In SIBs Case, Claimant Failed to Prove a “Total Inability to Work”
The Appeals Panel has reversed the decision of a Hearing Officer who concluded that that a claimant had offered evidence of a “total inability to work” in a SIBs case, and rendered a decision that the claimant was not entitled to SIBs for the disputed quarter.
The case, in Appeals Panel Decision Number 160541, decided June 1, 2016, concerned the claimant’s theory of entitlement to SIBs for the fourth quarter, which was based on a total inability to work. The Hearing Officer found that during the qualifying period for the fourth quarter the claimant was unable to perform any type of work in any capacity, and noted in her discussion that a designated doctor’s report in response to an LOC was sufficient evidence of a total inability to work. Therefore, the Hearing Officer concluded that the claimant’s unemployment was a direct result of his compensable injury. Medical records in evidence listed the claimant’s pre-injury job as a pipefitter.
Rule 130.102(d)(1) provides, in pertinent part, that an injured employee demonstrates an active effort to obtain employment by meeting at least one or any combination of the following work search requirements each week during the entire qualifying period:
(E) has been unable to perform any type of work in any capacity, has provided a narrative report from a doctor which specifically explains how the injury causes a total inability to work, and no other records show that the injured employee is able to return to work.
In Appeals Panel Decision Number 012286, the Appeals Panel “held that the narrative report from the doctor must specifically explain how the compensable injury causes a total inability to work.” The Appeals Panel examined whether the designated doctor’s response to the LOC satisfied this requirement. That report stated:
Given the severity of [the claimant’s] injuries from the forklift accident, along with compromised tissues from a previous motorcycle accident, it is not surprising that the claimant’s wounds, though closed at the time of my [d]esignated [d]octor [e]xamination, would have further problems healing, requiring the noted treatment. Although I placed him back to work with restrictions based on my examination of [December 1, 2014], and the [functional capacity evaluation (FCE)] performed on [December 9, 2014], his change in clinical condition by [January 8, 2015], requiring debridement and continuing to further treatment, should supersede my previous determination of return to work status.
Based on medical information provided, it is my opinion that the claimant’s medical condition worsened enough during the identified qualifying period . . . to have his work status listed as off work due to non-healing wounds that required extensive and serial treatment.
The Appeals Panel concluded that the report was not sufficient to show a total inability to work.
Although [the designated doctor]’s report states that the claimant’s work status is listed as off work, it does not state that the claimant has a total inability to work. None of the medical reports in evidence constitute a narrative report from a doctor which specifically explains how the compensable injury caused a total inability to work in any capacity. Accordingly, we reverse the Hearing Officer’s determination that the claimant is entitled to SIBs for the fourth quarter, May 1 through July 30, 2015, and we render a new decision that the claimant is not entitled to SIBs for the fourth quarter, May 1 through July 30, 2015.
A claimant who contends that he is totally unable to work in support of his SIBs application has a high burden of proof to show entitlement.
FOLIO
