Compensable Consequence Injury
The California law for workers’ compensation has been reformed in 2013, and the reformation created various challenges for the parties to such a claim to grapple with. Prior to January 1, 2013, workers that sustained injuries were entitled to full workers’ compensation benefits, regardless of where they were injured, and it was irrelevant whether the illness or injury that the worker sought compensation for was a “direct injury” or a “compensable consequence” resulting from a “direct injury”.
The reform, however, created a new challenge which was to be faced by claimants to workers’ compensation claims. While those who have sustained injuries at their workplace which are perceived by the law as “direct” are still entitled to all of the workers’ compensation benefits as before, the reform provisions of the Californian workers’ compensation law (SB863) added rules which are unique and specific to certain compensable consequences.
The complicated nature of distinguishing legally between direct injury and compensable consequence injury is an ample illustration of why it is good to contact workers compensation attorneys Los Angeles based to be consulted when facing such a claim. In order to provide clients and readers with basic insight on the issue, we have provided you with general clarifications.
What is the distinction between compensable consequence and direct injury?
The distinction is particularly important, because employees bringing workers compensation claims for direct injuries may qualify for higher amounts of compensation if it can be shown that they suffered a secondary injury as that occurred as a result of the direct injury.
Where workers compensation is concerned, direct injury is one where the cause of the injury was direct and cannot be disputed. For example: you are working in a warehouse and a box full of items falls on you, the injury you sustain as a result would be a direct result of that.
In contrast, a compensable compensation injury is a secondary injury which has developed as a result of the first, direct injury. For example, PTSD, sexual dysfunction, sleep disorder, or a bilateral body part injury which may have appeared as a result of the first injury. While this a simplified explanation and not a complete list of compensable consequnece injuries, it may make it seem like an easily distinguishable issue, in reality this is rarely so.
How may one determine when there is “compensable consequence”?
Compensable consequence is not specifically defined in the Labor Code, but rather finds its definition in relevant case law. The doctrine of compensable consequence has been explained in the following wording:
“Under this doctrine, where a subsequent injury is the direct and natural consequence of an original industrial injury, the subsequent injury is considered to relate back to the original injury and it generally is not treated as a new and independent injury” (Bates v. Serologicals Corp, 2013 Cal. Wrk. Comp. P.D. LEXIS 194 [2013 Cal. Wrk. Comp. P.D. LEXIS 194]).
The case cited above involved a laboratory technician who suffered an industrial injury related to his duties in the form of carpal tunnel cumulative trauma to his right wrist. After returning back to work, in fulfilling his day-to-day duties, the technician had to push a cart of lab equipment, which was a duty he could perform with difficulty due to his injured right arm, and he pushed the cart using only his left arm and his hips. One day, his left knee gave in and his lower body on the left was injured.
While seemingly not connected if viewed separately, the injury to the left side of the technician’s body could be actually seen as a result of him being unable to use both arms while pushing the cart.
What case law points to is that the determining factor is whether or not the original injury is a contributing cause to the injury in question. The answer to that question is reviewed on a case-by-case basis and the decision to be made based on a medical determination.
What are some types of compensable consequence?
This section examines some examples of instances where the court has determined that the injuries have not been direct, but rather compensable consequence injuries. This would help you in visualising the difference between direct and compensable consequence injury in the eyes of the Court.
1. Substance addiction – the Claimant had sustained a back-injury which was work-related. She subsequently developed an addiction due to her excessive use of pain medication in order to relieve the back pain caused by the work related injury. The Court held that treatment must be provided, as the addiction was caused by the back injury, thus making it a compensable consequence (Ballard v. WCAB, (1971) 36 Cal. Comp. Cases 34 [36 CCC 34] case).
2. Sexual impairment – the Claimant had suffered an industrial back injury, which led to the use of opioid substances. In turn, that use of opioid substances led to a sexual impairment. The Claimant was rewarded medical treatment for the sexual impairment, as it was considered to be a compensable consequence of the underlying industrial injury (Grom v. Shasta Wood Products, SCIF, (2004) 69 Cal Comp Cases 1567 [69 CCC 1567]).
3. Sleep disorder – the Claimant sustained an industrial back injury and later on suffered from sleep apnea. It was determined that the sleep apnea was the result of the weight gain associated with the inactivity that was caused by the Claimant’s back pain, and thus was a compensable consequence Miller v. California State University, (2012) 2012 Cal. Wrk. Comp. P.D. LEXIS 589 [2012 Cal. Wrk. Comp. P.D LEXIS 589]
This list is non-exhaustive and the case law presented here serves as a means to demonstrate, to the reader, the logic that the courts utilize in determining compensable consequence injuries.
What were the SB863 changes introduced to the treatment of compensable consequence injuries in 2013?
Depending on the circumstances, the level of the final permanent disability rating can possibly be increased as a result of the worker sustaining a compensable consequence injury. For all injuries that have been sustained, however, the date at which they were sustained is important. If an injury was sustained after January 1, 2013, the threshold for a compensable consequence injury which may lead to an increase in a worker’s whole person impairment (WPI) has changed.
According to the Labor Code § 4660.1(c)(1), “…there shall be no increases in impairment ratings for sleep dysfunction, sexual dysfunction, or psychiatric disorder, or any combination thereof, arising out of a compensable physical injury. Nothing in this section shall limit the ability of an injured employee to obtain treatment for sleep dysfunction, sexual dysfunction or psychiatric disorder, if any, that are a consequence of an industrial injury.”
Therefore, the amendment to the law has excluded the following three compensable consequence injuries listed above (i.e., sleep, sex and psych disorders), and those injuries will no longer be entitled to an increase in their whole person impairment (WPI) rating, but they may still be entitled to receiving medical treatment for those injuries under their work comp benefits.
But, if the claimant manages to prove that these disorders are either specific industrial injuries or industrial cumulative traumas, they may still be eligible for the WPI increase. This, again, would entail a detailed assessment of your particular situation and case facts, which as emphasized would include involving a workers’ compensation lawyer.
Is medical evidence of importance?
When dealing with workers’ compensation claims, medical evidence is always of importance. In cases where compensable consequence is concerned, the medical evidence will be the main consideration when deciding on the substance of the claim. It is therefore of extreme importance for each person who intends to bring a claim that the physician he or she contacts will be able to correctly identify the concepts and understand the nuances of LC 4660.1(c)(1), and have a thorough understanding of the workers compensation system.
The qualifications that need to be addressed in such circumstances include the following:
· Has the physician correctly explained the mechanism of injury?
· Has the physician identified an injury subsequent to the original industrial injury as a compensable consequence?
· If so, has the medical evaluator provided a thorough analysis, as well as a conclusion, of causation of the compensable consequence injury?
· If WPI increase is requested for the compensable consequence impairment caused by the industrial injury, is the injury subject to the new provisions of SB863?
· If the compensable consequence is psychiatric in nature, does it qualify for one of the exceptions to the WPI increase bar per LC 4660.1(c)(2)?
· If an argument is being made that a psych compensable consequence injury has resulted from a “catastrophic” industrial injury per LC 4660.1(c)(2)(B), have any of the physicians made a determination that the underlying physical industrial injury constitutes a “catastrophic” one?
· If the WPI increase is appropriate, has the medical evaluator provided a thorough analysis, as well as a conclusion, for causation of disability?
As it can be easily inferred from the information presented above, all matters pertaining to workers’ compensation laws are difficult to navigate and there are a lot of considerations to be taken into account when dealing with such an issue.
Our Workers Comp Attorneys Los Angeles remain at your disposal for providing you with the necessary advice based on our extensive experience, which shall always be tailored to your specific needs and shall provide you with the advice necessary in order for you to obtain the maximum benefits that you may be entitled to from the protections provided under California workers’ compensation laws.