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Phil Walker

Abstract

In April 2004, California implemented workers’ compensation reforms to reduce workers’ compensation premiums for California employers while speeding medical treatment for injured workers. The new law requires the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, particularly regarding apportionment analysis for impairment; the AMA Guides does not directly evaluate disability. Under the new California law, the following are clear: apportionment of permanent disability is based on a) causation and requires both the overall percentage of permanent disability caused by the industrial injury, and b) the percentage of permanent disability due to all other factors, including previous injuries. Less clear about the new law are the following: does apportionment to “causation” mean the physician should apportion out preexisting “pathology” even if it was not disabling prior to aggravation; what happens if a worker fails to disclose a prior injury; and are the standards of the AMA Guides on apportionment similar to those in California's new Labor Code? In the AMA Guides, the discussion of causation, apportionment analysis, and aggravation is different from the legal precedent for disability in California. New in the law is the explicit statement that the employer shall be liable only for the percentage of permanent disability directly caused by the industrial injury. Legal decisions are expected to clarify the interpretation of apportionment.

in AMA Guides® Newsletter
Christopher R. Brigham
and
Phil Walker

Abstract

Clients who request an independent medical or impairment evaluation are more likely to obtain a quality report from an evaluating provider if they request the appropriate evaluator, provide needed information, and clarify the specifics of their referral. The referral should identify the information needed for the assessment, define the standards for the evaluation, and provide detailed questions to be answered. Failure to provide this information often will result in a poor outcome. The article includes a sample generic referral letter to an impairment evaluator; this example letter can be modified based on the specifics of a case. For example, a workers’ compensation case in California could include the question, What is the overall percentage of permanent disability caused by the industrial injury, and what is the percentage of permanent disability due to all other factors, including prior injuries? The generic referral letter instructs the evaluator to use the standards in the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition and refers the evaluator to Chapter 2, Philosophy, Purpose, and Appropriate Use of the AMA Guides. The article includes a sample paragraph that could be included in the generic referral letter and includes specific questions that address statutory requirements under California law, along with instructions about apportionment decisions and documentation.

in AMA Guides® Newsletter
Craig Uejo
and
Phil Walker

Abstract

A 2005 Benefits Review Board decision by the US Department of Labor, Peter J. Desjardins vs Bath Iron Works Corporation affirmed a decision and order (2004-LHC-1364) regarding the utility of impairment rating critique. The administrative law judge credited the rating opinion of an expert physician reviewer (who had not seen the claimant) over that of the treating physician. The claimant's physician was awarded 20% upper extremity impairment, but, following the review and opinion of an expert reviewer, the award was reduced to 4%. The claimant appealed, largely on the argument that the expert reviewer had reviewed the report by the patient's physician, not the claimant himself and that the expert's opinion properly relied on the correct use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The appeals judges noted that the administrative judge properly noted that the AMA Guides was suitable for use (and was the basis of the treating physician's award). The administrative law judge found that the expert reviewer's opinion was based on the specifics of the present case and on his knowledge and application of the AMA Guides, which together warranted determinative weight, based on the expert reviewer's credentials, experience, and well-reasoned opinion. This decision confirms that expert reviewers can provide evidence for the fact finder to evaluate the treating physician's opinion to determine if it is well reasoned and documented.

in AMA Guides® Newsletter