Workers' Compensation Defense

The hearing was to challenge the Pennsylvania Bureau of Workers’ Compensation Fee Review Section’s final determination that an injured worker’s shoulder surgery expenses must be paid by the insurance carrier and the employer. We argued that the work-relatedness of the shoulder surgery is currently in dispute, thus barring the Bureau’s attempt to compel payment. We also proffered the argument that due process of the provider remained intact since a challenge to work-relatedness must be adjudicated before a provider has standing to challenge the amount or timeliness of payment. The decision of the court quashed the Bureau’s determination and held that no surgical expenses are payable.

The case involved a compensable claim for right hip and shoulder fractures sustained in a fall. At issue was the level of permanent disability for the compensable injuries and the relatedness of a subsequent hip replacement surgery. The petitioner’s demand before trial was more than $450,000, plus almost $78,000 for medical expenses. The employer’s final offer was $180,000. After a three-day trial in Ocean County, the judge awarded permanency benefits totaling less than $153,000. Further, the judge determined that the hip replacement surgery was not related and denied the entire $78,000 medical bill claim.

We successfully defended a survivor’s claim for Federal Black Lung Benefits. The miner had worked 11 years in underground mining, had acknowledged simple coal workers’ pneumoconiosis (CWP), and died due to heart failure and COPD (per the death certificate). The judge credited the opinions of our medical expert that the miner’s simple CWP did not cause or hasten his death, and rejected the opinions of the claimant’s medical expert, who opined that the miner’s CWP resulted in inflammation and arteriosclerosis that resulted in his heart failure and death.

We won a case on appeal, reversing the judge’s decision. ​Our insurance carrier client issued a Notice of Temporary Compensation Payable (NTCP), agreeing to pay both indemnity and medical benefits for a lumbar strain allegedly sustained by the claimant. The 90-day period began on April 22, 2018, and ended July 20, 2018. On June 21, 2018, the claimant filed a claim petition for workers’ compensation benefits, alleging a low back injury. On July 17, 2018, the carrier issued a Notice Stopping Temporary Compensation Payable, stopping benefits as of June 5, 2018, and a Notice of Compensation Denial. Thereafter, the claimant filed a petition for penalties, averring the carrier violated the Pennsylvania Workers’ Compensation Act by failing to stop benefits within five days of receipt of the last payment of benefits. Accordingly, the NTCP converted to a Notice of Compensation Payable (NCP). The judge issued an Interlocutory Decision, ordering the carrier to reinstate disability benefits due to its failure to stop the claimant’s benefits within five days of the last payment. The carrier appealed, arguing that the Interlocutory Order was a final adjudication, merely labeled as “Interlocutory.” The carrier argued that because the judge’s order drastically altered the procedure and burdens of the litigation, it was a final adjudication and the carrier had a right to appeal therefrom. The carrier further argued that, even when a defendant fails to file a notice stopping within five days after the last payment, but does so within the 90-day NTCP timeframe, the NTCP does not convert to a NCP. The Workers’ Compensation Appeal Board agreed and reversed the judge’s order.

We initially successfully defended a bifurcated claim petition filed by the claimant, an independent contractor. Opposing counsel appealed, and the Workers’ Compensation Appeal Board reversed and remanded the decision for evidence on the medical component of the claim. However, contrary to the defendant’s argument, on remand, the judge granted the claim petition, finding she was “constrained” to reaffirm the Board on the independent contractor issue. The defendant once again appealed, and the Board re-affirmed the claim petition. We took the case up on appeal, and the Commonwealth Court agreed that the record did not demonstrate a “high level of control” such that an employment relationship has been established. Accordingly, the court reversed the order affirming the claim petition.

​The claimant worked as a coal miner for approximately nine years in underground mining. The administrative law judge denied benefits, finding the claimant had failed to establish that he suffered from a totally disabling respiratory condition. The claimant appealed. The denial of benefits was affirmed on appeal. The Benefits Review Board dismissed the claimant’s arguments that he had additional coal mine employment that would have entitled him to a presumption that his total disability was related to his coal mine employment. The BRB noted that the claimant had failed to prove a total respiratory disability and, therefore, the presumption would not apply irrespective of the number of years of coal mine employment that he proved.

The claimant slipped and fell at work, injuring his head and neck. The carrier accepted a contusion injury. The claimant alleged multiple additional injuries including cognitive maladies, memory loss, speech problems, vision convergence, photophobia, cranial nerve injuries and balance issues. The claimant testified while wearing sunglasses due to his alleged photophobia condition. Thirteen hours of surveillance video disputed the claimant’s alleged symptoms (including his need for sunglasses). Prior health records revealed the claimant to be treating for all of his alleged cognitive problems before the work incident ever took place. The claimant’s first treating neurologist records supported the claimant’s symptoms to be non-anatomical. The carrier’s IME physician found the claimant to have suffered non-disabling contusion injuries which resolved. The judge found in favor of the employer and carrier, ruling that the claimant’s injuries were limited to contusions and had fully resolved. The claimant appealed the case to the Workers’ Compensation Appeal Board, arguing the judge capriciously disregarded the evidence. The Board held that the claimant’s appeal was a veiled collateral attack on the workers’ compensation judge’s credibility determinations and affirmed the judge. At issue were potential life-time indemnity benefit payments and over $1 million of medical expenses.

We successfully defeated a workers’ compensation appeal involving a claim penalty/termination petition on behalf of a worldwide youth adult development organization. ​A Medical Only Notice of Compensation Payable acknowledged liability for a skull contusion and denied any associated disability. The claimant alleged injuries to the cervical spine, head, eyes, a concussion and post concussive syndrome, resulting in total disability. It was the claimant’s position that the judge failed to render a well-reasoned decision in favoring the opinions of the three defense expert doctors and seven fact witnesses who challenged the mechanism of injury as well as disability. The Appeal Board concluded that the judge summarized the relevant evidence, rendered credibility determinations, provided objective explanations for those credibility determinations and was justified in granting the termination petition.

We successfully defended a workers’ compensation case that was transferred from the insurance carrier’s staff counsel after litigation and motion practice. ​After a settlement offer in excess of $16 million was rejected, the case went to trial. At trial, we were able to prove that an uninsured subcontractor was hired by the general contractor, who was the actual employer of the injured worker. Under New Jersey Law, this means that the general contractor is responsible for the workers' compensation benefits for the petitioner. The case was dismissed with prejudice, and the general contractor was also ordered to reimburse the carrier approximately $2.8 million that they had paid out, based upon a previous order to provide medical and temporary benefits to the petitioner.

​The petitioner filed a motion for additional medical and temporary disability benefits, essentially alleging she was permanently and totally disabled from prior compensable shoulder and leg injuries. After a three-day trial and extensive briefing, the judge dismissed the motion. He determined that, despite the compensable injuries, the petitioner had plateaued medically and was not entitled to any further benefits.

We successfully defended a machine shop in the litigation of a claim petition involving post-concussion syndrome. The claimant was struck in the head with a wrench while repairing a machine for the employer. The carrier accepted a head laceration by way of medical only notice of compensation payable. The claimant was treated for a laceration to the side of his head and released to return to work. Several months later, he was taken out of work by his treating neurologist for symptoms allegedly related to post concussive syndrome. The claimant then returned to modified duties within new work release restrictions. He abandoned that job several weeks later, alleging he was totally disabled due to post concussive syndrome. We presented surveillance evidence demonstrating the claimant’s ability to perform all activities of daily living. A nationally renowned neurologist testified that, while the claimant suffered a mild concussion at the time of injury, he did not suffer from post concussive syndrome and was fully recovered. The claimant’s co-workers testified that they observed the claimant after the injury, and the claimant was able to continue working with no signs of post concussive problems. We cross examined the claimant, and it was discovered that he was performing work duties on his own in the carpentry field, despite alleging he was totally disabled. The workers’ compensation judge opined that the claimant’s injuries were limited to the head laceration and mild concussion, and then concluded that those injuries had fully recovered. The claimant was due no additional workers’ compensation benefits other than what he had already received. The claim petition for disability was dismissed.

​The issue involved whether the injured employee was the statutory employee of our client, or of the subcontractor who actually hired him. The injured worker was hired by a subcontractor during the aftermath of the Category 5 storm, Hurricane Michael, that hit near Panama City, Florida on October 10, 2018. The subcontractor’s company could not provide hiring paperwork that would have confirmed workers’ compensation coverage by the employee leasing company due to lack of electricity, internet connections and cellular service. Therefore, the parties agreed that the hiring paperwork would be hand delivered to the risk manager for the employee leasing company. The worker was injured one day before the hiring paperwork was hand delivered, but after the parties had agreed on hand delivery of the paperwork. The court found this to be sufficient evidence of detrimental reliance and of a disputed issue of material fact that the motion for summary judgment was denied.

​In its order, the Supreme Court affirmed a decision of the Superior Court that had affirmed a Board decision regarding the compensability of travel expenses for trips to and from medical appointments. The claimant had petitioned for parking and toll expenses incurred during her trips to visit a doctor at University of Pennsylvania from her residence in Dover, Delaware. Although the amounts in question were low, the case is significant as it potentially applies to every Delaware workers’ compensation case. Specifically, the court agreed with the employer’s arguments that the plain language of the applicable Delaware statute provides that mileage expenses are to be reimbursed by the employer for travel to and from compensable medical appointments.

We successfully prosecuted a termination petition on behalf of a national water company. ​After securing all prior medical records, the defense  uncovered a past medical history of similar complaints and treatment, and a later fall that was not disclosed by the claimant. After questioning, the claimant admitted to the nature and extent of his prior treatment, including office visits, prescription medication and MRIs, which supported our contention that his prior complaints were virtually identical. The workers’ compensation judge found that the claimant was not credible because his testimony contradicted the defense medical expert. Additionally, the judge found the defense medical expert to be competent, credible, persuasive and showed that the claimant was fully recovered from his work injuries, the resulting three surgeries, and all residuals. As such, the termination petition was granted.

The claimant had established that he had worked in the coal mining industry and was exposed to coal dust for a period over 17 years. ​Medical evidence also established that the miner did indeed have coal workers’ pneumoconiosis (Black Lung). However, the judge found that the miner was not totally disabled due to his pneumoconiosis. Therefore, he was not entitled to benefits, and the claim was denied. In another Federal Black Lung benefits claim, we presented testimony to prove, through pulmonary function testing, arterial blood gas testing and medical opinion evidence, that a coal miner who had begun work in the coal mines at the age of twelve did not suffer from a totally disabling respiratory impairment that precluded him from engaging in his usual coal mine employment.

We successfully defended a worldwide youth development organization in litigation surrounding an employee fall at work. ​The claimant allegedly fell after walking into an object that he claimed had a metal connector that struck his head, causing his glasses to fall off. He claimed temporary total disability. He was diagnosed with orthopedic, neurologic and neuro-ophthalmologic injuries, including but not limited to the neck, eyes, skull contusion, concussion and post-concussive syndrome. The employer captured the incident on video. Due to the questionable mechanism of injury, the defense convinced the workers’ compensation judge to travel to the employer's location to view the actual video of the incident. The employer presented multiple fact witnesses who corroborated the video and lack of disability. Based upon the video and the credible testimony of the fact witnesses, the judge found only a head contusion and no disability, and no liability for the claimant's extensive litigation costs.

We successfully defended a Philadelphia-based law firm in litigation surrounding an alleged work injury with resultant post-concussion syndrome. ​The claimant tripped and fell at work, alleging that he struck his head during the fall. He donned sunglasses at the hearing and depositions, claiming his injury led to photophobia and post-concussion syndrome. During discovery, it was determined that the claimant had suffered and was treated for headache symptoms and memory loss prior to the alleged work injury. Surveillance revealed that the claimant did not use sunglasses when carrying out everyday activities. The claimant's medical expert admitted on cross-examination that he was unaware of the claimant's pre-existing medical condition and was not aware of the surveillance evidence when arriving at his opinions and conclusions. The workers’ compensation judge found that the claimant and the medical expert were not credible, leading to the successful resolution of the claim.

We successfully defended a Northeastern Pennsylvania manufacturing and supply company in an appeal involving high medical and indemnity exposure. ​The claimant suffered a shoulder strain while lifting at work. She returned to the job only to allege a recurrence of her shoulder disability shortly thereafter. She filed a reinstatement petition that was denied when the Workers’ Compensation Judge accepted our argument that the recurrence was due to a non-work-related motor vehicle accident. Thereafter, the claimant traveled to Florida and underwent cervical disc surgery. Nearly a year after the surgery, she filed a petition, alleging that the cervical disc herniation was caused by the original work injury and the neck surgery and resultant disability were work related. The judge found the cervical disc herniation was not caused, aggravated, accelerated or worsened by the work injury and the surgery was not payable. The claimant then filed an appeal to the Workers' Compensation Appeal Board, arguing that the judge disregarded substantial evidence of causation. The Board heard oral argument and ruled that the judge's ruling is free of error.

We successfully defended a petition for permanent total disability benefits, supplemental benefits and penalties, interest, costs and attorneys fees. The judge entered a Final Compensation Order, finding the claimant was not permanently and totally disabled despite a substantial, but not exhaustive, job search. The judge found the claimant’s job search was not sufficient or reasonable in light of the totality of the circumstances, including her physical impairment, age, employment history, training, education, motivation, work experience, work record, and diligence to establish entitlement to permanent and total disability benefits. The judge held the testimony of the employer/carrier’s vocational experts was persuasive in his decision to deny PTD benefits, finding the claimant was employable with the assistance of vocational counseling.

We successfully defended a Philadelphia-based university in an action by a local medical provider for submissions of compound cream medication. The provider submitted the medication to the carrier via three medical specialists from the same medical group. The first doctor submitted an expensive bill for the compound cream to the carrier for payment. A second doctor from the same office submitted another expensive bill for the same compound cream, allegedly based on an exam that took place on the same day as the first doctor’s exam. Then a physician’s assistant submitted an expensive bill for the same compound medication, allegedly arising out of an exam she had with the claimant on the same day as the first two doctors. The carrier refused payment of the bills and filed a Utilization Review Request against all three providers. The UR requests came back in the carrier’s favor, and the providers’ attorney filed a review petition to challenge the UR determinations. We defended the review by establishing that the providers illegally billed the carrier for exams that allegedly took place on the same day, resulting in the same medication being prescribed and submitted for payment three separate times by three separate practitioners. The judge found the medical providers not to be credible and upheld the UR determination in its entirety.

The order involved multiple petitions filed by a pro se claimant for compensability of contact dermatitis and concrete burns allegedly sustained while working. The judge ruled in favor of the employer on all petitions, finding compensability was previously resolved and the ongoing issues were moot. The judge denied and dismissed, with prejudice, claims for temporary total and temporary partial disability benefits, authorization of medical care, and all corresponding penalties and interest. Most significantly, the judge granted the employer's defense of medical non-compliance from March 21, 2017, present and found that the claimant required no further treatment for his work-related injury. The employer can recover taxable costs against the claimant pursuant to Florida Statute 440.34 as the prevailing party on all petitions.

Successfully defended a petition for permanent total disability benefits, supplemental benefits and penalties, interest, costs and attorneys fees. The judge entered a Final Compensation Order, finding the claimant was not permanently and totally disabled despite a substantial, but not exhaustive, job search. The judge found the claimant’s job search was not sufficient or reasonable in light of the totality of the circumstances, including her physical impairment, age, employment history, training, education, motivation, work experience, work record, and diligence to establish entitlement to permanent and total disability benefits. The judge held the testimony of the employer/carrier’s vocational experts were persuasive in his decision to deny permenant total disability benefits, finding the claimant was employable with the assistance of vocational counseling.    

In a case centered around a marijuana gummy bear, we used a violation of law defense to successfully defend a national can manufacturer in the litigation of a reinstatement petition. The claimant sustained an uncontested crush injury to his foot, which required amputation of one of his toes. The claimant returned to work to his pre-injury job and, sometime later, tested positive for marijuana during a routine employee drug screen. The claimant was discharged for cause thereafter. The claimant filed a reinstatement petition, alleging his total disability arising from his crush injury returned—his treating doctor opined that his work-related condition worsened immediately after his discharge, such that the claimant could no longer perform his duties. The defense cross-examined the claimant’s medical expert, exposing the fact that his diagnoses were unrelated to the accepted work injury. Fact witnesses supported the discharge-for-cause based on the drug violation. The claimant alleged that the marijuana gummy bear was given to him by a friend and that he used it to medicate due to his work injury. He further alleged that he was unaware of the company drug policy. The defense submitted evidence proving the claimant was made aware of the drug policy as contained in the company handbook. The Workers’ Compensation Judge ruled that the claimant was discharged for cause and that the expert testimony of the claimant’s medical witness was not credible. The reinstatement petition was denied.         

We successfully defended a nationally renowned canning and food corporation headquartered in Pennsylvania. The claimant alleged that she sustained an injury to her upper extremities due to repetitive motion at work. She described her duties to include placing slices of cheese on sandwiches and hand-making pizza in an assembly line, which she alleged led to her injuries. The claimant’s medical expert testified that he was told the job duties involved working with jars of mushrooms, repetitively causing the claimant’s injuries. On cross examination, this expert was pinned down as to the mechanics of the claimant’s job duties. The defense then presented fact witness testimony confirming that the claimant did not use her upper extremities at all in performing job duties—contradicting the claimant’s testimony and the expert’s testimony. The Workers’ Compensation Judge concluded that the claimant did not use her upper extremities repetitively at work and dismissed the claim.

We successfully defended a national home improvement store in the litigation of a claim petition. The petitioner alleged that as a result of his employment at the retailer, he developed back problems and was in need of medical treatment. The defense was able to call into question the petitioner's credibility, as well as that of the petitioner's expert doctor. The judge found that the petitioner did not sustain the burden of proof. Therefore, both the motion for medical and temporary benefits and the claim petition were dismissed, with prejudice.

We successfully defended a national home décor manufacturer in the litigation of a review petition, which sought to add a cervical disc herniation and surgery to the nature of injury accepted in the case. The litigation had wide ramifications since the same claimant had attempted to reinstate workers’ compensation benefits based on an accepted shoulder/arm injury a year earlier and failed. As a result, the claimant traveled to Florida and underwent cervical disc surgery, claiming it was part of the same work-related injury. The defense proffered medical evidence to support the fact that the surgery and disc herniation were not caused by the work injury and that the medical bills and disability associated with the surgery were, likewise, not work-related.

We successfully defended a fatal claim petition filed by the widow of a coal miner who had been awarded benefits for totally disabling coal workers’ pneumoconiosis in 1984. Despite the fact the miner had been collecting temporary total disability benefits from 1984 until the time of his death in 2016, we were able to present credible and persuasive medical evidence to the Workers’ Compensation Judge that coal workers’ pneumoconiosis was not a substantial contributing factor to the miner’s death. The fatal claim petition was denied.  

We successfully defended a national car company in a case involving the defense of a termination petition, the claimant’s petition for review of the utilization review determination, the claimant’s petition to review compensation benefit off-set, and a petition for penalties. The case involved a 2013 injury involving low back sprain/strain and an aggravation of degenerative disc disease with radiculopathy and facet arthropathy. The defense expert, a board certified orthopedic surgeon, reviewed all of the claimant’s pre- and post-injury medical records and diagnostic study films. The claimant admitted that he had increases of pain with activities not associated with work (long drives out of state, shoveling snow, housework) which he had failed to report to the IME physician or his own treating doctor. The Workers’ Compensation Judge ordered the termination of all the claimant’s benefits. The judge also dismissed the claimant’s petition to review the URO, finding the treating physician’s treatment no longer reasonable and necessary. Finally, the claimant’s penalty petition was dismissed.  

We successfully defended an eastern regional can corporation in the litigation of a brain injury case. The claimant was struck in the lower extremities by a form of sheet metal which caused him to become unconscious. Nearly three years later, the claimant filed a petition alleging that he sustained a brain injury with post-concussion syndrome and cervical disc herniations as a result of the incident. The defense presented fact witness testimony from the scene of the accident which directly contradicted the claimant’s version of the facts. Moreover, the defense emphasized the weaknesses in the claimant’s medical expert’s opinions on cross examination as to causation. The Workers’ Compensation Judge found the claimant did not sustain a brain injury, post-concussion syndrome or cervical disc herniations related to employment.  

Successfully prosecuted a modification/suspension petition on behalf of a large financial institution nearly 12 years after the claimant’s injury. ​The claimant sustained injuries to her left shoulder and cervical spine in October of 2005. Since that time, she had two cervical spine surgeries and two shoulder surgeries. The defense established that the claimant was able to return to work in a sedentary-duty capacity, working from home in a telemarketing position, thus modifying her total disability benefits to partial disability. The Workers’ Compensation Judge was particularly persuaded by the factual testimony demonstrating that the actual job duties were no more than what she had to do in her normal activities of daily living.