2-8-12; If you are defending/adjusting “non-accident accidents” watch your nomenclature, defense folks.

You can lose or mitigate all defenses by making one simple mistake. We have one great KC&A defense lawyer defending a claim involving a guy walking with a dolly (or two-wheeler) loaded with product and his leg got sore and/or popped. Claimant didn’t slip, trip or have anything even slightly unusual happen. Sadly, claimant is an older worker with a sore leg. We don’t see an accident in the accident investigation or medical histories but they are claiming one occurred.

Another KC&A defense attorney is defending a fully disputed stroke case—the guy felt a headache a couple hours before work and the condition really got bad an hour or two into work. Claimant wasn’t doing anything rushed, emergent or unusual. However, counsel is seeking full coverage. Please note if they prevail on this stroke, even though claimant is back to full work, if he has another stroke at work or at home or at a ballgame, the IWCC might relate it to this “event.”

If you review the facts above, neither case has an “accident” described—by that we mean nothing hit either claimant, they didn’t hit anything, no slip/trip, there was no safety breakdown or failure by the employer. You can’t prevent “non-accident accidents.”

In such claims, not to sound fussy, please take out the words “accident” and “injury” from any analysis, report or review. Please do not use the word “accident” or “injury” in your file, summaries or the IME background letter.

Probably more important for defense claims handlers, please ask your defense IME doctor and other experts not to use those words in their reports unless they are given a medical history of trauma or unusual occurrence that we don’t have. If you are an IME doctor in this state and want to provide value to your defense clients, consider this article carefully before you casually use such terminology.

Instead, we strongly urge everyone on the defense side of the workers’ comp matrix to characterize such events as “onset” or “alleged occurrence” or “event.” The problem we feel occurs if we call or name the onset of a medical condition at work an “accident” or “injury” and then send a letter to the IME saying it is an accident or injury, we start down the road of admitting an “accident” or “injury” occurred when the main issue is whether the sore hip/stroke or onset of problems has anything to do with work.

When you or an IME doc starts by calling the event/onset an “accident” or “injury”, in our view as veteran defense observers, you have gone half-way or more to losing the claim.

In the leg claim above, our IME doctor said the “accident was a temporary exacerbation of the underlying degenerative problem”—in Illinois, the Arbitrators aren’t going to focus on the word “temporary” in that opinion, they are going to focus on the implicit admission claimant had an “accident” when he didn’t have an event your mom or pop would consider accidental. Again, if you call it onset or claimed event or alleged occurrence, we affirm this problem at work had nothing to do with a  safety breakdown, trauma to client from an outside source or any of the issues that surround any definition of “accident” or “injury.” We should still be able to defend it.

To fully disclose, we are defending the claims above, we have not included strong identifying information and have no intention of affecting the outcome of the litigation—our goal is to advise our readers of the problem for future claims. We appreciate your thoughts and comments. Please do not hesitate to post them on our award-winning blog.

2-8-12; The Workers Compensation Research Institute reports Illinois highest in WC hospital outpatient costs. Sort of.

Please note some of these research results are from prior to the modified Illinois Medical Fee Schedule and some results are after it. Most important, this research cannot evaluate the impact of the sweeping cuts implemented by the 2011 Amendments to the Illinois Workers’ Compensation Act where actual treatment costs were brought down to just over 50% of hospital billings in the workers’ comp sector. For those reasons, we don’t consider their report/research to be critically important for our administrators and legislators to be concerned about. We do feel the report is noteworthy and wanted to give our readers the chance to review and understand this national news story.

Either way, WCRI just issued a report comparing outpatient hospital costs among 17 different states. WCRI researchers found the costs in states without fee schedules were 27-73 percent higher than the median of the study states with fee schedules. Also, states with fee schedule regulations based on a percentage-of-charges had higher costs compared to states with other types of fee schedules, such as per-procedure based or ambulatory payment classification based fee schedules with the exception of Illinois. The study measured hospital outpatient/ASC costs paid over a seven-year period from 2003 to 2009. Please note Illinois adopted medical cost reforms in 2005-6 and additional medical cost controls were enacted in 2011. The cost impact of PPP’s has not yet hit, as the concept is still tied up in rules committees.

Either way, WCRI found Illinois had the highest hospital outpatient costs among the 17 states and was 45 percent above the median study state, as of 2009. Researchers focused on services associated with the most common surgeries performed in workers' comp cases "since surgery-related costs make up approximately 60 to 70 percent of all outpatient costs," the report says. The services included diagnostic conditions involving knees and shoulders.

The 17 states studied were California, Florida, Illinois, Indiana, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, New Jersey, North Carolina, Pennsylvania, Tennessee, Texas, Virginia, and Wisconsin. They represent 60 percent of the workers' comp benefits paid in the U.S., according to the researchers. While Illinois had the highest costs among the states, Massachusetts had the lowest and was 60 percent lower than the 17-state median. Illinois' cost was more than three times the cost in Massachusetts for similar outpatient surgical episodes.

Five states studied had no fee schedule regulation as of 2009 -- Iowa, Indiana, New Jersey, Virginia, and Wisconsin. All had higher costs compared to states with fee schedules. Four states had fee schedule regulations based on percent of charges -- Florida, Louisiana, Minnesota, and North Carolina. The costs in those states were "67 to 113 percent higher than the median of the study states with other types of fee schedules," the study says.

With the exception of Illinois, states with per-procedure based or ambulatory payment classification-based fee schedules had relatively lower costs among the states studied. This analysis held true for six states including California, Maryland, Massachusetts, Pennsylvania, Tennessee, and Texas.

The researchers found growth in hospital outpatient/ASC costs resumed at faster rates after fee schedule changes in states with fee schedule regulations based on percent of charges rather than other types of fee schedules. For example, both Florida and California saw short-term cost decreases due to fee schedule reductions imposed around the same time. However, the costs in Florida resumed at faster rates than California. In 2004, California adopted an ambulatory payment classification-based fee schedule with maximum facility fees set at 120 percent of Medicare, while Florida adopted a percent of charge-based fee schedule. The following year, the hospital outpatient/ASC costs in Florida grew at 7 percent a year and increased 42 percent from 2004 to 2009. California, on the other hand, saw a slower increase of 30 percent, driven mainly by increases in the components of the fee schedule regulation, according to the report.

We thank the nice reader who sent this article for review and analysis. If you want the link to the WCRI article, send a reply. We appreciate your thoughts and comments.

2-8-12; The never-ending debate on the judicially legislated concept of “odd-lot” total and permanent disability rages

The Workers’ Compensation Division of the Illinois Appellate Court dispatched a rare reversal of the Commission despite the seemingly insurmountable “manifest weight of the evidence” standard. In doing so, the Court defined the limits of the “odd-lot” permanent and total disability theory. In Professional Transportation Services v. IWCC (WCC 3472012 IL), the Appellate Court considered an “odd-lot” permanent total disability award issued by the Commission.

Don’t spend a lot of time trying to find the words “odd-lot” in the IL WC Act

Your editors cannot help to point out the term “odd-lot” appears nowhere in the Illinois Statute. This concept of odd-lot total disability is a creation of our Commission and reviewing courts. In our view, it is a classic example of judicial legislation which permits a windfall of benefits to claimants who are clearly employable but find a way to remain unemployed until their payday hits at the Commission.

Please note the vast majority of Illinois state workers adjudicated to be totally and permanently disabled fall into the “odd-lot” category because our State government won’t defend such claims or offer substitute jobs. We are starting to call this phenomenon “odd-State-lot” claims—all of such claims could be ended immediately at a massive savings to Illinois taxpayers if State government leaders would locate alternate work for them and cut off their “double pensions.” Good luck waiting for that to occur.

That said, we are moderately comforted by the Appellate Court’s reversal of the IL WC Commission here, where the claimant clearly had the ability to work at a sedentary level according to his own doctors and an FCE, and where specific jobs were identified for which he was qualified.

This claimant, Mr. Clarke, was a 64 year old van driver assigned to shuttle workers to and from worksites. The slip and fall accident was not disputed and Petitioner had bilateral knee replacement (one replacement was disputed). Upon MMI, there was a sedentary release per an FCE.

A labor market study was performed by David Wolf, a vocational rehabilitation counselor employed by Respondent Professional Transportation. Wolf found, based on FCE restrictions, the claimant could not return to his employment as a van driver for Professional. He concluded the claimant had no "clear" transferable skills. Wolf believed claimant could perform as an entry-level cashier for an employer that would accommodate claimant's restrictions as to standing, walking, climbing, stooping, reaching, and lifting. Wolf concluded his report by stating, based upon the information provided by claimant, "it appears as if [the claimant] is capable of returning to work in a cashier position at an auto dealership." Jobs at dealerships were specifically identified as well.

At trial, the arbitrator awarded 65% loss of the leg and found claimant failed to prove his entitlement to PTD disability benefits either on the basis of medical evidence or on an "odd-lot" The Commission reversed, finding Petitioner permanently and totally disabled under the odd-lot theory.

Odd-lot Standard and “burden shift”

On appeal, our Appellate Court explained an injured employee can establish entitlement to PTD benefits under the IL WC Act in one of three ways, namely: by a preponderance of medical evidence; by showing a diligent but unsuccessful job search; or by demonstrating because of age, training, education, experience, and condition, there are no available jobs for a person in his circumstance, noting "an employee is totally and permanently disabled” when he is unable to make some contribution to the work force sufficient to justify the payment of wages.

The claimant need not, however, be reduced to total physical incapacity before a total permanent disability award may be granted. Rather, our courts rule a person is totally disabled when he/she is incapable of performing services except those for which there is no reasonable stable market. Conversely, an employee is not entitled to total and permanent disability compensation if they are qualified for and capable of obtaining gainful employment without serious risk to health or life.

Once the employee has initially established they fall in what has been termed the "odd-lot" category (one who, though not altogether incapacitated for work, is so handicapped that he will not be employed regularly in any well-known branch of the labor market), then the burden shifts to the employer to show some kind of suitable work is regularly and continuously available to the claimant.

In applying this standard, the Appellate Court correctly pointed out there was no medical evidence which could support a claim of total disability in this case. To the contrary, Drs. Smit, Michalow, Sheinkop, Cohen, and Fletcher each voiced opinions claimant could work, albeit with varying restrictions. As for evidence claimant engaged in a diligent but unsuccessful job search, the Appellate Court called claimant’s effort “meager” and agreed with the arbitrator, who concluded claimant failed to demonstrate he made diligent but unsuccessful attempts to find work. The Court explained that applying for cashier positions at nine auto dealerships and looking in the Sunday newspaper did not constitute a diligent job search.

The Court was then left then with the question of whether the evidence of record can support the Commission's conclusion: “Because of his age, training, education, experience, and physical condition...” claimant was not regularly employable in a well-known branch of the labor market.

In reversing the IL WC Commission, the Court concluded claimant failed to carry his burden in that regard, as he failed to present sufficient evidence he could not find stable employment. Basically, claimant’s job search was insufficient to prove he was unemployable. While we agree with the decision rendered by the Court, we remain alarmed that under slightly different facts, all this claimant would have to do is demonstrate a bit more effort with his job search and he may have perfected his six or seven-figure odd-lot permanent disability award.

We find it incredible a claimant’s entire team of doctors and a vocational expert can all agree a claimant is employable, yet, our IL WC Commission still reserved the right to declare them totally disabled from all work. Based on the legal analysis of the Court, such an award can be based on a valid but unsuccessful job search alone.

Why is this so alarming?

Illinois residents continue to struggle with 10% unemployment and a sluggish economy. There are tens of thousands of able-bodied, educated folks who cannot find work. Their inability to secure a steady job does not make any one of them regularly unemployable. Rather, many of the unemployed are simply victims of this rotten economy. Similarly, the claimant in this case, as in other alleged odd-lot disability claims, is not unemployable at all. He is very employable based upon unanimous medical and vocational expert testimony. Under such circumstances, we believe no claimant should ever be deemed permanently disabled. We know of no other state workers’ compensation system which affords lifetime disability benefits to a claimant who is medically cleared to work by his entire team of doctors. Only in Illinois!

What does this all mean for your biggest wage differential claims? Claim handlers and risk managers must beware of the otherwise employable claimant with permanent restrictions who trudges along with an “unsuccessful” job search for too long. After six or seven months, if no work is secured, aggressive Petitioner’s attorneys will turn your own vocational efforts against you with a claim of “odd lot” disability, simply because the claimant has had no luck finding work. You need to ramp up decision-making and documentation with your voc specialists.

This article was researched and written by John P. Campbell, Jr., J.D. Please feel free to contact John about it at jcampbell@keefe-law.com.