SIBs Case Reversed: Claimant Failed to Prove a Total Inability to Work
The Appeals Panel has reversed the decision and order of a benefit contested case Hearing Officer involving first quarter entitlement to SIBs and has rendered a decision that the claimant is not entitled to benefits. The case, Appeals Panel Decision Number 160590, decided May 31, 2016, involved a claimant’s contention that he had a total inability to work, which is one of several independent methods by which a claimant can show entitlement to SIBs.
The claimant offered a medical report from a Division-appointed designated doctor in an effort to establish his total inability to work during the qualifying period in accordance with Rule 130.102(d)(1)(E). The Hearing Officer found that the narrative report specifically explained how the injury caused a total inability to work during the qualifying period for the first quarter of SIBs. The Hearing Officer therefore determined that the claimant is entitled to SIBs for the first quarter due to a total inability to work. The Appeals Panel disagreed.
The report at issue stated:
The question then becomes can he work in ANY capacity.
My answer could be a conditional yes. Theoretically, a sheltered workshop with structure and supervision could potentially be a setting where the examinee could participate. He would need to be mostly sitting and also supervised closely for safety purposes. This is not to be confused with a competitive work setting with the ability to earn a meaningful wage.
While it is arguable that the work injury sequela are not the main reasons for his not working, they clearly are contributing significantly to his present dysfunction. The dizziness and degree of cognitive dysfunction seem to be related primarily to the work injury. Frankly, I cannot envision any job this man, with his age and health history, could safely perform well enough to satisfy a potential employer.
The Appeals Panel focused on the first part of the report – the part in which the doctor answered the question with “a conditional yes.” The Appeals Panel read this language as describing “circumstances in which the claimant could work.” It noted that the report “does not specifically explain how the compensable injury causes the claimant to be unable to work in any capacity.” Accordingly, the Appeals Panel concluded that the designated doctor’s report “did not constitute a narrative which specifically explains how the compensable injury causes a total inability to work pursuant to Rule 130.102(d)(1)(E).”
The remedy that the Appeals Panel imposed was rendition rather than remand for the development of additional evidence. This is because the claimant had been given a full and fair chance to offer evidence to support his position. His failure to do so meant that the carrier should prevail.
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