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One workers’ compensation benefit that may not be as well known is the benefit provided for harm to a worker’s mental health. Like physical injuries, these injuries must be caused by an accident that occurred in the workplace or during the performance of work-related duties. The Reviewing Board decision of O’Rourke v. New York Life Insurance (Bd No. 012706-11) reveals the considerations an ALJ must make when determining whether or not to award medical and total incapacity benefits for injuries that affected both physical and mental health.

In this lawsuit, the injured worker was a vice president of marketing and held a Master’s degree in Science and Administrative Studies. She was injured when a magnet weighing half to three-quarters of a pound fell from a door jamb onto her forehead. The woman was taken to the hospital and diagnosed with a concussion. Her injuries produced severe headaches and tingling along the left side of her nose and face, around her jaw, and up the other side of her face. The woman additionally suffered lower back and neck pain. She returned to work within a week part-time, and eventually she returned full-time. However, the pain, combined with depression and anxiety, prevented her from concentrating and fully functioning at her job.

The injured worker attempted various schedules, both part-time and full-time, while also seeking treatment for her numerous injuries. Two surgeries were performed in order to reduce the headaches and pain in her jaw. While the surgeries were partially successful, they failed to fully remove the pain in her jaw and teeth. After three years passed, the worker’s surgeon opined that she was unable to continue working. The worker claimed partial disability benefits from August 1, 2013 to September 15, 2014, and then total disability from September 16, 2014 onward. The judge ordered that the benefits be paid based on her earnings from August 1, 2013. All parties appealed.

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Underinsured motorist benefits are designed to help pay for costs related to a car accident when the at-fault party’s insurance policy falls short. Underinsured coverage is generally elective, and several cases have looked at whether or not benefits were explicitly rejected. In Progressive Direct Ins. Co. v. Wilson (16-P-544), a mother and a son appealed a declaratory judgment entered in favor of the mother’s auto insurance company. The insurer claimed that the policy only provided underinsured benefits to members of the household, and the son was not a member of the household as defined by the policy.

The mother and son argued that the court erred by granting the insurer’s motion, and the insurer should be estopped from denying the son benefits based on a conversation the mother had with a representative.  The appellate court looked first at the mother’s policy, which provides damages to “any household member…while occupying an auto not owned by you.” The household member must be related by blood, marriage, or adoption. To counter the mother and son’s claim, the insurer provided medical records, a driver’s license, and a lease to show that the son lived in Unit One of the building, rather than Unit Two, where his mother resided. The insurer also pointed to a conversation the mother held with an insurance representative prior to the purchase of her policy. In that conversation, the mother stressed that the son did not live in the unit with her and that he lived downstairs.

At the lower court, the mother and son insisted that they did live in the same household, pointing to all of the parties doing laundry in Unit One, the fact that both units were always accessible to the other members of the family through unlocked back doors, and the tradition of the mother cooking for the entire family. The mother viewed the conversation with the representative as proof that she relied on the representative in her understanding of the policy. The court disagreed, finding that estoppel was not applicable in this circumstance. For estoppel to occur, there must be a representation that is intended to induce reliance, an act or omission by the person because of the reliance, and a detriment as a consequence. The court did not think the mother could come away from the conversation with the mistaken understanding that her son was covered under the policy because the bulk of the conversation dealt with where he didn’t live. The representative did not make any statement or implication that the son did not need to be listed in order to receive underinsured benefits. There was no mention of underinsured motorist coverage. The lower court’s ruling was upheld, and the declaratory judgment against the insured and her son remained intact.

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Most would agree that it is challenging to deal with any type of car accident, regardless of the level of the injury. In Adams vs. Congress Auto Insurance Agency (15-P-452), the injured driver had to unfortunately deal with an at-fault party who not only struck his vehicle but also called posing as a state police officer, attempting to intimidate him. The at-fault driver was chased by the police while driving his girlfriend’s car, ultimately wrecking it. The girlfriend, when filing her claim for her wrecked vehicle, also looked at the private information of the injured driver and provided this information to her boyfriend, which allowed him to make this call.

Eventually, the girlfriend and the boyfriend both pled guilty to criminal charges, admitting that they attempted to intimidate the injured driver. The individual involved in the accident then pursued civil action against the girlfriend’s employer, claiming that they were liable for the misuse of her position. Three years before this accident, the girlfriend had an encounter with law enforcement in Iowa. Two loaded semi-atomic weapons were found in her purse. She was eventually released on bail and returned to work at the agency. Eventually, she was arrested by the U.S. Marshals Service at her workplace. Her manager advised the owner of the company of this arrest, but the owner conducted no independent examination of the arrest or the underlying case, figuring it did not have much to do with her employment. The girlfriend was allowed to continue work. Seven weeks later, the car accident that gave rise to this case occurred.

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Massachusetts General Laws c. 152, § 11A(2) of the Workers’ Compensation Act states that an impartial medical examiner is to be used whenever there is a dispute within a claim or a complaint over medical issues that is the subject of an appeal. In order to offset the cost of the medical examination, the injured worker must submit a fee equal to her or his average weekly wage in the Commonwealth at the time of the appeal. A failure to do so can quash the appeal, as seen in the Reviewing Board decision of Saini v. Jeffco Fibers, Inc. (Board No. 044894-91).

In this case, the employee had a work injury in 1991 and settled four years later for $145,000. Eleven years after the settlement, the injured worker filed a claim for the payment of medical bills, which was denied by the ALJ. A timely appeal was filed but was not accompanied by the appeal fee. Notice was sent to the claimant’s attorney, but the fee remained unpaid. A month after the notice of the overdue fee was sent, the case was withdrawn. The injured employee’s attorney complained after the withdrawal, but the ALJ kept it in place, pointing out that the impartial medical examination was not waived by the insurer. A second and third claim were filed but were also withdrawn. Eventually, at another hearing, an ALJ formally denied and dismissed the claim for medical benefits, tying it back to the original submission and pointing out that the failure to pay the fee amounted to an acceptance of the order under General Laws c. 152, § 10A(3).

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At an administrative hearing for Social Security Disability, the administrative law judge (ALJ) may hear from a vocational expert (VE) to help determine whether or not the applicant qualifies for SSDI benefits. The vocational expert provides impartial expert opinion evidence that gives insight on the physical and mental demands of a job, the work setting, the type of labor performed in a certain job, and whether certain skill sets are transferable. The Eighth Circuit Court of Appeals case Gieseke v. Colvin (No. 14-1395) reveals the effect a VE’s opinion can have on an SSDI claim.

In Gieseke, the claimant suffered a long history of low back pain, which worsened following a work injury. The claimant went to physical therapy and returned to work with restrictions for several more months. He applied for disability, citing the lower back issues, leg problems, and dizziness as reasons he could not work. At the hearing, the ALJ found that he had a history of degenerative disc disease of the lumbar spine, obesity, and a history of substance abuse. Regarding his physical abilities, the judge found that while he was unable to perform his past relevant duties, his residual functional capacity (RFC) showed he had the ability to perform light work. The ALJ made these determinations based on the VE’s testimony and found that the claimant could work as a cashier, security guard, or usher. Since the claimant had the ability to work, his SSDI benefits were denied.

On appeal, the claimant argued that the ALJ did not give enough weight to the testimony of the claimant’s treating physician. The claimant’s physician testified that he was limited to lifting less than 10 pounds occasionally or frequently, standing for less than two hours a workday, frequently changing seated positions during the workday, and never climbing, crouching, stooping, crawling, or kneeling. This contrasted with the ALJ’s finding he could lift and carry 20 pounds occasionally, lift and carry 10 pounds frequently, stand and sit for six hours a day, and sometimes balance, stoop, crawl, kneel, or crouch. The treating physician’s assessment would have limited the claimant’s ability to do almost any type of sedentary work.

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When an accident occurs outside a business on a walkway, it can be initially difficult to tell who is responsible for a walkway when there are hazards. A recent Appeals Court case, Halbach v. Normandy (15-P-1500), discusses how liability is determined when the sidewalk right outside a business actually belongs to the city or another property owner. In this case, the injured man suffered serious injuries after he fell on uneven pavement outside a parking garage.  The sidewalk was public property. The building was maintained by a separate group, which the injured man alleged was responsible for repairing the sidewalk or warning pedestrians of any hazard.

The managing company moved to dismiss, and the trial court granted it. To prove negligence occurred, one must show that a duty existed under the law. Under premises liability case law, the owner or manager of a business must use reasonable care to protect guests from harm. However, the scope of the duty created only extends to areas for which the business is actually responsible. The lower court ruled in this case that the managing company did not owe a duty to the injured pedestrian. The appellate court looked at whether the lower court was correct in its determination and also addressed whether the scope of the duty should be extended.

The injured pedestrian tripped and fell near a garage. The pavement was uneven on the sidewalk owned by the city, which was adjacent to the garage maintained by the defendants. After the accident, the managing company hired someone to grind down the uneven pavement. The injured pedestrian initially argued that the managing company exercised control over the sidewalk, and because of this control, it owed a duty to the injured party. The Appeals Court pointed out that the duties of an owner of property abutting a sidewalk or another public way are limited. Case law states that an owner cannot create a hazardous condition that could interfere with travel but does not have an affirmative duty to keep a public sidewalk clear.

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During the course of a career, the employing company may re-organize different aspects of its business, including its workers’ compensation insurer. Workers’ compensation law provides for this situation, in the event that a long-term worker suffers an ongoing injury with another injury. The successive insurer rule requires an insurer to pay for the compensation of all of the injuries that a worker suffers, even if it was not the insurer when the original incident or ongoing injury occurred. As long as the recent injury has a causal relation to the disability claimed, the insurer must cover the risk. The insurer must take the employee “in the condition in which he finds him,” so the provision of benefits is streamlined and expedited.

In Linton v. G.P.C. International (Bd. No. 035380-10), the second insurer appealed a decision granting medical benefits for a repetitive injury to an employee’s right shoulder. The employee worked for the employer since 1996, performing repetitive, heavy lifting of 75 to 100 pounds as a paper processor and machine operator.  He began having pain in 2003 in his right arm, which resulted in physical therapy. Seven years later, the worker returned for shoulder pain care and could not work for two months. During this period, he received weekly workers’ compensation benefits. The first insurer paid for medical expenses, including physical therapy and a TENS unit he still uses.

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As one nears retirement, many decisions await from family to financial matters. A recent federal appellate decision, O’Shea v. UPS Retirement Plan (No. 15-1923), reveals the importance of careful estate planning alongside serious illnesses or retirement. In this case, an employee, diagnosed with cancer, died one week before his official retirement date but after his final day of work. Following a diagnosis in the previous year, the employee originally planned to retire at the end of the calendar year. The employee met with a human resources supervisor, who advised him to take his accrued time, which pushed back his official retirement date. This advice given was standard practice, and the HR supervisor had no knowledge that he was terminally ill.

Following the submission of his retirement application, the employee was told that his annuity start date would be March 1, 2010 after his official retirement on February 28, 2010. The employee chose the Single Life Annuity with 120-Month Guarantee and named his children as the beneficiaries. The Guarantee allowed him to receive payments of over $4,000 each month for 10 years. If he died during this term, his listed beneficiaries would receive the payments. Neither the HR supervisor nor the retirement benefits applications made it clear that he needed to live until the annuity start date on March 10, 2010 for the guarantee to be realized. The employee was unaware that he risked forfeiting his payments by delaying the retirement date.

While the retirement application did not explicitly lay out the requirements in the body of the application, it did note that the benefits plan designations are subject to the terms of the Plan. The Plan states that payments can be made to the beneficiaries if the participant dies before the first payment but after the annuity starting date. The only exception listed is for a spouse or domestic partner, who would be entitled to receive a pre-retirement survivor annuity. In addition to the annuity plan, the employee also participated in the Special Restructuring Program, which provided a year’s compensation in exchange for signing a release of claims and retiring. The employee accepted this with his attorney on February 12, 2010 for a single pre-tax payment of $98,800. The release included his employer and “all related companies,” which included the benefit programs, as well as any claims of which he might not know.

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Duty is a term that one may hear frequently in a personal injury lawsuit. In any negligence action, it is one of four elements that must be proven at trial to hold a defendant liable for her, his, or its actions. The duty to act in a certain manner to ensure the safety of others is often created by statute. However, certain duties are strengthened or lessened by case law formed by one or more appellate decisions. This can be seen in a recently issued wrongful death case, Bernier vs. Smitty’s Sports Pub, Inc. (No. 14-P-1967).

In this case, the decedent patron had entered the rear entrance of a pub. He opened a door with an “Employees Only” sign, thinking it was the bathroom. The bathroom’s door and the “Employees Only” door looked similar. However, the “Employees Only” door opened into a concrete staircase with a large drop. This door was typically locked during business hours but was unlocked at this time, causing the man to fall and injure himself. The man died a couple of weeks later as a result of his injuries. His estate filed suit against the pub, alleging negligence, and a jury found the pub to be 80% negligent and the deceased to be 20% negligent.

The pub appealed, arguing that they did not owe a duty to the man because he was a trespasser. Under case law, a landowner owes a duty to those it invites onto its property. The premises must be maintained in a reasonably safe condition, with the owner acting as a reasonable person would act. A court will consider the likelihood of injury to others, the seriousness of the injury, and the burden of avoiding the risk. However, if the person is a trespasser, this duty disappears. A landowner is only required to refrain from reckless or wanton conduct that could cause harm to a trespasser. A trespasser cannot file a negligence action against the owner of the property.

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When you work at a physically intensive workplace for a long time, minor to moderate individual injuries that occur over several years can become a sustained injury. A recent Reviewing Board Decision, Breire v. Lowell General Hospital (BOARD NO. 036471-11), highlights considerations made by deciding authorities in Massachusetts’ workers’ compensation system. In this case, the injured employee worked for nearly 40 years as a certified nurse’s assistant (CNA). Throughout this time, she incurred several injuries, some from the workplace and some from her personal life.  Those of note included a workplace injury in which she hurt her back lifting a 350-pound man into a car, as well as car accidents outside work in which she hurt her back and neck. The injured CNA also sustained multiple injuries while working for the employer in this case, hurting her back, hip, and neck on different occasions over 10 years.

The injury that led to this litigated claim occurred when she helped her co-workers lift a 400-pound patient. The CNA suffered hand, neck, and back injuries. On the date of the injuries, she finished her shift, and she returned to work the next day but eventually sought a leave of absence from her job. The injured worker advised her employer that she could no longer perform her duties, due to the combination of injuries suffered. The employee sought temporary total disability benefits, among others. The insurer filed a denial, arguing that the injury suffered was not a workplace injury. After a conference and a hearing, the Administrative Law Judge (ALJ) awarded the injured CNA § 34A (total permanent disability benefits), finding that the last injury was the major cause of her disability.

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