GQ Corner
Q. A claimant has pre-existing heart issues and now needs shoulder surgery. The doctor tells him that he has to have cardio clearance before they can do surgery and he goes to his heart doctor and gets cleared. Then the claimant sends in a mileage request and the co-pay charge, asking if we are going to pay for the mileage and co-pay. I do not think I should. It is not just the normal referral by surgeon for chest x-ray and bloodwork at hospital, I usually pay for that, but this was different.
A. You typically take your claimant as you find him and the employer assumed the risk by employing someone with a heart condition. The heart doctor should have billed you so that the bill could be audited. The co-pay part is problematic but unless it is a lot of money, it may be cheaper to pay it than the MAR value of the heart doctor’s bill.
Q. For some reason I am stuck and cannot make up my mind about how to classify the following incident:
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- What is the difference between cumulative and repetitive trauma?
- How should I classify the following incident? I am inclined to say trauma as it is tied to a specific activity, albeit not a single act. I need to decide whether or not it is cumulative:
“EE worked at Topping station for 2 days in a row (6/21 and 6/22) followed by 1 day at the oven packing station. Started feeling pain on 6/23 from wrist to the hand unable to lift anything, even the cell phone. Pain scale at moment about 6 on 10. Pain in the LH wrist/hand due to over exertion from food preparation.”
A. Acute injuries are basically those traceable to one specific incident at a particular time and place, while repetitive or cumulative trauma injuries (often referred to as “occupational disease” claims) are those that develop over an extended period of time as a result of repeated exposure to harmful occupational activities. The Appeals Panel no longer requires a claimant to commit to a particular theory of injury in arguing for a compensable injury, and sometimes there are gray areas between the two. I think yours sounds more akin to a repetitive trauma claim involving the alleged gradual onset of pain during the course of various work activities. Note that if the claimant is specifically asserting a repetitive trauma injury, he or she must prove that repetitious, physically traumatic activities occurred while on the job and that there is a causal connection between those activities and the injury asserted. Davis v. Employer’s Ins. of Wausau, 694 S.W.2d 105 (Tex. App.-Houston [14th Dist.] 1985, writ ref’d n.r.e.). Once the causal connection is proven, the claimant need not further prove that the disease is inherent in or present in his or her employment to a greater degree than employment generally. APD 961008. Proof of a repetitive trauma injury should consist of some presentation of the duration, frequency, and nature of the activities claimed to be traumatic. APD 960929.
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