A worker was entitled to medical and disability payments under the Massachusetts worker’s compensation statute for a work related injury even though there was evidence in his own medical record that he had a pre-existing back condition.
The Massachusetts Appeals Court determined that the insurer for the employer had failed to produce evidence to overcome the opinion of the worker’s chiropractor that the injuries were primarily related to the new injury, rather than the pre-existing degenerative back condition, as was required under G.L. c. 152, s. 1(7A).
On December 31, 2004, Scott MacDonald was cleaning up a worksite at the end of a work day. While lifting buckets of waterproofing, he felt a tightness in his back, which did not seem sufficiently serious at the time to prevent him from completing his workday. However, the following day the pain became excruciating, and he sought treatment with a chiropractor, which continued for the next four months.
The chiropractor also recommended that he obtain an MRI, which revealed disc herniations and degenerative changes. MacDonald then sought treatment from a group of neurologists, whose reports referenced prior back injuries and treatment, and made a diagnosis of pre-existing degenerative disc disease. The records show that MacDonald’s condition was improved in March, 2005 and he was back to work by the beginning of May, 2005.
McDonald sought benefits for a work related injury, which his employer’s insurer challenged on the basis that his injury was pre-existing and not work related. An administrative judge heard MacDonald’s claim and awarded medical benefits, temporary total incapacity from January 1, 2005, to March 15, 2005, and temporary partial incapacity from March 16, 2005, until April 30, 2005.
In concluding that MacDonald was entitled to benefits, the administrative judge rejected the only evidence presented by the insurer, which was an opinion that the chiropractor’s treatments were unnecessary and excessive. The board affirmed.
The Appeals Court upheld the Administrative Judge’s finding that the medical records introduced by MacDonald were the sole basis for the insurer to meet its burden under Section 1(7A) to demonstrate that his claimed injury was the combination of a prior injury with the current work injury.
The judge had found, and the Appeals Court agreed, that at most the records produced an ambiguous medical picture, notwithstanding the heightened standard imposed by the statute on the employee when he seeks benefits in a situation where an injury results from a combination of a claimed compensable injury and a prior noncompensable injury.
In such instances the employee must prove that the compensable injury or disease remains a major but not necessarily the predominant cause of disability. The Court refused to alter the findings of the administrative judge because the insurer had wholly failed to introduce any evidence of its own on the subject of combination injury, and therefore did not meet its burden of production.
MacDonald’s Case, No. 08-P-187. February 9, 2009.
Comment: It is apparent that an employee claiming a work related injury, who also has a related pre-existing condition stands to benefit greatly if the insurer elects to rely wholly on the employee’s prior medical records. In this particular case the parties had agreed to opt out of an Independent Medical Examination because the benefits claim was for a closed period. Bad idea for the insurer in this case, and likely one not to be repeated by insurer’s counsel who have reviewed this decision.