Five Recent Cases You Should Know About (12/10/2010)

Larson's Spotlight on PPOs, AMA Guides, Going and Coming, Lost Wages, Telecommuter. Larson's surveys the latest case developments that you need to know about. Thomas A. Robinson, the staff writer for Larson's Workers' Compensation Law, has compiled the list below.

LA: Supreme Court Allows Discounted Payments to Medical Care Providers Under PPO Contract

Reversing lower appellate court, the Supreme Court of Louisiana held that under appropriate circumstances, payments to a health care provider may, pursuant to a valid preferred provider organization contract ("PPO"), be discounted below the reimbursement schedule provided within the Louisiana Workers' Compensation Act ("LWCA").  Citing strong policy that favored the freedom of parties to contract with each other, the high court observed that the employer/insurer was simply paying what the medical care provider had contractually agreed to accept under the PPO arrangement.  The court also stressed that in no way did the payment of the lesser amount to the health care provider relieve the employer or carrier of any liability to the injured employee under the LWCA.

FREE VERSION: Access the case on lexisONE free case law. Click on tab for Free Case Law. Click on the radio button for Search by Citation. Enter this citation: 2010 La. LEXIS 2605. Then click on the red button Search for Free. Note: If you haven’t registered for free at lexisONE, you will be prompted to do so in order to access the free case law.

FULLY FEATURED VERSION: Lexis.com subscribers can read the fully featured case here. See generally Larson's Workers' Compensation Law, § 94.02.

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WY:  Physicians Must Base Disability Ratings on AMA Guides in Effect on MMI Date

The Supreme Court of Wyoming recently held that a permanent partial impairment rating must be made based on the most recent edition of the AMA Guides at the time the injured worker reached maximum medical improvement, disagreeing with the worker's contention that the 6th edition did not provide the most reliable guidance in determining a PPI rating.  The worker introduced excerpts from a letter from his surgeon describing the 6th edition as ambiguous and difficult to interpret.  The court indicated, however, that the state legislature clearly intended that the PPI be rated using the most recent edition at the time of the ascertainable loss.

FREE VERSION: Access the case on lexisONE free case law. Click on tab for Free Case Law. Click on the radio button for Search by Citation. Enter this citation: 2010 Wyo. LEXIS 166. Then click on the red button Search for Free. Note: If you haven’t registered for free at lexisONE, you will be prompted to do so in order to access the free case law.

FULLY FEATURED VERSION: Lexis.com subscribers can read the fully featured case here. See generally Larson's Workers' Compensation Law, § 80.07.

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TX: High Court Quotes Melville, Finds Employee's Injuries Not Barred by Going and Coming Rule

In an 8-1 decision, the Supreme Court of Texas has reversed an earlier decision by the state's Court of Appeals and held compensable the severe injuries sustained by an employee in an automobile accident that occurred while she traveled from a work-related dinner meeting to a company-provided self-storage unit near her residence.  The high court indicated the employee was within the course and scope of her employment as defined in Tex. Lab. Code Ann. § 401.011(12) in spite of the fact that she was homeward-bound.  Noting that the "dual purpose" rule was devised for the distinct situation in which the employee is traveling between work and a place other than home, while the "going and coming" rule developed separately, specifically for travel between home and work, the supreme court indicated that here the employee had been on her way from the employer-sponsored dinner to an employer-provided storage facility to empty her company car of business supplies. That she would have gone home after the dinner even if she had not decided to drop off the supplies did not control.  The court quoted Herman Melville ("Whoever afflict us, whatever surround, Life is a voyage that's homeward-bound!") and noted that in some sense much of our travel is homeward-bound.

FREE VERSION: Access the case on lexisONE free case law. Click on tab for Free Case Law. Click on the radio button for Search by Citation. Enter this citation: 2010 Tex. LEXIS 894. Then click on the red button Search for Free. Note: If you haven’t registered for free at lexisONE, you will be prompted to do so in order to access the free case law.

FULLY FEATURED VERSION: Lexis.com subscribers can read the fully featured case here. See generally Larson's Workers' Compensation Law, § 13.01.

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MO: Long-term Disability Carrier May Offset—as Payment for "Lost Wages"—Permanent Partial Disability Benefits Received by Workers' Compensation

A Missouri appellate court, following the doctrine earlier established by the state's supreme court in Sheldon v. Board of Trustees of Police Retirement System, 779 S.W.2d 553 (Mo. 1989), which generally provides that workers' compensation benefits for physical injury are divided into only two categories: wage-loss payments based on the concept of disability, and payment of hospital and medical expenses from a work-connected injury regardless of wage loss or disability, recently held that an insurance company that provided group long-term disability benefits to Missouri state employees was entitled to offset the value of workers' compensation PPD benefits received by a state employee under the "lost wages" setoff clause of its disability policy.  The appellate court reversed a decision of the trial court that held a lump sum payment negotiated between the employee and the workers' compensation carrier for a 35 percent partial disability of the shoulder was not the same as "lost wages."  The appellate court indicated that because "lost wages" constituted deductible income under the group disability policy and because the compromise settlement payment was a lump sum payment of lost wages, the carrier properly offset the amount the employee received.

FREE VERSION: Access the case on lexisONE free case law. Click on tab for Free Case Law. Click on the radio button for Search by Citation. Enter this citation: 2010 Mo. App. LEXIS 1617. Then click on the red button Search for Free. Note: If you haven’t registered for free at lexisONE, you will be prompted to do so in order to access the free case law.

FULLY FEATURED VERSION: Lexis.com subscribers can read the fully featured case here. See generally Larson's Workers' Compensation Law, § 157.04.

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NJ: Telecommuter's Fatal Embolism Was Not Compensable as an Occupational Disease

In an unpublished decision, a New Jersey appellate court has determined that an employee's fatal pulmonary embolism was not an occupational disease; in order for her dependents to prevail on their death claim, they must, on remand, establish that she sustained a cardiovascular injury or death under N.J.S.A. 34:15-7.2 (Section 7.2).  The employee was permitted to work at home three days per week and was provided with an employer-issued laptop and a speakerphone.  Her family indicated that when she worked at home, she sat at her computer for long hours to meet various deadlines. A physician opined that her pulmonary embolism could have been caused in part by her sedentary job.  The appellate court observed that the employee was 47-years old and morbidly obese (weighing 304 pounds). Quoted Larson's Workers' Compensation Law, § 42.02, the appellate court held that her condition was not an occupational disease; her job required her to meet deadlines, not to sit in front of her computer and remain still.  The employee was free to decide whether she should sit, stand, or walk.  Her condition did not develop gradually. 

FULLY FEATURED VERSION: Lexis.com subscribers can read the fully featured case here. See generally Larson's Workers' Compensation Law, §§ 42.02, 52.04.

Note: This unpublished case is not available on lexisone. It can found at the court website at http://www.judiciary.state.nj.us/opinions/a3237-09.pdf.

Source: Larson’s Workers’ Compensation Law, the nation’s leading authority on workers’ compensation law.

   Offer good through December 2010.