Watson v. Tuthill Corporation and Second Injury Fund, Case Nos. SD37293 and SD37294 Consolidated (Mo. App. 2023)

FACTS: In April of 2015, the claimant injured his lower back when he caught a falling motor. He underwent a fusion surgery in August 2015. On January 25, 2016, he returned to work full time but had difficulty getting up and down and could not do some things he could perform prior to his back injury like lifting heavy parts. On February 1, 2016, the claimant sustained a new injury to his neck. The neck injury was minor and he received only conservative treatment. In the 10 days after the neck injury, the claimant worked only two or three days per week. On April 23, 2016, he retired because he could no longer do the job. He did not reach MMI for the back injury until July 2016.

The claimant’s medical expert, Dr. Koprivica, opined that the work accident causing the back injury, in isolation, rendered claimant permanently and totally disabled. The employer’s expert, Dr. Belz, opined that neither the back injury nor neck injury, in isolation, met the requirements for permanent total disability, but when considered together with all prior injuries and non-work-related degenerative conditions, claimant was PTD.

The ALJ found the back injury, in isolation, rendered claimant PTD as of July 18, 2016, the date of MMI, and the Fund was not liable because claimant’s “last injury” was the back injury and not the neck injury. The Commission affirmed the ALJ. The employer appealed.

HOLDING: The Court affirmed the Commission’s decision finding the Award was supported by competent and substantial evidence. The ALJ considered and found Dr. Koprivica’s findings and opinions more credible than Dr. Belz. When a Judge expresses determinations regarding credibility, the Court is bound by these determinations.

Also, the employer’s argument, that the claimant could not have been PTD from the back injury alone because he returned to work, was not the proper standard. The Court stated that an employee can be PTD without becoming completely inactive or inert. A claimant who returns to work for an employer which accommodates the claimant’s disabilities will not preclude a finding of PTD because “the test is whether the claimant could compete in the open labor market.” Furthermore, there was no disability found as a result of the subsequent injury to the neck, and thus it was not the “last injury.” Therefore, there was no Fund liability.

Obermann v. Second Injury Fund, Case No. ED111004 (Mo. App. 2023)

FACTS: The claimant’s claim for benefits against the Fund arose from a workplace injury to his right shoulder (the primary injury) on November 3, 2017. The claimant previously suffered five other workers’ compensation injuries, four of which were qualifying disabilities under Section 287.220.3 in that each exceeded 50 weeks of PPD. The non-qualifying disability was a 1995 injury to the left knee that resulted in less than 50 weeks of PPD.

The Commission denied the claim based on its finding that claimant’s medical and vocational rehabilitation experts included the non-qualifying 1995 left knee disability in their report and testimony. The Commission said “no medical or vocational expert opined that the employee’s PTD resulted solely from the combination of the November 3, 2017 primary injury and the pre-existing disabilities exclusive of disability attributable to his compensable 1995 left knee injury.” This disqualified claimant from PTD benefits from the Fund. The claimant appealed.

HOLDING: The Court reversed the Commission. It found that the Commission’s decision improperly considered Section 287.220.3 of the statute. The record demonstrated that claimant’s vocational rehabilitation expert repeatedly opined that claimant was unemployable, irrespective of his left knee disability, “based upon the limitations from the shoulder injury plus the pre-existing conditions that he had from his feet injuries.” The Court noted that this evidence directly refuted the Commission’s decision. The case was remanded back to the Commission with instructions to enter an Award in favor of the claimant against the Fund for PTD benefits since the Court concluded the undisputed expert testimony was that claimant’s PTD resulted from his primary injury combined with his qualifying pre-existing feet disabilities.

State of Missouri, Ex Rel., Jeff Peters and John Newman v. Treasurer, State of Missouri, Case Nos. WD85719 and WD85777 (Mo. App. 2023)

FACTS: On November 14, 2006, Peters suffered severe injuries in a motor vehicle accident in the course of his employment. Peters filed a workers’ compensation claim against both his employer and the Fund through his counsel, Attorney Newman. His claim against the Fund was based on allegations that his employer was uninsured and that the Fund was responsible for his medical expenses under Section 287.220.5.

On December 2, 2011, the ALJ issued her Award findings Peters’s injury compensable, that his employer was uninsured, and that his employer had paid none of the medical bills at issue. The Award found that the fair, reasonable, and necessary charges resulting from his medical treatment was $1,142,169.57. The Award allowed Newton’s attorney’s fees “in the amount of 25% of all payments hereunder.” Finally, the Award ordered that interest shall be paid as provided by law. No Application for Review or appeal was filed and the Award became final.

After the Award became final, Peters filed an Application for Judgment on the Award in the Circuit Court under Section 287.500. On July 31, 2012, the Circuit Court entered judgment against the Treasurer of the State of Missouri (custodian of the Fund) in the amount of $1,142,169.57, with interest of 10% per annum from January 12, 2012. This judgment was not appealed and became final.

In September and November 2013, the Fund paid 9 of the 10 medical providers the total of their billed amount less Newman’s 25% attorney fee. They also paid the 10^th medical provider approximately $100,000.00, and in exchange, the medical provider executed a release providing that the amount paid satisfied all liability. The Fund also directly paid Newman 25% of the amount paid to that medical provider, approximately $25,000.00. The payments made by the Fund did not include any amounts for interest. Peters and Newman did not consent to the payments to the medical providers.

On October 9, 2019, Peters and Newman filed for a Writ of Mandamus ordering the Fund to pay the outstanding judgment entered in their favor for the full amount of $1,142,169.57 plus interest as required by Section 287.220.

HOLDING: The Court noted that Peters did not dispute that the Fund paid his medical bills. There was also no genuine dispute that the 10^th medical provider released Peters from liability. Pursuant to the Award and consistent with Section 287.220.5, the Fund paid Peters’s fair, reasonable, and necessary medical expenses, and he was released from all liability for them. The Award did not indicate that the Fund was not permitted to negotiate the existing unpaid medical bills. The Award did not order the Fund to pay any amount of medical bills directly to Peters.

The Court reasoned that to allow Peters to recover the full cost of his medical bills from the Fund would result in an impermissible windfall to him. The Court pointed out that pursuant to Section 287.220.5 the Fund has limited liability to employees who are not covered by insurance as required by law. The Statute provides that only an employee’s actual expenses be paid by the Fund. It does not direct the manner in which the funds withdrawn from the Fund are to be paid. Moreover, “An employee of an uninsured employer should not receive a windfall from the Second Injury Fund on account of his employer’s failure to carry insurance, as required under the law.”

With respect to the attorney’s fees, the Court noted that in compliance with the Award, the Fund paid Newman 25% of the full amount of the medical bills paid to each of the 10 medical providers. Accordingly, the Fund paid Newman everything he was due under the Award. Any additional payment to Newman would result in a windfall contrary to the language and intent of Section 287.220.5.

Huffman v. Second Injury Fund, Injury No. 15-073745

FACTS: In September 2015, the claimant sustained an injury to her shoulder. She obtained treatment, including surgery. She settled her primary case in January 2018 against the employer on a disputed basis for $23,500.00 representing 24% of the right shoulder.

At the Hearing against the Fund for PTD, the claimant testified that due to employer denying her work related accident, she developed a sense of distrust in people which increased her longstanding anxiety and depression for which she had been receiving treatment and medication for over 20 years. She testified that her current levels of anxiety were now worse than before her alleged work accident and she was unable to perform any type of gainful employment due to the combined effects of her psychological conditions, pre-existing chronic headaches, and diabetes.

The claimant was initially examined by Dr. Koprivica in March 2018 who provided a rating of 25% PPD of the right shoulder from the September 2015 work injury. He also identified several pre-existing conditions including chronic disabling headaches resulting in 15% PPD of the body and pre-existing diabetes for which he assigned 15% PPD of the body. He also found significant pre-existing psychological disability and recommended a mental health evaluation.

Dr. Jackson, a licensed psychologist, was of the opinion that claimant had a total psychological disability of the whole person of 45%, 25% pre-existing and 20% psychological disability to the work accident of 2015. Vocational expert, Mr. Cordray clarified that the claimant was PTD due to the combination of the right shoulder injury and psychological disability.

It was also noted that Dr. Koprivica opined in a supplemental report that claimant’s pre-existing psychological disability would qualify to trigger Fund liability, which in his opinion directly and significantly aggravated or accelerated the subsequent work related injury. He felt that as a result of the pre-existing condition and the work related injury, in combination, rendered the claimant PTD.

In his Award, the ALJ noted that the claimant’s allegations for PTD and Fund liability are based on the claimant’s alleged psychological condition in combination with her shoulder injury. However, the claimant needed to show that the work injury of September 2015 resulted in psychological injury, which when combined with her pre-existing condition aggravated or accelerated that condition and rendered her permanently and totally disabled. The Judge further noted that claimant’s decision to settle her claim for disability for only the right shoulder, and not any psychological disability was significant. Therefore, he found that the claimant failed to meet her burden of proof to established Fund liability and the claim against the Fund was denied. The claimant appealed.

HOLDING: The Commission noted that the Supreme Court of Missouri’s recent decision in the March case in 2022 held that the fact that the Fund did not offer contradicting evidence did not establish a “presumptively valid claim.” The Court stated that to establish a claim, the employee must meet not only their burden of production but also the burden of persuasion.

In this case, the Commission affirmed and adopted the Award of the ALJ noting that to establish that she was entitled to compensation from the Fund under Section 287.220.3, she was required to establish that a qualified pre-existing psychological disability combined with a psychological disability related to her September 2015 work injury to result in PTD.

The Commission noted that the Judge denied the claimant’s Fund claim because the testimony of the claimant and her experts failed to persuade him that she sustained any psychological disability related to her September 2015 work injury. The ALJ discredited the claimant’s medical and vocational expert views on the basis that their opinions were not sought until after she settled her claim against the employer based on 24% PPD of the right shoulder.

The Commission noted that Missouri courts have held that while a settlement with the employer does not bind an ALJ or the Commission, it “does serve as relevant evidence of the nature and extent of the employee’s permanent disability attributable to the primary injury.”

Eckardt v. Second Injury Fund, Injury No. 15-105268

FACTS: At the time of the Hearing, the claimant was 74-years-old and retired, after working almost his entire adult life as an airplane mechanic. He had sustained several prior injuries for which Dr. Volarich provided ratings for pre-existing disability. The claimant’s last work accident, the primary work injury, occurred on October 3, 2015, when he was getting out of a van at work. The van started moving and he was struck by the door and fell, injuring his right shoulder, wrist and neck. As a result of this accident, he had a neck fusion.

In his August 16, 2018 report, Dr. Volarich provided a 35% PPD of the body rated at the cervical spine as a result of the October 2015 work injury. Dr. Volarich also provided several other ratings for pre-existing disabilities, including a 20% rating of the right upper extremity for a prior injury. He also opined, “Based on my medical assessment alone, it is my opinion that Mr. Eckardt is permanently and totally disabled as a direct result of the work related injury of 10-3-15 in combination with his pre-existing medical conditions.”

The ALJ concluded that the claimant had met his burden to prove that he is PTD from the combination of his primary work-related injury and his qualifying pre-existing injuries and, therefore, the Fund was liable for permanent total disability. The Fund appealed.

HOLDING: The Commission considered two points on appeal.

First, the Commission found that the claimant’s work related bilateral carpal tunnel syndrome, exceeding 50 weeks of disability in each hand, qualified as a pre-existing disability under Section 287.220.3(2)(a)(ii). The Commission disagreed with the Fund’s argument that carpal tunnel syndrome is not an injury because the statute section which defines the term “injury” provides that an “injury” shall in no case except as specifically provided in the Chapter be construed to include occupational disease in any form.”

The Commission stated that in the absence of controlling Appellate case law, that the doctrine of stare decisis has no application to administrative tribunals. They were allowed to deviate from a prior Commission’s ruling on the matter as long as their action “is not otherwise arbitrary or unreasonable.” They respectfully disagreed with the 2020 Commission’s conclusion, discussed only briefly in a footnote in the Lexow opinion that carpal tunnel syndrome would not satisfy Section 287.220.3(2)(a)(ii) solely because carpal tunnel syndrome is the result of an occupational disease as defined by Section 287.067.

Secondly, on the issue of whether the claimant met his burden of proving that his PTD was attributable to his October 3, 2015 work injury in combination with pre-existing disabilities that qualify under Section 287.220.3, the Commission reversed the Award of the ALJ

The Commission noted that no party disputed that Dr. Volarich’s evaluation of disability to the claimant’s right shoulder as 20% PPD of the right upper extremity (46.4 weeks) fell short of the 50 week threshold required by Section 287.220.3(2)(a)(ii). In her Award, the ALJ acknowledged, “Claimant’s only injury that does not reach the statutory threshold is claimant’s right shoulder.”

The Commission noted that the ALJ awarded PTD against the Fund based on her finding that the exclusion of one work related injury was not significant when considering all of claimant’s qualifying pre-existing injuries. The Commission found that the ALJ erroneously substituted her own opinion.

The Commission concluded that under Section 287.800, they would strictly construe the provisions of the workers’ compensation law and weigh the evidence impartially without giving any party the benefit of the doubt. They found no credible or persuasive evidence in the record that the employee was PTD due to the primary injury in combination with only pre-existing disabilities that qualify under Section 287.220.3. Therefore, claimant did not meet his burden of proof and persuasion because he did not produce credible and persuasive evidence suggesting that he was PTD as a result of the combination of the primary injury and only his qualifying pre-existing disabilities. Therefore, claimant’s claim against the Second Injury Fund was denied because his evidence failed to satisfy the standard set forth under Section 287.220.3.

Roe v. Darden Restaurants, Inc., Case No. WD86109 (Mo. App. 2023)

FACTS: In September 2018, claimant cut her finger while sorting silverware for the employer. She notified her manager of the injury. Over the next several days, the small cut became infected resulting in emergency hospitalization. After her hospitalization, employer sent claimant for follow up treatment. Due to her injury, claimant incurred medical expenses totaling $30,879.21.

Subsequently, claimant hired an attorney to pursue a workers’ compensation claim to help pay her medical bills. She signed a fee agreement in which her attorney would receive 25% of all benefits paid, including 25% of claimant’s incurred medical bills resulting from the injury.

In January 2020, following a discussion with the ALJ, employer paid claimant’s total medical bills. After paying claimant’s medical bills, employer sent copies of all paid medical bills and their associated explanation of benefits with a letter to claimant’s attorney advising them that the information would also be introduced into evidence at the hearing. Although employer paid all of her medical bills, the claimant was not aware. The record is not clear why the claimant remained unaware her medical bills were paid despite the employer informing her attorney and providing proof of payment.

In March 2022, two years after employer paid claimant’s medical bills, the parties appeared for a final hearing before the ALJ. During the hearing, the employer introduced and the ALJ admitted into evidence, over claimant’s objection, Exhibit A, showing an affidavit and the payment of nine separate checks with accompanying explanation and Exhibit E, employer’s letter to claimant’s attorney sent in April 2020.

As a result of the hearing, the ALJ limited claimant’s attorney’s fees to 25% of the permanent partial disability Award. The Award did not include a fee on the claimant’s medical expenses, since those expenses were already paid two years prior. The claimant appealed. The Commission affirmed and adopted the ALJ’s decision.

HOLDING: The Court noted that because the claimant’s attorney worked the majority of hours after employer paid claimant’s medical bills in January 2020, the ALJ correctly limited claimant attorney’s fees to “25% of the permanent partial disability awarded.” The amount of work done prior to the payment of the medical bills was limited to about 17 hours with additional time expended for negotiations of settlement. The Court concluded that the Commission acted within its authority, under Section 287.260, in determining the fair and reasonable amount of claimant’s attorney’s fees to compensation for services rendered “in obtaining payment of her medical bills as well as permanent partial disability benefits.” They saw no reason to disturb the Commission’s findings. Also, the Court noted that in the findings of fact, the ALJ chastised claimant’s attorney about the needless work performed as well as claimant’s attorney’s failure to communicate with his client.