Brown v. W.T. Martin Plumbing & Heating, Inc., 2013 VT 38
The holding of this case boils down to doctors don’t necessarily have to follow “the book” when making diagnoses in workers’ compensation cases. This one’s for the workers.
Oh, of course it’s more specific than that. This case deals with Complex Regional Pain Syndrome or “CRPS” for short and the criteria for diagnosis under the American Medical Association (AMA) Guides. More specifically the question is whether an expert can diagnose CRPS under alternate criteria, which still meets the reasonable-medical-certainty test, and which in turn supports a permanent-partial-disability award, even if this does not follow the AMA standards. The SCOV majority gives this approach a favorable nod.
Here’s the lowdown. Claimant was injured on the job and applied for workers’ compensation. Plaintiff claimed CRPS and was diagnosed with such. CRPS is characterized by pain that can seem disproportionate to the actual injury. In this case, Claimant tore his rotator cuff, had surgery, and had a complicated recovery. He showed symptoms of, and was diagnosed with, CRPS by a treating physician. Employer’s medical expert agreed with the diagnosis, and Claimant received temporary disability payments.
But the positions changed later. When it came time to assign a permanent impairment rating, Claimant’s expert agreed with the treating physician that CRPS was present (though not in accordance with the AMA Guides’ diagnostic criteria) and assigned a forty-six-percent permanent impairment rating (in accordance with the AMA Guides’ whole-person-impairment rating system when CRPS is present). The employer’s expert concluded that the CRPS diagnosis did not meet the AMA Guides criteria for diagnosis, and so assigned a three-percent permanent impairment rating (without CRPS factored in).
Long story short, both the Commissioner of the Department of Labor and later the trial court sympathized with Claimant and found Claimant’s medical experts more persuasive, but concluded that this language precluded them from assigning a permanent impairment rating that included CRPS:
Any determination of the existence and degree of permanent partial impairment shall be made only in accordance with the whole person determination as set out in the fifth edition of the [AMA Guides].
21 V.S.A. § 648(b)
It’s worth noting that Claimant’s condition likely met the criteria for CRPS under another guide as well as the new AMA Guides.
In a nutshell, the question on appeal is whether the statute’s language precludes any permanent impairment rating when the diagnosis does not comport with the AMA Guides’ criteria.
Workers’ compensation, in general, provides no-fault coverage for work injuries. Benefits include temporary total or partial disability benefits; vocational rehabilitation benefits; and permanent partial or total disability benefits.
Temporary disability benefits are based on ability to work. Permanent partial disability benefits are based on the degree of impairment, without direct consideration of work capacity.
The SCOV first explains that the triggering event for workers’ compensation coverage is an “injury.” There is, the SCOV notes, no requirement that the injury meet any particular medical criteria to qualify as an injury. The SCOV further explains the purpose of the AMA Guides (standardized, objective criteria was needed) and the lack of intrinsic correlation between diagnoses and impairment ratings.
The SCOV will traditionally defer to the Commissioner’s interpretation of workers’ compensation statutes, but it is not a big fan of unjust, unreasonable, or regulatory-undermining interpretations. Also, the SCOV interprets the Workers’ Compensation Act liberally. Finally, the SCOV’s primary objective in construing statutes is to effectuate legislative intent.
The way the SCOV majority sees it, the statute’s language applies to determining permanent impairment ratings, but says nothing about the diagnostic process. Accordingly, the SCOV reasons that “the Guides do not necessarily contain the exclusive authoritative standard for diagnosing the condition.”
The SCOV notes that the statute specifically authorizes the Commissioner to develop methods for rating impairments not covered by the Guides. A good portion of the decision is then spent refuting the dissent’s reasoning. The bottom line, however, is that the diagnosis of an impairment and its subsequent rating are two separate processes and only the rating must be performed in accordance with the AMA Guides.
The majority concludes by emphasizing the limited scope of its holding. The majority speculates that the Commissioner could find no impairment associated with CRPS on remand, but that the Commissioner can’t sidestep the finding by deferring to the AMA Guides.
Justice Dooley dissents and is joined by Judge Eaton (specially assigned). Dissents are generally interesting. This one uses the term “paper tiger,” which is a fun term. And though a portion of the dissent reads like a medical journal article, the points are easy to grasp. The dissent puts it this way: “The majority reads the language as saying that only the degree of permanent partial impairment must be taken from the Guides; any other step in the determination can come from anywhere, no matter what is the basis for the medical diagnosis of CRPS.” That may be a little harsh, but it’s a dissent—it’s allowed.
As the dissent sees it, the majority opinion eviscerates legislative intent. The dissent notes that the impairment ratings in the Guides are are wholly dependent on the corresponding diagnosis of CRPS under the Guides’ standards. The majority glosses over this hiccup in a creative effort to maximize the claimant’s recovery.
The dissent throws out another zinger: “Apparently, the majority would conclude that the choices work like a Chinese menu—however CRPS is diagnosed, the claimant’s physician can chose whichever impairment rating methodology the physician desires, even if it is not paired with the diagnosis method.”
The dissent reasons that the majority’s opinion throws objectivity, consistency, and predictability in the impairment-determination process to the winds.
This is one of those cases that illustrate the importance of perspective. If we’re counting “the checkmarks,” employer had four votes for strict statutory construction (Commissioner, trial court, and the two dissenters) and Claimant only had three. But Claimant’s position carries the day with those three all-important votes at the SCOV.
So in the end, Claimant gets another shot to up his disability percentage, and the standards for diagnosis get a little bit looser. Let the new claims roll in.