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.
Moo-shu, anyone?
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