9/1/17 that addressed changes to the SLU process, IMEs, and other things have been eliminated and replaced with a new Section 325-1.26 which incorporates the proposed 11/22/17 Impairment Guidelines by reference and requires their use in all evaluations for schedule loss of use. Our summary comments are below; for a more detailed analysis, please read our Summary and Analysis of the 11/22/17 Proposed SLU Guidelineshere.

In April 2017, the Workers’ Compensation Law was revised to include a new WCL §15(3)(x), which required the Board to adopt new permanency guidelines by 1/1/18 for calculation of schedule loss of use that are “reflective of advances in modern medicine that enhance healing and result in better outcomes.” Arguably, the draft guidelines released on 9/1/17 addressed this statutory requirement in providing SLU guidelines that, in general, resulted in markedly lower SLU awards. Rather than relying primarily on loss of range of motion, the 9/1/17 Guidelines ranked injuries according to their severity into A, B, and C groupings to establish a baseline schedule loss. After the initial grouping, the examiner would then be required to analyze loss of range of motion, loss of function, and pain. This analysis would then be combined with the Board’s determination of the claimant’s loss of earning power to determine the final schedule loss of use award. This multi-factored analysis was designed to be reflective of “better outcomes” in healing that one might expect in the 20 years of medical advances since the publication of the 1996 Guidelines. The 9/1/17 draft Guidelines rejected the simple range-of-motion analysis from the 1996 Guidelines and emphasized that determination of SLU was a legal determination based in part on medical evidence and in part on an analysis of the claimant’s “loss of earning power.” The 9/1/17 draft guidelines were met with vociferous opposition from labor and the claimants’ bar.  

Rejecting the new system envisioned by the 9/1/17 draft guidelines, the 11/22/17 revised guidelines return to the 1996 Guidelines, but in a somewhat easier to understand package that attempts to clarify a few ambiguities. As noted above, the 11/22/17 proposed guidelines will result in largely the same awards for SLU as under the current 1996 Guidelines. The primary calculation is based on loss of range of motion. The proposed guidelines contain helpful diagrams illustrating the various motions used in evaluating schedule loss of use. Each section of the proposed guidelines states that the examiner should first assess whether any special considerations apply. If so, then the schedule loss of use enumerated in the special consideration should apply without any addition for loss of range of motion unless the special consideration requires it. If the special consideration is silent on schedule loss of use value, then the examiner can consider loss of range of motion. If no special consideration applies, then the SLU analysis is based solely on loss of range of motion, using the chart provided in each section. Again, the percentage SLU values for loss of range of motion are basically unchanged from the 1996 Guidelines. 

These proposed guidelines present little more than the current 20-plus year old SLU guidelines in a new package. They contain some minor tweaks and provide clarification regarding some issues but do very little to address the enormous cost of schedule awards for major extremities in cases with little or no lost time. Despite its flaws, the 9/1/17 Guidelines would have attempted to address this with the “loss of earning power” analysis.

We recommend that our clients strongly oppose the 11/22/17 proposed guidelines. We suggest that the Board return to the 9/1/17 draft impairment guidelines but eliminate the regulations regarding cooperation with IMEs objected to by labor and the regulations restricting the employer's right to cross-examine the claimant objected to by business. The 9/1/17 draft at least appeared to consider "advances in modern medicine" by tying the SLU evaluation to a claimant's medical outcome, rather than a mere loss of range of motion analysis. The 11/22/17 proposed guidelines do not address the statutory requirements of WCL Section 15(3)(x) because they are virtually the same as the 1996 Guidelines and thus cannot be said to be “reflective of advances in modern medicine that enhance healing and result in better outcomes.”

The proposed guidelines only state that examiners “should consider” the limitation in range of motion in the claimant’s uninjured contralateral limb, which indicate that the loss of range of motion in the contralateral limb should be deducted from the calculation of loss of range of motion in the injured limb. Such comparison was not part of the 1996 or 2012 Guidelines but was included in the initial 9/1/17 draft guidelines. The inclusion of this suggestion in both the 9/1/17 and 11/22/17 proposals highlights its apparent importance. At the very least, when submitting comments to the Board, we would urge our clients to recommendrequiring examiners to compare a claimant’s injured limb with the baseline normal range of motion on the claimant’s contralateral limb andmandate that the loss of range of motion in the injured limb be calculated from the baseline range of motion in the contralateral uninjured limb.
 
Additionally, the award for defects in range of motion should never equal ankylosis or amputation of the relevant joint.  To award a person with reduced range of motion, even if it is marked, benefits equal to a person with no movement in the joint or with an amputation, is inequitable and does not accurately represent the functional loss.  For example, range of motion deficits in the hand may not exceed 55% as ankylosis is 60%.  The same result should apply to all joints.  Placing a maximum of 90% of the value of the ankylosed or amputated member would recognize that some movement is better than none, while at the same time, compensating for significant reduction in function.
 
We recommend that our readers take time to provide commentsvia the Board’s online survey, accessible through this link. The Board will close the public comment period on 12/22/17. Although we expect little more than technical changes from the Board when it finalizes these proposed guidelines, there will be no change at all unless Board hears comments from its stakeholders. 

 

Appellate Division Split Decision Creates New Standard for Permanent Total Disability

 

On 11/16/17, the Appellate Division, Third Department, decided Wohlfeil v. Sharel Ventures, LLC. This split 3-2 decision represents a marked departure from previous practice and precedent on how non-statutory permanent total disabilities are determined. Because it is a 3-2 split decision, the employer and carrier have an appeal as of right to New York State’s highest appellate court, the New York Court of Appeals. It is unknown at this time if the carrier/employer will pursue such an appeal.

At issue was a claim for permanent total disability versus permanent partial disability.  Claimant’s treating physician issued a report with a Class 5F permanent partial disability ranking under the 2012 Guidelines. He also opined a "less than sedentary" work capacity. The carrier’s IME consultant opined a Class 4G permanent partial disability under the 2012 Guidelines.  During deposition testimony, the treating physician said that he gave the claimant, “rather significant restrictions” and that the claimant was “not…capable of performing any type of gainful employment at this time.” The carrier’s IME consultant testified during his deposition that “It was unlikely claimant would ever be able to return to meaningful employment.”

The WCLJ classified claimant with a permanent partial disability and a 75% loss of wage earning capacity. A three-member Board Panel affirmed on appeal. 

The Appellate Division majority reversed, relying on the above statements from the physicians. The Court stated, “Since the Board’s findings as to claimant’s ability to perform some type of sedentary work are contrary to the consistent medical proof presented, the Board’s finding of a permanent partial disability and a 75% loss of wage earning capacity is not supported by substantial evidence….”  Had the Court stopped there and remanded the case for further proceedings regarding claimant’s exertional capacity, this decision would be arguably consistent with previous precedent. However, the Court went a step further and classified claimant with a permanent total disability, stating, “The operative standard here isgainful employment, not some undefined type of limited sedentary work.” (emphasis added). The Court did not define the term “gainful employment.” This statement departs from past precedent, because a claimant has always been considered partially disabled if there is any form of work he or she can do, however limited.  The “gainful employment” standard described by the Court here represents a re-definition of the standard for finding total disability.

Both physicians opined permanent partial disabilities under the Board’s 2012 Guidelines in their reports and only opined total disabilities off-the-cuff during their depositions. The Board's decision finding a 75% loss of wage earning capacity was based on the 2012 Guidelines. The Board is entitled to apply the Guidelines it has promulgated to ensure consistency in disability assessments. The Court’s decision conflicts with previous precedent holding that the Board, in its role as fact finder, is entitled to selectively adopt and reject portions of medical opinions and testimony so long as the final result is based on substantial evidence. In this case, the Board rejected the total disability statements from the treating physician and IME consultant and credited the permanent partial disability assessment from the treating physician based on the 2012 Impairment Guidelines. If previous precedent were applied here, this decision should have been affirmed as a legitimate exercise of the Board’s fact-finding powers to selectively adopt and reject portions of an expert’s medical opinion.

The Court’s decision is further inconsistent with its previous holding inBurgos v. Citywide Insurance Program, which held that a claimant’s exertional ability is irrelevant to the degree of medical impairment.  In that case, the Court rejected a claimant’s argument that a less than sedentary exertional capacity represents a de facto permanent total disability.  Ironically, the New York Court of Appeals, affirmed the Appellate Division’sBurgos holding the very day the Appellate Division issued this decision.  The Court’s decision here appears to rely heavily on the treating physician’s testimony that claimant has a less than sedentary exertional capacity.  In this vein, the “gainful employment rather than some undefined type of limited sedentary work” standard appears to establish ade facto permanent total disability in cases where a claimant has a less than sedentary exertional capacity in direct contravention to the Court’s holding inBurgos.

The Court’s holding also blurs the distinction between the medical issue of permanent total disability and the functional/vocational issue of total industrial disability.  Permanent total disability is purely a question of medical impairment whereas total industrial disability applies to permanently partially disabled claimants who meet various requirements for functional and vocational limitations.

 

Contact Us

 

Hamberger & Weiss - Buffalo Office
700 Main Place Tower
350 Main Street
Buffalo, NY 14202
716-852-5200
buffalo@hwcomp.com

Hamberger & Weiss - Rochester Office
1 South Washington Street
Suite 500
Rochester, NY 14614
585-262-6390
rochester@hwcomp.com

 

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1 South Washington Street       
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Hamberger & Weiss
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350 Main Street
Buffalo, NY 14202
         
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