February 20, 2018

Colorado Court of Appeals: Workers’ Compensation Claimant Need Only Prove Either Wage Loss or Disability for TPD

The Colorado Court of Appeals issued its opinion in Montoya v. Industrial Claim Appeals Office on Thursday, February 2, 2018.

Workers’ Compensation—Medical Incapacity—Temporary Partial Disability.

Claimant worked as an interior designer for Ethan Allen Retail, Inc. Her pay was based entirely on commissions. Claimant suffered admitted work-related injuries. Although she was neither given work restrictions nor medically limited in her ability to work, her medical appointments caused her to be absent from the showroom floor and not be able to meet potential and current clients. Claimant sought temporary partial disability benefits (TPD) in a workers’ compensation action. She testified that the absences caused her to lose more than $20,000 in commission earnings. The administrative law judge (ALJ) awarded claimant TPD benefits to compensate her for the commissions she lost while attending medical appointments.

A panel of the Industrial Claim Appeals Office (Panel) set aside the award of TPD benefits, reasoning that disability benefits are only available if a claimant demonstrates both medical incapacity and temporary loss of wage earning capacity. Here, because the ALJ had found that claimant had no work restrictions and was able to perform her job duties, the Panel held she did not establish the requisite “medical incapacity” prong of disability and therefore, as a matter of law, was not entitled to receive TPD benefits.

On appeal, claimant contended that the Panel’s interpretation of “disability” was too narrow. The court of appeals concluded that although the concept of disability incorporates both “medical incapacity” and “loss of wage earnings,” a claimant need not prove both components to establish entitlement to disability benefits under the Workers’ Compensation Act. The court then found that the evidence presented amply supported the ALJ’s finding that claimant’s wage loss was attributable to her work-related injury. The Panel erred in setting aside the ALJ’s decision.

The Panel’s decision was set aside and the case was remanded with instructions.

Summary provided courtesy of Colorado Lawyer.

Colorado Court of Appeals: Claimant Released to Full Duty but Unable to Perform Work Entitled to TTD

The Colorado Court of Appeals issued its opinion in Archuleta v. Industrial Claim Appeals Office on Thursday, April 21, 2016.

Workers’ Compensation—Temporary Total Disability Benefits—C.R.S. § 8-42-105(3)(c)—C.R.S. § 8-42-103—C.R.S. § 8-42-105(1).

Claimant sustained a work-related injury in February 2014. His physician imposed temporary restrictions and released him to modified duty. On March 5, the attending physician released him to full duty work with no restrictions. On May 21, the attending physician determined claimant had reached maximum medical improvement (MMI) with no impairment restrictions. Employer filed a final admission of liability.

Claimant continued to maintain that he could perform only light duty work because of his injury. He was laid off one week after reaching MMI because, according to him, he was “hurt on the job,” could no longer perform his duties, and was on “light duty.” He requested a division-sponsored independent medical examination (DIME) to challenge the MMI finding. The DIME physician concluded he was not at MMI. An administrative law judge (ALJ) then awarded claimant temporary total disability (TTD) benefits, finding that he was laid off because of his industrial injury. On review, the Industrial Claims Appeal Office (Panel) reversed, finding that under C.R.S. § 8-42-105(3)(c), once a claimant has been released to full duty work TTD benefits must cease.

On appeal, claimant argued that C.R.S. § 8-42-105(3)(c) applies only to the termination of benefits and because he didn’t have any benefits when the attending physician released him to work, his case should have been analyzed under C.R.S. §§ 8-42-103 and -105(1), which apply to the commencement of benefits and do not have a restriction based on release to full duty. The court of appeals agreed, holding that C.R.S. § 8-42-105(3)(c) did not apply to claimant’s case because the statute can only terminate benefits that have already commenced and therefore can only be applied prospectively.

The order was set aside and the case was remanded with directions to reinstate the ALJ’s order.

Summary provided courtesy of The Colorado Lawyer.

Tenth Circuit: Failure to Exhaust Administrative Remedies Resulted in Dismissal of ERISA Claim

The Tenth Circuit Court of Appeals issued its opinion in Holmes v. Colorado Coalition for the Homeless Long Term Disability Plan on Tuesday, August 12, 2014.

Lucrecia Carpio Holmes was employed by Colorado Coalition for the Homeless and suffered from a number of debilitating medical conditions. She applied for disability benefits through the Coalition’s employee benefit plan disability policy through Union Security Insurance Company. Union Security denied her claim, and Holmes appealed the denial on November 21, 2005. Union Security had 45 days within which to either overturn or uphold the denial, excluding certain tolling periods. Union Security issued its denial on April 7, 2006, 137 days after Holmes appealed. Included in each of Union Security’s denials was a document detailing the appeal procedure, which consisted of two levels of administrative appeal with Union Security prior to filing a civil action in district court.

Instead of filing a second appeal with Union Security, Holmes filed a civil action against the Coalition’s Long Term Disability Plan in the district court on April 28, 2008. The defendant was not aware of the appeal, and default judgment entered against it. Upon learning of the suit, Defendant removed the action to federal court and moved to have the default judgment set aside. The district court granted Defendant’s motion, ruling it had not been properly noticed in the lower court proceeding. Both parties filed cross-motions for summary judgment. While those motions were pending, Holmes filed a motion to stay decision, reopen discovery, and proceed to trial if necessary. The district court denied her motion and granted summary judgment to Defendant, holding that Holmes’s claim was barred because she failed to exhaust her administrative remedies. It found that although Union Security issued its second denial after 137 days, 67 of those days were attributable to Holmes, and Holmes had forfeited her right to enforce ERISA deadlines. The district court also held Union Security had complied with applicable ERISA notice and disclosure requirements. Holmes appealed.

The Tenth Circuit first evaluated Holmes’s argument that the district court erred by ruling she failed to exhaust her administrative remedies. Holmes argued that her Summary Plan Description failed to define the two-level review process, and alternatively she should be deemed to have exhausted her administrative remedies because Union Security failed to comply with ERISA’s timing and notice requirements. The Tenth Circuit addressed the language regarding administrative remedies contained in the plan and the Summary Plan Description, and determined that the administrative appeal process was contained in the plan by reference. Because Holmes failed to complete the administrative appeal process, district court review was barred.

The Tenth Circuit agreed with Holmes that Union Security failed to comply with ERISA’s timing and notice requirements; however, it found Holmes was not prejudiced by that failure. Although the Summary Plan Description failed to inform claimants of the review process, it incorporated by reference the letter detailing the review process that Union Security included with each denial.

The Tenth Circuit affirmed the district court’s dismissal.

Colorado Court of Appeals: ICAO Exceeded Its Authority by Finding Worsening of Condition Despite ALJ’s Ruling to the Contrary

The Colorado Court of Appeals issued its opinion in Apex Transportation, Inc. v. Industrial Claim Appeals Office on Thursday, March 13, 2014.

Worker’s Compensation—Injury—Temporary Total Disability Benefits—Factual Determinations.

Claimant worked as a truck driver for Apex when he sustained an injury to his shoulder. He refused medical attention at the time because it was “Apex’s busiest season” and he “thought the pain would go away.” When the pain did not subside, claimant obtained a “pain pill” containing morphine from his brother. Claimant thereafter reported the injury to his employer, and was sent to employer’s workers’ compensation healthcare provider to be examined and treated. Under employer’s policies, any employee who sustains a work-related injury must submit to a drug test when initially examined. The test proved positive for morphine. Because claimant did not have a prescription for the medication, he was terminated. Several days after being terminated, claimant returned to the medical clinic, and a physician found that his condition had worsened, gave claimant pain medication, and ordered him “off work.” The administrative law judge (ALJ) thereafter denied claimant’s request for temporary total disability (TTD) benefits. The Industrial Claim Appeals Office (Panel), on the other hand, concluded that because the physician’s work restrictions were imposed post-termination, the work restrictions, not the termination, caused claimant’s wage loss, entitling him to TTD benefits.

On appeal, employer contended that the Panel exceeded its authority when it set aside the ALJ’s original order denying claimant’s request for TTD benefits. Because the factual determination of whether claimant’s termination was volitional and that his condition had not worsened after he was terminated fall squarely within the ALJ’s province, the Panel exceeded its authority by reweighing the evidence. Substantial evidence supported the ALJ’s factual findings that claimant had not suffered a worsened condition and that his for-cause termination led to his wage loss. The Panel’s final order was set aside and the case was remanded with directions to reinstate the ALJ’s original order.

Summary and full case available here.

Colorado Supreme Court: MMI Not Statutorily Significant Where No Final Admission of Liability Filed

The Colorado Supreme Court issued its opinion in Harman-Bergstedt, Inc. v. Loofbourrow on Monday, January 27, 2014.

Workers’ Compensation—Temporary Total Disability Benefits—Maximum Medical Improvement—Final Admission of Liability—Division-Sponsored Independent Medical Examination.

Harman-Bergstedt, Inc. and its insurer sought review of a court of appeals’ judgment reversing a decision of the Industrial Claim Appeals Office (Panel). The Panel had disallowed claimant’s award of total temporary disability (TTD) benefits, reasoning that once her treating physician placed her at maximum medical improvement (MMI), notwithstanding the failure of her injury to result in any work loss, TTD benefits could not be awarded for the injury for which she initially had been treated in the absence of a division-sponsored independent medical examination (DIME) challenging that placement. The court of appeals found that under the unique circumstances of this case—including the fact that claimant had never been awarded TTD benefits and her employer had never filed a final admission of liability from which the statutory window for seeking a DIME could be measured—a DIME was not a prerequisite to an award of TTD benefits.

The Supreme Court affirmed the court of appeals’ judgment. The Court held that because a determination of MMI has no statutory significance with regard to injuries resulting in the loss of no more than three days or shifts of work time, claimant’s award of TTD benefits was not barred by her failure to first seek a DIME.

Summary and full case available here.

Colorado Court of Appeals: No Right to Reimbursement for Temporary Total Disability Benefits in Excess of Statutory Cap

The Colorado Court of Appeals issued its opinion in United Airlines v. Industrial Claim Appeals Office on Thursday, March 28, 2013.

Workers’ Compensation—$75,000 Statutory Cap for Temporary Total Disability Benefits.

In this workers’ compensation action, United Airlines (employer) sought review of a final order of the Industrial Claim Appeals Office (Panel) affirming the administrative law judge’s (ALJ) denial of employer’s request for reimbursement of temporary total disability (TTD) benefits in excess of the $75,000 statutory cap. The judgment was affirmed.

After claimant sustained a compensable injury in 2007, employer admitted liability for TTD benefits. TTD benefits ceased when claimant was released to return to work in May 2011, by which time she had been paid $99,484.14. Shortly thereafter, a physician performed a division-sponsored independent medical examination and placed claimant at maximum medical improvement (MMI) with a permanent impairment of 5% of the whole person.

Relying on CRS § 8-42-107.5, which caps combined TTD and permanent disability benefits at $75,000 for a claimant whose impairment rating is 25% or less of the whole person, employer sought to recover the $24,483.14 it had paid in excess of the cap. Claimant responded that under CRS § 8-42-105(3), employer was required to continue paying TTD benefits until she was released to work.

The ALJ concluded the cap did not apply as long as claimant was entitled to receive TTD benefits. The Panel agreed and the Court of Appeals affirmed.

The Workers’ Compensation Act (Act) limits the total disability benefits that a claimant whose personal impairment rating is less than 26% may receive. However, the Act provides that benefits continue until one of a number of conditions is met.

Employer argued that benefits paid in excess of the cap must be repaid once claimant’s entitlement to TTD benefits has ended. The Court rejected that contention. Here, claimant received benefits to which she was entitled, and the amount in excess of the cap therefore did not constitute an overpayment.

The Court also found unpersuasive employer’s argument that allowing claimant to keep more than $75,000 in TTD benefits violates equal protection. Equal protection guarantees that similarly situated persons will receive like treatment under the law. Here, no fundamental right is affected or suspect class involved, so a “traditional or rational basis standard of review” applies.

Employer asserted that two classes of claimants are created by the Panel’s decision: those whose benefits will be capped because their benefits had not exceeded the cap when they reached MMI or were released to work, and those whose benefits exceeded the cap before they reached MMI or were released to work. This disparity does not, however, violate equal protection. First, the two classes are not similarly situated. Those claimants who take longer to reach MMI are different from those who take a shorter time. Second, even if they were similarly situated, requiring a claimant to pay back benefits to which she was entitled and needed would create hardships at odds with the purposes of the Act. Proceedings to recover excess payments also could burden the administrative process. These reasons rationally justify the resulting difference in treatment. The order was affirmed.

Summary and full case available here.