Why Medical History Matters
Mar. 2019
Vallier v. Labor and Industry Review Commission, Aurora Health Care, Inc., and Sentry Insurance Co., Circuit Court No. 2017CV6073, Appeal No. 2018AP936
Court of Appeals Decision Dated and Filed February 26, 2019. This is an unpublished decision and holds no precedential value.
Background: Vallier worked as a nurse for Aurora St. Luke’s. She alleged an injury after she struck her a right elbow and shoulder on the corner of the wall as she exited a patient’s room. She reported the injury the same day, but did not seek treatment until the following day. Vallier was examined by Dr. Petro on November 11, 2010. The exam and x-ray were normal. Despite the normal exam, Vallier continued to treat for numbness and tingling that extended from her right shoulder through her right hand. Due to the continued complaints, Dr. Petro ordered an EMG, which showed lower cervical radiculopathy. Following the EMG, Dr. Petro ordered a cervical MRI, which showed a large disc extrusion at the C6-7 level. Vallier subsequently saw Dr. White, who recommended a C6-7 disc replacement and put Vallier on light duty work restrictions. Vallier sought a second opinion with Dr. Lloyd; he confirmed Dr. White’s diagnosis.
Dr. Lyons, a neurosurgeon, did an IME for the respondents. He also confirmed the diagnosis, but concluded it was not work-related. Vallier continued to treat with Dr. Lloyd, and ultimately underwent a discectomy and fusion at C6-7. Dr. Lloyd said Vallier had pre-existing degenerative changes in her neck, but this was precipitated, aggravated, or accelerated beyond its normal progression by the November 19, 2010 incident. After a worker’s compensation hearing, the ALJ decided Vallier was entitled to compensation for temporary total disability and permanent partial disability. The ALJ stated Dr. Lloyd’s medical reports credible, stating “it was not until the work incident that she had trouble”. Aurora petitioned LIRC for a review. LIRC reviewed Vallier’s medical records and reversed the ALJ determination. Importantly, LIRC found the credibility of Vallier’s treating physicians was “diminished” and incomplete because Vallier did not inform them that she had seen her primary care provider for right shoulder pain in August 2010, prior to the claimed work incident. LIRC also found this diminished Vallier’s credibility. Vallier filed a petition for judicial review and the circuit court affirmed LIRC’s decision.
Vallier appealed again; she argued (1) there was no credible and substantial evidence in the record to support LIRC’s determination, and (2) LIRC exceeded its authority by basing its decision on an erroneous finding of material fact. The Court of Appeals (CoA) noted LIRC’s decision was based on its evaluation of conflicting medical evidence and incomplete opinions from Vallier’s providers (issues of fact); therefore, they found LIRC’s factual findings to be supported by substantial and credible evidence. The CoA also noted LIRC’s decision was based on credibility determinations, so Vallier’s challenge regarding an erroneous finding of fact was not material to the determination. Moreover, LIRC disregarded the medical opinions after August 2010 because they were based on inaccurate or incomplete information.
What does this mean? When LIRC’s decisions are based on an issue of fact, their findings are conclusive on appeal as long as they are supported by credible and substantial evidence. Evidence is credible if it excludes speculation and conjecture. Further, LIRC must deny benefits if a legitimate doubt exists as to the facts necessary to establish a claim. In worker’s compensation, claimants must prove all facts beyond a legitimate doubt. If “facts” essential to recovery are based on inaccurate or incomplete information, the claimants do not meet this burden.
What is the practical takeaway? Medical opinions are only as good as the facts those opinions are based on. Comprehensive review of medical records is essential because it provides an opportunity to determine whether a claimant’s providers have based their opinions on a complete understanding of the claimant’s medical history. This case is an excellent example of how important medical history and review of past records is to defending a worker’s compensation claim. Additionally, this shows how information gathering can be a difference maker in litigated matters.