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The Missouri Supreme Court reversed a denial of benefits in a divided 4-3 opinion and found there was sufficient evidence in an expert’s written report to find medical causation, despite the fact the ALJ, the Commission, and the Court of Appeals found the specific opinion about causation to be too ambiguous. Malam v Department of Corrections, 2016 Mo. Lexis 210 (Mo 2016) (June 28, 2016) (Lexis Advance), 2016 Mo. Lexis 210 (Mo 2016) (June 28, 2016) (lexis.com).
The case primarily involved a dispute as to whether the employee or the employer would pay medical expenses of $138,000. The claimant, a 50-year-old corrections officer, started coughing up blood at work and went into a state of hypertensive crisis shortly after an altercation with a prison inmate that resulted in a minor physical injury. The claimant had a complex medical history in which he was previously hospitalized for congestive heart failure, hypertension, primary cardiomyopathy, pulmonary hypertension, left ventricular dysfunction, biventricular failure, and morbid obesity. The claimant’s expert stated that the altercation involved substantial physical exertion. The employer’s expert found the worker’s prior medical condition was the prevailing cause for his hypertensive crisis.
Section 287.020.3(1) (Lexis Advance), 287.020.3(1) (lexis.com) provides that "[a]n injury by accident is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and disability." A "prevailing factor" is "the primary factor, in relation to any other factor, causing both the resulting medical condition and disability."
The ALJ originally found "Dr. Koprivica does not explain, in his report, what he meant by the foregoing phraseology, and he was not deposed, so we are left with a causation opinion that is, at best, equivocal with regard to whether the accident was the prevailing factor causing both the resulting hypertensive crisis and disability." 2014 MO WCLR Lexis 125 (Lexis Advance), 2014 MO WCLR Lexis 125 (lexis.com). The court of appeals affirmed. 2015 MO App. Lexis 683 (Mo. App. 2015) (Lexis Advance), 2015 MO App. Lexis 683 (Mo. App. 2015) (lexis.com).
The Supreme Court indicated the Commission was being overly technical when it denied benefits on the basis that the claimant’s expert failed to articulate the standard clearly, which left it open to multiple interpretations. A dissent argued that the limited standard of review did not allow disturbing what was essentially an implicit credibility finding that the claimant’s expert was not persuasive because his opinion was too ambiguous. The majority indicated that it deferred to credibility findings by the Commission to resolve conflicting medical opinion, but the Commission had not made an express finding that the claimant’s expert lacked credibility.
The court may construe the expert opinion of a prevailing factor to support an award based on the totality of the report, even when the opinion is not articulated precisely with the statutory magic words or in a somewhat muddled fashion, as in this case that uses both prevailing and precipitating factor. A claimant still has the burden to show the prevailing factor, and evidence based on a precipitating factor alone is insufficient.
The case demonstrates the peril of either side proceeding when an expert opinion does not clearly articulate the statutory standard and is open to mixed interpretation. The claimant was found to come up short for a prima facie case based on his medical evidence by the ALJ, the Commission, and the court of appeals. The defense acted at its peril by apparently not challenging the report on its admissibility or assuming the report was sufficiently ambiguous to demonstrate the claimant did not have a case. Neither party ever asked the expert to testify to find out what he really meant.
Source: Martin Klug, Huck, Howe & Tobin. Read Martin Klug’s Mo. Workers’ Comp Alerts.
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