E\Cs Must Prove a Pre-existing Condition to Assert Idopathic Defense

Tuesday, August 14, 2012 | 0

Nothing is as frustrating to an employer/carrier as when an employee suffers an accident and cannot explain how the accident took place. This occurs often in slip and falls where the employee readily admits she does not know (or sometimes remember) how she fell. She was walking down and a hallway at work one minute. The next minute, she was on the ground and in pain.

Many E/C’s view these type of injuries as “idiopathic” and deny the claim because the accident could have occurred anywhere (at home or in public) and the fact it occurred at work was just a coincidence. None of the physical aspects of the job caused the accident.

The problem is this thinking is wrong. Even the definition of “idiopathic” is misinterpreted by many E/C’s. All “idiopathic” means (as defined by Webster’s Dictionary)  “arising spontaneously or from an obscure or unknown cause.”  So, when an E/C cries out “idiopathic!” and denies the claim, all they are saying is they have no idea what happened. And, that has no bearing to proving the claim is non-compensable.

The truth of the matter is that if no one (not even the claimant) knows how an accident happened, the courts are going to favor the claimant and award compensability. And, we have a couple of new cases from the 1st District Court of Appeal that proves this point.

First in Caputo v. ABC Fine Wine & Spirits, claimant fell from a ladder at work while conducting his normal job duties. He landed on his head and suffered severe injuries. Due to the head trauma, claimant had no recollection of the accident and no witnesses saw him fall. The E/C sought an independent medical examiner that testified the landing, not the fall caused claimant’s injuries. Claimant’s own IME could not state whether any factor related to the employment caused the fall.

At trial, the judge denied the claim on the grounds that claimant did not prove his employment was the major contributing cause of his accident and subsequent injuries. While the judge rejected the E/C’s defense that Claimant had a pre-existing condition which predisposed him to falling, the judge did find that claimant’s fall was idiopathic, occurring fortuitously while Claimant was at the Employer’s store, and was not caused by the employment.

On appeal, the 1st DCA reversed. The court found that in absence of a competing cause to his injuries, the judge erred in denying benefits. The evidence was undisputed that the impact of claimant’s head on the floor caused his injuries. It was also undisputed that claimant did not have a pre-existing condition that could have caused the fall. In the absence of any other cause, claimant satisfied the major contributing cause requirement by simply testifying he fell off a ladder while at work.

Despite the continuing confusion of idiopathic accidents, this principle is based on an old Florida Supreme Court case from 1981. In Hacker v. St. Petersburg Kennel Club, 396 So.2d 161, the high court issued a narrow ruling where an accident occurs while an employee is at his place of employment during working hours an no evidence of cause is available, the burden shifts to the employer to show idiopathic cause if the claim for compensation is to be denied.

In the very recent case of Walker v. Broadview Assisted Living, the Claimant tore her rotator cuff moving a package delivered by UPS.  She was in the course and scope of employment at the time of the accident.   This was undisputed.

The 1st DCA found that since the E/C did not present a competing cause to her injuries, the work activity became the de facto cause. Just like in Caputo and Hacker the presumption is favored towards the Claimant that the accident is compensable despite the fact that the claimant cannot point to a cause of the accident.

What the court is doing is clearing up the long standing misconception of E/C’s that a claimant must prove the exact reason why she had the accident. Remember, that is not the original rationale of the Workers' Compensation Act. The rationale is that as long as an accident occurs within the course and scope, the E/C will accept it. To rule otherwise would render workers' compensation in the same position as personal injury law.

When looking at the cause of an accident, a claims professional must investigate if there is a “competing cause” to the accident other than claimant’s version. There are cases where a claimant’s seizure caused the fall or an arthritic knee caved in. But, if there is no competing cause, then accepting the claim is the best thing to do.