|
So it was with a case that we recently reviewed here - at the Supreme Court of Ohio - involving a man named Ralph E.
Jackson. Jackson, who worked for International Truck and Engine Corporation (ITE), had filed a Workers' Compensation
claim that was allowed for several low back conditions.
In 2004, Jackson sought authorization for back surgery. But Dr. David C. Randolph examined Jackson and concluded that he
wasn't an acceptable candidate for surgery.
A staff hearing officer for the Industrial Commission of Ohio, which administers these claims, denied Jackson's request
based on Dr. Randolph's report. Several months later, Jackson requested authorization for the same surgery. That request
was denied in August 2005 by a staff hearing officer who determined that "the requested extensive low back surgery and
related services to that surgery are not necessary and reasonably related to the allowed industrial injury."
After being denied twice, Jackson decided to pursue the surgery on his own. He had his operation on November 17, 2005,
with good results. Jackson then requested temporary total disability (TTD) compensation for his postsurgical recovery
period.
ITE, which was self-insured, objected, arguing that because the surgery had been disallowed, payment for any related
expense was inappropriate. But a staff hearing officer awarded compensation, finding that even though the surgery was
disallowed, the procedure stemmed from the allowed conditions, making compensation payable.
After that, ITE filed a complaint with the court of appeals alleging that the Industrial Commission abused its discretion
in awarding compensation. ITE argued, among other things, that the August 2005 staff hearing officer order that denied
surgery stated that the surgery was not related to the allowed conditions.
ITE maintained that the causal-relationship issue was thus settled, which barred the commission from later awarding
compensation for the surgery based on a causal relationship to the allowed conditions.
The court of appeals effectively acknowledged this point, but then held that the August 2005 order was unsupported by
the evidence. The court of appeals thus upheld the TTD award and the causal-relationship reasoning underlying it.
After the court of appeals ruled on the case, it came before us for a final review. By a five-to-two vote, our court
reversed the ruling of the court of appeals.
Why did the majority of our court reach a different conclusion? The decision related to a Workers' Compensation ruling
by our court in 1994.
That case endorsed a three-part test for authorization of medical services: "(1) Are the medical services 'reasonably
related to the industrial injury, that is the allowed conditions'? (2) are the services 'reasonably necessary for
treatment of the industrial injury'? and (3) is 'the cost of such service... medically reasonable'?"
Jackson asserted that the 2005 staff hearing officer's order did not deny a causal relationship but instead stated that
the surgery did not meet the second requirement of the three-part test. But the majority found that argument unpersuasive.
The majority concluded that the August 2005 order gave two reasons for disallowing surgical authorization: (1) that it
wasn't necessary, and (2), that it was not "reasonably related to the allowed industrial injury." The former reason
speaks to the second prong of the test, but the latter addresses the first. Thus, according to the majority, ITE was
correct in contending that the causal-relationship issue was a settled matter.
Justice Evelyn Lundberg Stratton and I cast the two dissenting votes in this case. Why did we disagree with the majority?
We believed that Jackson was entitled to TTD compensation because, as Justice Stratton wrote, "his biKk surgery resulted
in a functional change in his medical condition that again caused TTD. The surgery was related to his allowed back
condition and constituted a new and changed circumstance that warranted reinstatement of the TTD compensation during his
recuperation."
In 2004, and again in 2005, the commission denied Jackson's request to authorize payment for back surgery. "Physicians
disagreed over the appropriate treatment for him - surgery versus more conservative options of therapy and medication -
and those doctors disagreeing with surgery did so primarily because they believed that his risk factors (age, weight,
and smoking) outweighed the potential for its success."
Thus, the commission denied his requests "not on the basis of a lack of connection between the allowed conditions and
the proposed treatment, but merely based upon other contradictions."
But Jackson proceeded with the surgery at his own expense, and it was successful at reducing his back pain. "This
constituted a functional change in his medical condition that was temporary. The fact that the commission previously
refused to authorize payment for the surgery should not be determinative of the TTD issue."
Although the commission terminated Jackson's TTD compensation when he reached maximum medical improvement, his condition
changed postsurgery. New and changed circumstances related to his allowed conditions again temporarily disabled-ban.
The commission awarded TTD compensation based on medical evidence submitted by Jackson's treating physician that his
current period of disability was related to his allowed conditions. Justice Stratton and I did not believe that the
Industrial Commission abused its discretion when it resumed TTD compensation from the date of his surgery until he was
able to return to work.
Despite the commission's refusal to pay for the recommended surgery, Jackson exercised his right to follow his treating
physician's advice, which improved his condition. But the majority of our court determined that he is not entitled to
TTD compensation during the period of recuperation for the successful procedure because the commission had refused to
authorize the procedure in the first place.
Justice Stratton and I believed that determination defeats the purpose of TTD compensation and is counterproductive to
the goal of returning the injured worker to his former position of employment.
|
In the Workers' Compensation systems of our country, sometimes an injury is so obvious, and the treatment options so clear-cut, that
following the right path for the injured worker is straightforward. Other times though, if the injury, or treatment,
isn't so apparent, it's difficult to strike an equitable solution for both the employer and the injured employee.