The right to compensation for disability or death is barred unless a claim therefore is filed within one year after the injury or death. 33 U.S.C. § 913. Continue reading The Statute of Limitations in Longshore Claims
Settling Workers’ Compensation Cases Involving the World Trade Center Health Program
Where a claimant has a New York or New Jersey or Longshore workers’ compensation claim and is entitled to benefits under the James Zadroga 9/11 Health and Compensation Act of 2010 (“Zadroga Act”) you can obtain a Section 32 (NY WCL § 32), Section 20 (N.J.S.A. 34:15-20) or 8(i) LHWCA (33 U.S.C. 908[i]) lump-sum dismissals of state or Federal workers’ compensation benefits if the secondary payer rights of the WTC Health program are considered.
The Zadroga Act and the World Trade Center Health Program.
The James Zadroga 9/11 Health and Compensation Act of 2010 (“Zadroga Act”) establishes the World Trade Center Health Program (“WTC Health Program”) administered by the Department of Health and Human Services. The Act also extends the September 11th Victim Compensation Fund (VCF), initially operated from 2001 to 2004. The WTC Health Program provides medical monitoring and treatment for emergency responders, recovery, and cleanup workers, and volunteers who helped after the terrorist attacks on September 11, 2001 and for people who were present in the dust or dust cloud on 9/11 or who worked, resided, or attended school, childcare, or adult daycare in the New York City disaster area for a period of time on 9/11 or during the following months.
Continue reading Settling Cases Involving the World Trade Center Health Program
All compensation rates are based on a calculation of the claimant’s weekly wage. In every case, the actual benefit amount requires reference to the National Average Weekly Wage as a ‘maximum’ on the possible benefits. The Department of Labor determining the National Average Weekly Wage as follows:
As soon as practicable after June 30 of each year, and in any event prior to October 1 of such year, the Secretary shall determine the national average weekly wage for the three consecutive calendar quarters ending June 30. Such determination shall be the applicable national average weekly wage for the period beginning with October 1 of that year and ending with September 30 of the next year.
See 33 U.S.C. §906(b)(3).
The U.S. Department of Labor has announced the annual rate increase effective October 1, 2011 based on a newly-calculated National Average Weekly Wage (NAWW).
The new NAWW effective October 1, 2011, is $647.60. This represents a 3.05% cost of living increase over October 1, 2010. All beneficiaries receiving permanent total disability or related death benefits as of September 30, 2011, receive a 3.05% increase in their weekly rate.
The new NAWW also establishes the new maximum and minimum rates under section 906(b); effective October 1, 2011, the maximum weekly rate under the Longshore Act is 200% of the NAWW, so the new maximum rate is $1,295.20 per week. The minimum rate is 50% of the NAWW, so the new minimum rate is $323.80 per week.
How is jurisdiction established under the LHWCA?
The Longshore and Harbors Workers’ Compensation Act (“LHWCA”) covers longshore/harbor workers and other “maritime” workers. The Act has also been applied to certain other workers under the Defense Base Act. (See my overview of the LHWCA).
“Status” and “situs.”
The LHWCA set forth the requirements for coverage. “Status” refers to the nature of the work performed; “situs” refers to the place of performance.
The employee claiming benefits under the LHWCA must be engaged in maritime employment, including any longshoreman or other person engaged in longshoring operations, including any harbor-worker including a ship repairman, shipbuilder, and ship-breaker. There are specific exclusion which apply to status.
The jurisdictional trigger for a claim under the LHWCA is an injury upon the navigable waters of the United States (including any adjoining pier, wharf, dry dock, terminal, building way, marine railway, or other adjoining area customarily used by an employer in loading, unloading, repairing, dismantling, or building a vessel). Jurisdictional questions based on issues of situs are fact-sensitive.
In a new case, decided last month, the employer argued that the claimant did not satisfy either the status or situs prerequisites of the LHWCA. The Benefits Review Board ruled that the claimant did satisfy the status requirement, because he was maintaining and repairing loading equipment used in Longshoring activity.
However, the claimant worked in a garage, more than 400 feet from any navigable water (the Monongahela River). The employer argued that the claimant did not meet the ‘situs’ test.
Taking a liberal view, the Circuit Court adopted a broad reading of “other adjoining area customarily used by an employer in loading, unloading, repairing, dismantling, or building a vessel,” requirement of the Act. In defining “adjoining area,” the court held that “[s]o long as the site is close to or in the vicinity of navigable waters, or in a neighboring area, an employee’s injury can come within the [Act]. To require absolute contiguity . . . would frustrate the congressional objectives of providing uniform benefits and covering land-based maritime activity.” The Board ruled that the garage where claimant was injured was a covered situs, and awarded benefits.
Case: Consolidation Coal Co. v. BRB, et al. [Smith], __ F.3d __, 2010 WL 5176847 (3d Cir. 2010).
Have any questions about this article? Contact Greg Lois.
My book – “Longshore and Harbor Workers’ Compensation Act and Defense Base Act Claims 2011 Edition” is getting ready for publishing and we are finalizing the cites and references for the 2011 editiion (shipping: April 2011). Here’s a sneak preview of the Chapter 6: Medical Benefits (note: 43 footnotes with citations have been removed):
Chapter 6: Medical Benefits under the LHWCA
Section 907 of the Act requires that the
. . . employer shall furnish such medical, surgical, and other attendance or treatment, nurse and hospital service, medicine, crutches, and apparatus, for such period as the nature of the injury or the process of recovery may require.
The employer must respond to a request for treatment upon notice of the injury, even if the work-relatedness of the injury is challenged. The duty of the employer to provide medical treatment is absolute. The medical care provided must be both “reasonable and necessary” and appropriate for the injury. The claimant has the right to choose his own attending physician.
The physician chosen by the claimant must submit a report to the carrier within 10 days.
The right of the claimant to choose his own physician is only limited by the ‘prohibited’ provider list of physicians and facilities who do not meet standards established by the DOL.
The employer is liable for all medical expenses for any consequences of the compensable injury, including the chosen physician’s malpractice. While an employer is not liable for medical expenses due to the degenerative processes of aging, an employer is responsible for ‘aggravations’ of prior injuries. An employer is responsible for treatment even if the work-related injury only partly causes the need for that treatment, and that is true in psychological injury cases as well as physical injury ones.
Any injury sustained during the course of a medical examination scheduled at the employer’s request for an alleged work-related injury is covered under the LHWCA, because such an injury necessarily arises out of and in the course of employment.
Exceptions to the claimant’s choice of physician
The employer is allowed to select a doctor or facility the claimant can not due to the nature of his injury and the injury requires urgent treatment, the employer is to select a physician for him. The claimant must be incapacitated and in need of emergent treatment for this exception to be invoked. Once the claimant regains his faculties, then he regains the freedom to chose his own attending doctor.
Once a claimant has made an initial unrestricted choice of a physician, he may change physicians only upon obtaining prior written approval of the employer, carrier, or deputy commissioner. If the claimant fails to obtain the required authorization to switch treaters, the carrier/employer does not have to reimburse the claimant for the costs of the new, unauthorized treatment. Note: referral to a specialist from an attending physician will not invoke a need for new authorization from the carrier.
The claimant must report his injury and request treatment in order to trigger an employer’s responsibility to pay for such care. There are many instances where an employee does not have to formally report his injury – for example, where an employer’s representative is at the scene of the accident. An employer “has knowledge of an injury” when an accident occurs and a reasonable person could conclude that there might be liability for compensation and should investigate further.
Mere knowledge of an accident is not enough to make an employer liable for paying medical bills – accident happen everyday and no treatment is sought. The employee must affirmatively request care in order to trigger responsibility on the part of the employer for any resulting medical bills.
The employee does not have to request treatment when a request would be futile. For example, if the claimant was fired for reporting the accident, there would be no duty on the part of the claimant to seek treatment from the employer.
Judicial review of medical treatment
A claimant only has to present the opinion of a qualified physician that treatment was necessary for a work-related condition to establish a prima facie case for compensable medical treatment. The judge can order the employer to make payment for medical treatments already received by the claimant. The Judge can also order that a specific course of medical care be authorized by the employer. However, a judge can not pick specific medical facilities for the care to take place – that would abrogate the claimant’s right to pick his own doctor.
A judge has no authority to deny a medical expense on the technical grounds such as a particular physician’s expertise, whether the fee charged was within the customary range, or where the medical treatment was not documented. The Judge can only rule on the reasonableness of the medical services.
It is up to the employer to raise the reasonableness and necessity of treatment before the presiding judge.
What counts as medical treatment?
Stories are legion and Longshore caselaw is replete with references to dubious medical treatment prescribed by treating physicians and ruled to be the employer’s expense (for example – the install of a jacuzzi for the ‘recovery’ of a claimant, a physician ordered who ordered his patient relocate to a ‘warmer climate,’ or a doctor writing prescriptions for first class travel). The regulations define medical care to include laboratory, x-ray, and other technical services, such as prosthetic devices for the care and treatment of the injury or disease. Treatment does not have to be ‘medically accepted’ but merely “helpful.” The treatment does not have to be administered by a therapist or practitioner with any sort of license. Meeting this rather low burden are pseudo-medical treatments such as biofeedback.
Chiropractors are allowed to treat Longshore patients and are paid for their care only to the extent that it consists of manual manipulation of the spine to correct a subluxation shown by x-ray or clinical findings. Chiropractors are not to be paid for treating shoulders, hips, knees, etc., or administering physical therapy.
Travel to and from medical appointments, as well as special travel needs, are generally compensable.
Generally, travel will be reimbursed for physicians within 25 miles of the residence of the claimant.
Regulation 20 C.F.R. § 702.403 states:
In determining the choice of physician, consideration must be given to availability, the employee’s condition, and the method and means of transportation. Generally, 25 miles from the place of injury or the employee’s home is a reasonable distance to travel, but other pertinent factors must also be taken into account.
Independent Medical Examinations
33 U.S.C. § 907(e) states:
In the event that medical questions are raised in any case, the Secretary shall have the power to cause the employee to be examined by a physician employed or selected by the Secretary and to obtain from such physician a report containing his estimate of the employee’s physical impairment and such other information as may be appropriate. Any party who is dissatisfied with such report may request a review or reexamination of the employee by one or more different physicians employed or selected by the Secretary. The Secretary shall order such review or reexamination unless he finds that it is clearly unwarranted. Such review or reexamination shall be completed within two weeks from the date ordered unless the Secretary finds that because of extraordinary circumstances a longer period is required. The Secretary shall have the power in his discretion to charge the cost of examination or review under this subsection to the employer, if he is a self-insurer, or to the insurance company which is carrying the risk, in appropriate cases, or to the special fund in section 44 [33 USC § 944].
The IME Process
When a medical question is raised, the Secretary may have the claimant examined by a physician employed or chosen by the Secretary and receive a report to determine the diagnosis, estimate the claimant’s physical impairment, or comment on whether additional medical treatment is necessary.
Following the initial report, either the claimant or the employer can then request a review or a reexamination of the employee by a different physicians employed or chosen by the Secretary within two weeks.
The findings of the initial examining physician’s findings are not binding on any party.
Immediately following the initial exam, the employer or carrier may request, to have the employee examined.
If the claimant refuses to attend an IME
If the employee refuses to submit to the examination, the proceedings shall be suspended and no compensation is paid until the claimant attends the exam. This applies equally to initial exam and employer-requested IMEs. A claimant’s failure to attend an exam with the employer’s chosen examining physician can not be excused. Claimants have argued that the physician chosen by the employer are biased or incompetent as excuses for not attending exams. A Judge can not excuse a failure to attend an IME on the grounds that the claimant lacks confidence in the physician, although that would obviously be accepted by the court as a reason to not allow the doctor to act as a treating physician.
From Chapter Five of my upcoming book, “Longshore and Harbor Workers’ Compensation Act”:
The following are excluded from coverage under the Longshore and Harbor Workers’ Compensation Act:
- Master or member of a crew;
- Small vessel workers;
- Officers and agents of the federal, state, local, or foreign governments;
- Clerical/secretarial/security/data processing employees;
- Employed by a club, camp, recreational operation, restaurant, museum or retail outlet;
- Marina workers;
- Employees of suppliers, transporters or vendors;
- Aquaculture workers;
- Small vessel building/repairing/dismantling.
The claimant’s right to receive benefits under the Longshore and Harbor workers’ Compensation Act by filing a claim for an receiving state workers’ compensation benefits.
Notice & Prejudice
The claimant must provide notice of injury to the employer within 30 days of the injury except for occupational disease cases. In an occupational claim, the notice period extend to one year from when the employee was aware or should have been aware of the condition and the relationship of the condition to work. The claimant must show that either the employer had knowledge during the filing period, or that the employer was not prejudiced by the failure to file timely notice, or that the failure was excused.
Failure to file notice may be excused by the judge where notice was given to an official of the employer or carrier and no prejudice resulted, even if not given to the designated official.80 This frequently happens where an employee reports an injury to a colleague rather than a supervisor. The notice requirement may also be excused if a satisfactory reason exists as to why such notice could not be given.
The employer can show prejudice when due to a lack of timely written notice the employer was unable to effectively investigate to determine the nature and extent of the alleged illness or to provide medical services.
Despite ‘notice’ being a defense, please note that notice is presumed under the Act and must be affirmatively plead.
In order for this defense to prevail, the employer must show that the intoxication was the sole cause of injury.
Section 903(c) of the Act states that “ (c) No compensation shall be payable if the injury was occasioned solely . . . by the willful intention of the employee to injure or kill himself or another.”
Suicide or self-harm.
In order to prevail with this defense, the employer must show that the claimant’s injuries arose out of a willful intent on the part of the employee to harm himself – this is more than just a ‘careless’ attitude towards safety or even willful refusal to use a specific piece of safety equipment. The burden of proof is on the employer to demonstrate that the suicide or self-inflicted injury did not arise out of the employment.
Intent to harm another.
The employer bears the burden of showing that the claimant was injured will attempting to harm himself or another. The employer must show willful intent on the part of the claimant, which can be demonstrated by the claimant’s speech and physical activity (gestures and contact) at the time of the incident. The burden shifts to an employer seeking to rely on an employee’s own intentional acts.
An employee’s own intoxication being the sole cause of the accident is a defense to compensability. However, in order to prevail, the burden shifts to the employer to show that the accident arose solely due to the intoxication of the employee with no contribution from the work.