eNotes: Workers’ Compensation – November 2024 – West Virginia

SIGNIFICANT CASE SUMMARIES

West Virginia Case Summaries

Eloirzazi v. AM Communications
Intermediate Court of Appeals of West Virginia
No. 24-ICA-110

Decided: October 28, 2024

To expand a compensable injury to include new conditions, a claimant must prove the conditions are causally related to the work injury. To reopen a case for TTD benefits, a claimant must show an aggravation/progression of a compensable condition or facts not previously considered.

Background

The Claimant sustained a work-related injury to his neck as a result of being in a motor vehicle accident in 2017. The Claim Administrator issued an order holding the claim compensable for a neck sprain. The Claimant underwent medical treatment for four years before his doctor determined he reached maximum medical improvement, and further medical treatment was not anticipated. At that time, an MRI of the Claimant’s cervical spine was conducted, and it did not include findings of C5-C6 disc disorder with radiculopathy and C5-C6 disc displacement.

Two years later, the Claimant requested the addition of C5-C6 disc disorder with radiculopathy and C5-C6 disc displacement as compensable conditions of the claim, authorization for physical therapy of the cervical spine, reopening of the claim for TTD, and payment of a receipt for emergency room treatment for a C5-C6 herniated disc. The Claim Administrator denied these requests. The denial of the expansion of the definition of injury was based on the MRI from 2021, which revealed no herniated or displaced disc at C5-C6. Therefore, these findings were considered to be new findings unrelated to the compensable injury. The denial of the request to reopen the claim for TTD was because there was no evidence of aggravation/progression of the compensable injury. The Claimant protested the denial orders. The BOR affirmed the Claim Administrator’s orders, finding the preponderance of the evidence did not establish the C5-C6 disc disorder with radiculopathy and C5-C6 disc displacement were casually related to the compensable injury. The Claimant appealed the BOR’s order.

Holding

The ICA affirmed the BOR’s order, holding that the BOR was not clearly wrong in upholding the order denying reopening the claim and expanding the compensable injury. The BOR was persuaded by the 2021 MRI, which did not include the findings the Claimant sought to add to the compensable claim. The preponderance of the evidence did not show the new conditions Claimant sought to add and be treated for were causally related to the original work injury. Second, for a claim to be reopened for TTD benefits, a claimant must show an aggravation or progression of a compensable condition, or facts not previously considered. The ICA found that neither had occurred here. The two other requests for treatment to be paid for were similarly properly denied since they were not medically necessary and reasonably required in the treatment for the compensable injury. The ICA held the BOR was therefore not clearly wrong and noted this a deferential standard of review.

Takeaway

First, when a claimant seeks to expand a compensable injury to include new conditions, the preponderance of the evidence must show the conditions are causally related to the work injury. Failure to do so is grounds for a denial of the request. Second, for a claimant to reopen a case for TTD benefits, they must show an aggravation or progression of a compensable condition, or facts not previously considered. Notably, both are burdens for the claimant to meet.

Questions about this case can be directed to Evan Jenkins at (412) 697-7403 or ejenkins@tthlaw.com.