GQ Corner
Q. I have a claimant who has been disabled and receiving TIBs. The claimant recently indicated that he had not returned to work since the work injury. However, we recently received an employment verification form from a non-claim employer confirming that the claimant was hired there some time ago. May I safely dispute disability and suspend TIBs based on this information alone?
A. No. This is because the employment verification alone does not indicate what his current wages are, or whether these are less than his pre-injury average weekly wage. Therefore, if the claimant is still earning less because of the compensable injury, then he is still disabled and entitled to TIBs. For these reasons, the prospect of unilaterally suspending TIBs may be problematic from a compliance standpoint, possibly resulting in a complaint and potentially a violation against the carrier. Ideally, from a practical perspective, you would share the employment verification with the claimant and get him to admit that he has in fact returned to work. He could then provide you with his post-injury earnings (as is his obligation) and you could reduce or suspend TIBs accordingly.
Q. I have a claimant with a past medical history significant for serious knee problems. Apparently, she was simply standing up from a seated position when she experienced an onset of knee pain. She went to the doctor and received a number of diagnoses, including a strain. Would this be likely deemed compensable?
A. Yes. In such cases, which seem to lack any significant mechanism of injury, the Appeals Panel has adopted a very broad interpretation of causation to find a nexus between the employment and claimed injuries of this sort. Historically, a specific instrumentality of the employer had to at least cause the claimed injury. More recently, the Appeals Panel has held that an instrumentality of the employer does not have to cause a fall or similar injury in order for resultant injuries from same to be deemed compensable; in other words, a fall or similar injury may simply be idiopathic and still compensable. See APD 051610-s. Ultimately, assuming the records confirm some new injury, i.e. damage or harm to the physical structure of the body, the Division would likely find a compensable injury since the event arguably would not have carried the consequences it did but for the employment.
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