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If a Georgia worker is not honest about their condition, it can not only take away their right to workers’ compensation benefits but could also land them in jail. However, in a recent case from one state, a court found that a worker might still be entitled to benefits even after a criminal conviction for workers’ compensation fraud.

NewspaperIn that case, the employee was working at a car company and slammed the trunk of a car on his hand accidentally. He crushed one of his fingers and claimed he could not continue to work, due to pain in his hand and shoulder. He filed a workers’ compensation claim in California and received benefits as a result. The workers’ compensation provider later hired a private investigator to monitor the employee. The investigator filmed the employee leaving three doctor’s visits. Video showed the employee taking off his sling, using his hand to get in and out of his car, using his hand to drive, and using his hand to carry a bag of groceries. The workers’ compensation provider notified the district attorney, who then began their own investigation.

In certain circumstances, under that state’s law, if a worker is convicted of fraud in obtaining workers’ compensation benefits, the worker cannot recover benefits arising from the fraud. However, if a worker is able to show that he or she was entitled to benefits independent of fraud, benefits can still be awarded. In this case, the court found that there was evidence that the worker had suffered a compensable injury and was entitled to benefits independent of the fraud. Therefore, even though the worker eventually was convicted of a misdemeanor crime, the court found he was entitled to benefits as a result of his work injury.

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Car accidents often involve complex issues of liability involving different insurance policies. When one or more injured individuals is working at the time of a car accident, workers’ compensation laws may also come into play and could limit an individual’s recovery through other policies, as was the situation in a recent Georgia workers’ compensation case.

Car AccidentIn that case, the plaintiff was in a car accident and suffered substantial injuries. Two cars were involved in the accident, and the plaintiff filed a lawsuit against the other vehicle’s driver. The other driver was underinsured, and the other driver’s insurance paid him only $25,000 in a settlement. The plaintiff was working at the time of the accident and also received workers’ compensation benefits of $197,966.55 for his injuries. Yet the plaintiff’s workers’ compensation provided him with a weekly amount that was less than his weekly income at the time of the accident, and he therefore accumulated $183,022.38 in lost wages. The plaintiff also did not receive compensation for pain and suffering or for future medical expenses.

However, the plaintiff’s insurance provided uninsured motorist (UM) insurance coverage to the plaintiff, and he sought additional compensation through his UM coverage. His policy provided a total limit of $100,000 in UM benefits. The policy also had a provision that stated that the limit would be reduced by any money paid under the workers’ compensation law.

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Many Georgia workers’ compensation cases are appealed by one of the parties, meaning that those decisions can be reversed on appeal. Therefore, understanding the standard of review in an appeal is key in any case. In a recent Georgia case, one employee’s favorable decision was reversed on appeal because the reviewing court applied the wrong standard of review.

Rear-End AccidentIn that case, the employee was rear-ended by another car while she was working as a driver, and she injured her back and neck as a result. The employee underwent medical treatments and requested approval for spinal fusion surgery under workers’ compensation. Her employer sent her to be independently evaluated by another doctor. The doctor believed that she was not permanently impaired and that she was able to do regular activities and work without restriction. The parties agreed to forego a hearing and have the administrative law judge (ALJ) decide whether her surgery was reasonable and necessary, based on the briefs and the evidence submitted. The ALJ found the surgery was not reasonable or necessary and denied the employee’s request for benefits.

The employee appealed to the Board of Workers’ Compensation, which found that the ALJ was in the best position to determine credibility and adopted the ALJ’s decision. The case was then appealed to the superior court. The superior court determined the independent doctor was less credible and reversed the decision in favor of the employee. The employer appealed the case again to the court of appeals.

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In a recent case, one state’s supreme court clarified the standard for the termination of rehabilitation benefits, an issue that regularly comes up in Georgia workers’ compensation cases. In that case, the employee injured both her knees and her right elbow at work and was awarded workers’ compensation benefits, including rehabilitation services. She eventually obtained part-time employment with another employer.

Gavel and BooksThe original employer then sought to terminate the employee’s rehabilitation services. At a hearing, the workers’ compensation judge found that the claimant returned to suitable gainful employment and thus could no longer receive rehabilitation services. On the worker’s appeal, the court held that the workers’ compensation judge used the wrong legal standard to grant the employer’s petition to terminate the employee’s rehabilitation services.

The workers’ compensation judge determined that since the employee had obtained “suitable gainful employment,” she could no longer receive rehabilitation benefits. However, the state’s supreme court found that if the individual who is receiving rehabilitation benefits is no longer a “qualified employee,” a judge must apply the good-cause standard before terminating benefits. That is, a rehabilitation plan may be suspended, terminated, or altered upon a showing of “good cause,” such as an employee’s refusal to cooperate with a rehabilitation plan or if the employee is not likely to benefit from further rehabilitation services.

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Georgia workers’ compensation cases are sometimes resolved through an agreement between the claimant and the employer. A recent case demonstrates the importance of obtaining competent representation before entering into a settlement agreement because of the permanent effects an agreement can have in a case.

Signing a ContractIn a recent case, a hair stylist at J.C. Penney claimed she suffered a work-related injury in March 2010 and filed a workers’ compensation claim in February 2011 for pain in her left foot. J.C. Penney accepted the claim as compensable. Under an agreement, the claimant received a payment “in full and final settlement of all claims for any and all benefits, injuries, disease, illnesses, conditions, and/or symptoms and any and all sequelae allegedly sustain as a result of” her workplace injury. It also stated that the agreement was “intended to be a general release of all claims of the employee against the employer and the insurance carrier arising from employee’s agreement with employer.”

About six months after the settlement was approved, the claimant filed a new notice of injury, alleging a March 10, 2015 injury to her foot. The employer denied the claim, stating that the claim was a preexisting condition and unrelated to employment, and it filed a motion for summary judgment. The Commissioner of the Department of Labor denied J.C. Penney’s motion for summary judgment. The Commissioner determined that the 2014 settlement agreement released the employer from claims related to the March 2010 injuries and was enforceable. However, the Commissioner found the remainder of the settlement agreement was void on public policy grounds because it could not bar unrelated claims. J.C. Penney appealed, arguing that the Commissioner lacked the authority to invalidate an approved settlement agreement.

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Although most Georgia workers’ compensation claims result from a physical injury at work, some workers also suffer a mental health injury at work. In a recent case, one court considered whether a worker’s psychological injury was compensable under that state’s law.

Judge's GavelThe Applicable Law

The case was brought in Florida, and under Florida law, there is a requirement that there be an “accompanying physical injury requiring medical treatment” before benefits for mental or nervous injuries can be paid. In order for a mental or nervous injury to be compensable, there must be clear and convincing medical evidence from a licensed psychiatrist, and the physical injury has to be the major contributing cause of the mental or nervous condition. Additionally, there has to be a connection between the mental or nervous injury and an underlying permanent, compensable physical injury. There is also a state statute that provides that an employee cannot be paid temporary benefits for a “mental or nervous injury” for “more than 6 months after the date of maximum medical improvement for the injured employee’s physical injury or injuries.”

The Facts of the Case

In this case, the court had to consider whether the six-month period mentioned in the statute can begin at any time after the worker reaches physical maximum medical improvement, or whether the time period expires six months after the worker reaches physical maximum medical improvement.

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In many Georgia workers’ compensation cases, there is a question of whether the employee’s own actions played a role in causing the injury. In a recent case, Georgia’s Supreme Court explained the meaning of “willful misconduct,” which can bar compensation in some cases.

Cell TowerIn that case, an employee was attempting a controlled descent from a cell phone tower and was seriously injured when he fell to the ground. The employer had instructed technicians not to attempt a controlled descent from cell phone towers but instead to climb down from towers. The administrative law judge found that the employee was barred from receiving workers’ compensation benefits because he engaged in “willful misconduct.” The employee appealed, and a Georgia court of appeals reversed the decision, finding the employee’s actions did not constitute “willful misconduct.”

However, Georgia’s Supreme Court reversed, determining that the court of appeals improperly made its own findings. The Court explained that a mere violation of instructions or engaging in an obviously hazardous act does not mean it was willful misconduct. Yet an intentional violation of rules can constitute willful misconduct if it involves knowingly engaging in a hazardous act in which the danger is obvious. In these cases, the fact finder must determine whether the intentional act was done with knowledge that it was likely to result in a serious injury or with a wanton and reckless disregard of its likely consequences. In this case, the Workers’ Compensation Board failed to make findings, and the court of appeals improperly made its own findings. Therefore, the case was sent back to the Board for further proceedings.

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In many Georgia workers’ compensation cases, even when one injury is covered, there is an issue of whether other injuries are related and covered under Georgia’s Workers’ Compensation Act. In a recent case, one state’s supreme court found that although a worker’s groin injury was covered under the workers’ compensation program, his back injury was not.

SpineThe Facts of the Case

The employee was working at an energy services company, delivering and setting up equipment. One day, he was transporting equipment from Wyoming to Nebraska. The equipment included hazardous materials, and he was required to have a sign on the back of his truck warning that hazardous materials were on board. The sign was on the truck when he left, but when he stopped shortly after beginning the journey, he saw that the sign had fallen off. The employee called his supervisor, who met up with him and helped him locate the sign. The employee and his supervisor then put the sign in the back of the supervisor’s truck. The sign weighed about 100 pounds and was in an 8.5-foot metal frame. As the two were lifting the sign into the truck, the employee stood on his toes to lift it into the truck, and he felt a sharp shooting pain down the right side of his groin.

The employee continued to Nebraska, but when he completed his assignment, he returned to his home in Idaho and saw his primary care physician. He was diagnosed with a right inguinal hernia. His employer covered his injury to his right groin.

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Many Georgia workers’ compensation cases involve only minor or temporary injuries. However, some tragic cases result in an employee’s death. In these cases, the worker’s dependents may be entitled to benefits.

Operating RoomIn a recent case, an employee filed a workers’ compensation claim against his employer for a torn thoracic aorta, which was later settled for a lump sum. As part of the settlement agreement, the employee agreed to waive all future claims, including waiving his right to reopen his claim. A year later, the employee died from his work-related injury. Two years after the employee’s death, his wife filed a motion to reopen her husband’s injury claim to assert her own claim for a workers’ compensation death benefit. The wife was not a party to her husband’s settlement. The Administrative Law Judge allowed the wife to reopen the claim and awarded her death benefits. The employer appealed, and the case eventually made its way to that state’s supreme court.

The court considered whether the wife had a separate and viable claim for death benefits, and whether she could assert her claim by reopening her husband’s settled claim. The court determined that the husband’s settlement did not prevent the wife from seeking death benefits. It explained that a state statute provided a surviving spouse with benefits if an employee died from a work-related injury. Those benefits were separate from the benefits awarded to the worker and gave the spouse the right to a separate claim.

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Often, when a Georgia workers’ compensation case is denied, the employee chooses to appeal their case to a higher court. In many cases, there can be multiple rounds of appeals, resulting in ongoing uncertainty. However, ultimately the goal of filing an appeal is to reverse a negative decision, so it is important to carefully present a case and follow the procedural requirements at each step of the way.

CalendarAppeals in Workers’ Compensation Cases

In Georgia workers’ compensation cases, the initial determination of whether benefits are appropriate is made by an administrative law judge. Either party can appeal an administrative law judge’s decision to the appellate division of the State Board of Workers’ Compensation. The Board will then review the evidence and issue a decision.

If the Board finds the administrative law judge’s findings are supported by a preponderance of competent and credible evidence, the Board will accept the administrative law judge’s findings of fact. The Board generally does not hear additional testimony or receive additional evidence, but it can remand the case to an administrative law judge to take additional testimony or receive additional evidence. However, the Board may reject the administrative law judge’s findings, or it may accept the findings but come to a different legal conclusion. This may result in the approval of a claim that was initially denied.

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