When is a treating doctor's opinion accepted on causation?

Disputes on the causal relationship of an injury are common in the workers’ comepnsation context. Oftern, these disputes arise in the context of an alleged “consequential” injury, where the claimant is alleging that because of “altered gait” or other consequence of a compenaable injury, she developed some other disabling condition. When the

“medical opinion of the clamant’s treating physician [is] neither speculative nor a general expression of possibility and it ‘signifies a probability as to the underlying cause of the claimant’s injury which is supported by a rational basis'” and where there is no conflicting medical evidence, the Board may not reject the treating physician’s uncontroverted medical opinion on causation.

Matter of Maye v. Alton Mfg., Inc., 90 AD3d 1177 (2011), quoting, Matter of Mayette v. Village of Massena Fire Dept., 49 Ad3d 920 (2008).

A recent decision (Matter of New York Presbyterian Hospital and State Insurance Fund, 13 NYWCLR 165 [September 11, 2013]) addressed these questions.

This lays out the following test for when a treating physician’s opinion on causation will be accepted:

  1. Comes from the treating physician;
  2. Is not speculative;
  3. Is not merely expressing a “possible” cause;
  4. states that the condition is at least probably causally related;
  5. is supported by a rational basis; and
  6. there is no conflicting medical evidence.

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Greg Lois is the managing partner of LOIS LLC and dedicates his practice to defending employers and carriers in New York and New Jersey workers' compensation claims. Greg is the author of a popular series of "Handbooks" on workers' compensation, and is the co-author of the 2016-2019 Lexis-Nexis New Jersey Workers' Compensation Practice Guide. Greg can be reached at 201-880-7213 or glois@loisllc.com