Workers’ Compensation Claim Disallowed for Failure to Establish Causal Relationship on Appeal
Case Study

Workers’ Compensation Claim Disallowed for Failure to Establish Causal Relationship on Appeal

November 3, 2020

The New York State Workers’ Compensation Board has disallowed a complex workers’ compensation claim in a matter involving a claimant employed in the health care sector who alleged stress-induced cardiomyopathy.

The claimant was the sole employee and medical practice manager at the office of his brother, a health care provider. Prior to retaining counsel, the claimant allegedly developed intense pressure and chest pain while preparing surgery preauthorization documentation. The initial claim was for an alleged myocardial infarction; however, during preliminary depositions, Goldberg Segalla associate Ashley Payne, a member of the firm’s Workers’ Compensation practice, obtained a concession from the treating physician that led to a finding of no prima facie medical evidence. The claimant subsequently produced his own IME and alleged stress-induced cardiomyopathy. Notably, after retaining counsel, he filed a revised C-3 claim, adding new details to enhance the argument that the claimant experienced unusual stress.

With no employer witness (as the employer/insured was also the claimant’s brother) and despite obtaining a concession from the claimant that the work he was doing on the date of the alleged accident was not out of the ordinary, the judge found his testimony credible, as well as the testimony of the claimant’s IME. The case was established for stress-induced cardiomyopathy, and the carrier was directed to pay all medical expenses and pay three months of indemnity awards.

On appeal, Ashley argued that the claimant failed to show that he experienced stress greater than what normally occurs in his work environment and that the medical evidence did not support a finding of causal relationship. She also argued that the claimant failed to provide any evidence that the fate of the medical practice was dependent on the successful authorization of the procedures for the cases he was working on at the time of the incident. She highlighted that this narrative did not come to light conveniently until after he retained counsel, and also noted his concession that this was not the first occasion he experienced difficulty obtaining preauthorization for a procedure. She also argued that he had other preexisting medical conditions that could have caused his episode, and the medial record indicated that the condition could be idiopathic in nature.

Based on the varying diagnoses presented throughout the claim, there was no clear agreement on the diagnosis and the claimant couldn’t change his claim to fit the medical testimony. Ultimately, Ashley argued that the carrier should not be held liable for speculations. The Board unanimously found in our client’s favor, holding that the claimant failed to establish causal relationship and disallowed the claim. The claimant filed an application for full board review, which was denied on September 22, 2020.

 


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