Alabama Workers' Comp Blawg

Alabama Court Again Rules “Mere Possibility” Is Not Enough For Medical Causation

On July 22, 2016, the Alabama Court of Civil Appeals released its opinion in Smith v Brett/Robinson Construction Company, Inc. and again found that evidence which only establishes a mere possibility that the injuries are related to the work accident is not sufficient to prove medical causation.

In May of 2013 the employee tripped and fell on the job causing her to suffer an injury to her left knee. The employer sent her to Dr. Greg Terral who ordered an MRI and stated the employee possibly suffered from an meniscus tear. Surgery was ultimately scheduled and took place 6 months after the accident. The pre-operative diagnosis was osteoarthritis and suspected meniscal pathology. The post-operative diagnosis was grade 3 chondromalacia of the medial and patellofemoral compartment with unstable chondral tissue. Dr. Terral went on to note in the operative report that the plaintiff had intact meniscal tissue. After surgery the employee stated the pain was worse and ultimately selected Dr. Joseph McGowin from a panel of 4. Dr. McGowin opined that the employee’s symptoms were from arthritis which was pre-existing and that the employee had no evident tears in her knee. In November of 2013, Dr. McGowin stated that he did not think the accident caused the employee’s arthritis. He went on to state that the current symptoms may have been the result of the injury and an aggravation of the arthritis. The employee returned in January of 2014 when Dr. McGowin placed her at MMI with a 5% impairment rating to the left leg. The employee returned in November of 2014 and reported that she felt there was some shifting. Dr. McGowin stated again that he felt that her problems were arthritic in nature. However, an MRI was performed and the doctor noted that the MRI revealed a little intrasubstance degeneration of the medial meniscus, chondrol changes and a little edema of the cruciate ligaments. The employee returned in February of 2015 and the doctor noted that the employee said that she had turned and felt her knee pop about a week prior and had felt pain since. Dr. McGowin opined that she suffered a flare up of her arthritis (of note, at trial the plaintiff denied saying that she had a new accident). In March of 2015, another MRI was performed at which time the MRI referenced a meniscal tear. However, Dr. McGowin read the MRI and again stated that she suffered from intrasubstance degeneration of the medial meniscus and that he did not think there was tear. He also noted that she was suffering from IT band tendonitis. Dr. McGowin then stated that he did not believe she would benefit from surgery. The employee returned to Dr. McGowin in April 2015. Dr. McGowin indicated that there was an option of considering an arthritic arthroscopic exam to assure that there was no tear but there was only a limited likelihood that this would result in some symptom improvement. He recommended that she be evaluated by Dr. James Cockrell for an evaluation and consideration of surgery. During this period Dr. McGowin responded to a letter from the workers’ compensation carrier and stated that it was possible that the meniscal tear was, if there, a new injury given the change in the MRI. He then stated he thought that if there was a mensical tear, it would be unrelated to the original injury. The plaintiff was treated by Dr. Cockrell in November of 2015 and reported that she wanted surgery. The doctor stated that he only thought there was a possible tear and this could all be related to arthritis and the surgery would not be beneficial. As a result, the workers’ compensation carrier refused to pay for the surgery.

At the Trial Court level in Baldwin County, AL, testimony was presented by the plaintiff and her co-workers establishing that prior to the fall she was working full duty without knee problems and that after the accident, she had been unable to do the same. Upon hearing testimony and reviewing medical evidence, the Trial Court found that the employer was not responsible for the surgery. The Trial Court based its opinion on Dr. Terral performing surgery to repair the left knee, which noted no meniscus tear and then Dr. McGowin stating there was no meniscus tear and the employee’s problems were arthritic in nature and not work related. It further noted Dr. Cockrell’s opinion that there was a possibility of a tear but her problems could all be arthritic in nature and the Trial Court stated that Dr. Cockrell gave no opinion on medical causation in making this statement. The Trial Court’s ultimate findings were that the left knee pain, pursuant the medical evidence, was arthritic in nature, not accident related, and that there was no medical evidence supporting that she needed surgery. Therefore, they felt that the surgery was not reasonable and necessary as a result of the original injury.

On appeal the employee argued that her current problems are due to work related meniscus tear and/or the arthritis and that arthritis was caused or accelerated by the on the job accident. The employee support this by the fact that prior to the accident she did not have knee problems and that she had pain ever since. The employee cited Equity Group-Ala. Div. v Harris, 55 So. 3d 299, 311 (Ala. Civ. App. 2010). The Appellate Court pointed out that the employee’s position was correct that the Trail Court can infer medical causation based on someone’s ability to work prior to an accident and then their inability to work after the accident. However, the Court of Appeals state that this did not mean the Trial Court was required to ignore medical evidence indicating that the alleged symptoms were not work related. In the current case, the Alabama Court of Civil Appeals stated that the medical evidence only suggested a possibility of a torn meniscus, therefore, the Trial Court was within its discretion to conclude that there was not substantial evidence to support that the on the job accident resulted in a torn meniscus.

As it relates to the plaintiff’s assertion that the current problems are arthritic in nature and that the on the job accident caused or accelerated her arthritic condition, the Alabama Court of Civil Appeals stated that while it is true that no pre-existing condition is deemed to have existed for the purpose of awarding of workers’ compensation benefits if the employee could work before the accident and then is unable to work afterwards. However, again the Alabama Court of Civil Appeals stated that did not mean that the employee was not required to prove that the work accident actually caused the arthritis to manifest or to become aggravated. The Court of Civil Appeals pointed out that the employee relied on the fact that she was in no pain before and that there was one note from Dr. McGowin that the symptoms may have been the result of the injury and aggravation of the arthritis. The Court of Civil Appeals again stated that the mere possibility was not enough to establish medical causation, especially, when other evidence stated that the current problems were not work related.

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About the Author

The article was written by Joshua G. Holden, Esq. a Member of Fish, Nelson & Holden, LLC, a law firm dedicated to representing employers, self-insured employers and insurance carriers in workers’ compensation and related liability matters. Mr. Holden is AV rated by Martindale-Hubbell, which is the highest rating an attorney can receive. Holden and his firm are members of The National Workers’ Compensation Defense Network (NWCDN). The NWCDN is a national and Canadian network of reputable law firms organized to provide employers and insurers access to the highest quality representation in workers’ compensation and related employer liability fields.