An employee slipped off a chair and injured her elbow, back and head. Would workers’ compensation pay for surgery more than a decade later?
Unlike some of the other workers’ comp cases featured on this website, the question in this case wasn’t whether falling out of a chair was in the course of and arose out of work.
The question in this case boiled down to whether surgery for the worker’s injury was warranted several years after the incident.
Marilyn Cook, a teacher for the Logan County Board of Education in West Virginia, slipped off of the chair in the playground and fell onto pavement.
An MRI of her lumbar spine revealed degenerative changes to a disc.
Her neurosurgeon determined Cook wasn’t a good surgical candidate.
Several years later, a second MRI revealed “multi-level degenerative changes.” The neurosurgeon found a disc protrusion was similar to her symptoms following the injury. The doctor requested workers’ comp authorization for surgery to repair the damage because Cook’s pain continued after she received injections and medication.
The workers’ comp claims administrator denied authorization for the surgery.
The Workers’ Compensation Office of Judges considered the testimony of the neurosurgeon who said Cook’s situation several years later was medically related to her injury.
There was no other medical opinion that refuted or challenged the neurosurgeon’s opinion.
But the Office of Judges found the requested surgery wasn’t reasonably necessary because the neurosurgeon said it wasn’t the only available treatment and admitted it might not be successful.
The West Virginia Workers’ Compensation Board of Review upheld the decision.
From there the case went to the state’s Supreme Court of Appeals.
Board is rebuked
The appeals court had harsh words regarding the decision:
“The decision of the Board of Review is based on a mischaracterization of the evidentiary record. The Office of Judges reached its conclusions without any medical support and thereby exceeded its statutory authority and abused its discretion.”
The appeals court said the Office of Judges substituted its own judgment when the only medical opinion in the case – that of the neurosurgeon – stated the surgery was a reasonable option for treating Cook’s pain.
The decision was reversed and remanded with instruction to authorize Cook’s surgery.
Lesson learned: It’s difficult to argue against a medical opinion when you don’t have a differing one from a medical expert.
(Marilyn G. Cook v. West Virginia Office of Insurance Commissioner, State of West Virginia Supreme Court of Appeals, No. 12-1378, 4/29/14)