Causal Relationship for Preauthorized Surgeries: Questioning Causality

It is easy to accept preauthorized surgeries as a foregone conclusion where the site of surgery is established and the procedure is approved by the Medical Treatment Guidelines. However, it shouldn’t be.

Earlier in 2019, Goldberg Segalla’s workers’ compensation team won an appeal on this very issue. The claimant underwent preauthorized left shoulder surgery on a file established to the left shoulder for an injury that occurred in 2016. However, the claimant underwent left shoulder surgery secondary to a 2004 motor vehicle accident prior to …

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I Love You, You’re Perfect, Now Change: Latest Updates on Amending The Compassionate Care Act

At the end of 2018, the original sponsors of the Compassionate Care Act, New York State Senator Savino (D) and Assemblymember Gottfried (D), introduced legislation that will require the following public health insurance plans in New York State to cover medical marijuana:

  • Medicaid
  • Child Health Insurance Plan (CHIP)
  • Workers’ Compensation
  • Elderly Pharmaceutical Insurance Coverage (EPIC) Program, and
  • Family Health Plus Plan.

The bill remained inactive in the fall and has yet to be re-introduced since January 9, 2019 when the New York State legislative session …

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“You Can’t Get There From Here”: Maine Supreme Court Says Compelling Medical Marijuana Coverage Conflicts with Federal Law

Recently, the Maine Supreme Court issued a decision that surprised workers’ compensation professionals across the country. In Bourgoin v. Twin Rivers, 2018 ME 77, 2018 WL 2976309 (June 14, 2018), the court decided that a workers’ compensation carrier cannot be compelled to subsidize a claimant’s medicinal marijuana treatment. In that case, the claimant received a certification under the Maine Medical Use of Marijuana Act (MMUMA) for the use of medicinal marijuana to treat work-related injuries. The court determined that requiring the carrier to subsidize …

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“New York State of Mind”- Altering Substances: Carriers Must Now Reimburse Claimants for Medical Marijuana

On June 4, 2018, the New York Workers’ Compensation Board in Our Lady Victory of Homes officially directed a carrier to reimburse a claimant for medical marijuana expenses. G085 6672, 2018 WL 2752819 (N.Y. Work. Comp. Bd. June 4, 2018). This decision has been in the making since February of this year, when the board panel found in WDF Inc. that reimbursement is proper if the medical provider requests a variance from the Medical Treatment Guidelines (MTG). G140 3803, 2018 WL 1723750 (N.Y. Work. Comp. …

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The Illinois Appellate Court Narrows the Scope of Compensable Parking Lot, Slip and Fall Claims

As the harsh conditions of winter wind down in the Midwest, slip and fall claims tend to ramp up. Traditionally, injuries sustained as the result of a hazardous condition in an employer maintained parking lot have supported a finding of compensability. Suter v. Illinois Workers’ Compensation Comm’n, 2013 IL App (4th) 130049WC. However, recent decisions from the Illinois Appellate Court and Illinois Workers’ Compensation Commission have narrowed the scope of what are considered “hazardous conditions” under neutral risk analyses in evaluating compensability of parking …

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New York Sets Boundaries: How to Calculate Schedule Loss of Use of the Shoulder in 2018

The New York Appellate Division has provided direction on what constitutes an improper calculation of the schedule loss of use of a shoulder. In Matter of Maloney v. Wende Correctional Facility, 2018 WL 456207 (January 18, 2013), the claimant injured his right shoulder as a result of a work related accident on July 30, 2013. The claimant’s treating physician rendered a permanency finding of 90 percent schedule loss of use of the right arm. The employer and the insurance carrier, collectively “the employer”, obtained …

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It’s Possible to Avoid Total Industrial Findings When Claimants Have a High Impairment Rating

Recent Board Panel decisions are providing guidance for employers to successfully avoid a total industrial finding when addressing Loss of Wage Earning Capacity. Indeed, there does not appear to be any basis under the law for an administrative law judge to find a total industrial disability. In Town of Fenton, Case Nos. G0501597, 90502069, G0087246, 2015 WL 7067972, at *6 (N.Y. Work. Comp. Bd. Nov. 5, 2015), the Board Panel noted “that the claimant’s request for a 100 percent loss of wage earning capacity …

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