preparing the record for appeal and tips for appellate ......preparing the record for appeal and...

Winter 2011 Kelly A. Benedict & Jo H. Stegall III, editors Section Newsletter

1. Thinkabouttheappealprocesswhenyouarecreatingtherecord.Keeptherecordclean.Statetheissuesclearlyatthebeginningofthehearingsothatthereisnodoubtthatallissueshavebeenraisedattheappropriatetime.Attheappellatelevel,reframeyourissuestofocusontheALJ’serror.

2. Donotinterrupteachotherorthewitnesses.Whentwoattorneysaretalkingovereachotheroranattorneyandawitnessaretalkingatthesametime,notonlydoestheALJbecomefrustrated,butthecourtreportermaynotcapturetheexactconversationeither.Whenyou(oryourassociate)readthetranscripttowritethebrief,itwillbeajumbledmess.Mostsignificantly,whentheappellatecourtslookatthetranscript,theywillbefrustratedwiththeinabilitytoreadacompleteandintactquestionandanswer.Withoutthefacetofaceinteractionthatoccursatthehearinglevel,thesignificanceoftheevidencepresentedmaybelostinthefrustrationofreadingamessyandconfusingtranscript.So,avoidthisproblemthroughwitnesspreparation.Explaintothewitnessthatbothyourquestionandhisanswerareimportantandthatthejudgeneedstoheareverythingclearly.Explainthattheriskofspeakingprematurelyisthathewillnotunderstandoranswerthequestionyouintended.Finally,despiteyourunendingdesiretospeak,holdyourtongueandwaituntilyourwitnesscompleteshisanswerbeforecontinuing.Keepyourquestionssimple.Donotusewordsthatyourwitnessmaynotknow.Askonlyonequestionatatime.

3. PresentyourcaseinanorderlyfashionatthehearingsothattheALJandappellatecourtsunderstandyourposition.Keepinmindthatwhileyouhavebeenlivingwiththeclaimandknowthesequenceofeventsalltoowell,theALJandappellatecourtsdonotevenknowwhattype

ofworktheEmployeeperformed.Itiseasiertounderstandanovelifyoustartatthebeginningandworktotheend.Thesameistruewithaclaim.Presentthesequenceofeventsinalogicalfashion,tellingtheEmployee’sstoryfromthebeginning.

4. Anticipateevidentiaryobjectionsandbepreparedwithalegalbasisforyourpositionastotheadmissibilityofevidence.BringcopiesofsupportingcaselawfortheALJtoreview.Offertobrieftheissueandaskthatarulingontheadmissibilitybedeferred.Ifyouoffertobrieftheissue,besuretodoso.Makeanofferofproofifanevidentiaryrulingdoesnotgoyourway.Thisistheonlywaytheappellatecourtswillbeabletoconsidertheadmissibility(andthesubstanceifadmissible)oftheevidence.Ensurethatallappropriatewitnesses(includingthosenecessarytotheintroductionofdocumentaryevidence)attendthehearingandthatyouwillbeabletoclosetherecord(otherthanbriefs)attheendofthehearing.Writeoutyourquestionsorimportantpointstocover.Itistooeasytogetcaughtupinanevidentiaryissueandtoforgettoproveacrucialelementwithoutareferencesheet.

5. IfyouwanttheALJtotakejudicialnoticeofaBoardform,besurethatallapplicableinformationontheformisreadintotherecordbyeitheryouorthejudge.Remember,theformwillnottravelaspartoftherecord.

6. Donotleadyourownwitnesses.TheALJandappellatecourtsarenotissuingrulingsbasedonthetestimonyoftheattorneys.Thetestimonyislesspersuasiveifitcomesfromyouratherthanfromthewitness.

7. Donotmakeassumptions.Donotassumethatsomethingthatseemslikeitshouldbecommonknowledgedoesnothavetobeprovedatahearing.ThinkabouteverythingtheALJ/appellate

Preparing the Record for Appeal and Tips for Appellate Practice at the BoardBy Judge Melodie Belcher & Delece Brooks

Workers’ Compensation Law Section

courtsmustknowforyoutowinandconsiderhowtoproveit.

8. Hirecompetentinterpreters.Makesurethattheyareexperiencedinthelanguagethatneedstobetranslatedandthattheyhavecourtroomexperience.Ifyoudonottrusttheinterpretertheopposingpartyisproviding,bringyourowninterpreterandposeobjectionsifnecessary.Instructwitnessestospeakinonelanguageonly

andtowaituntiltheinterpreterfinishesinterpretingbeforeansweringthequestion.Again,constantinterruptionsmakeforasloppyrecord.

9. Organizeyourexhibitsandmarkeachpagewithboththeexhibitnumberandthepagenumber.Donotduplicateexhibits.Donottenderirrelevantmedicaldocumentationsuchashospitalinstructions.Donottenderillegiblerecords.Ifyoucannotreadthem,chancesaretheALJcannotreadthemeither.Tenpagesofextremelyrelevantmedicalevidencearemuchmorepersuasivethanonehundredpagesofnurses’notes,cardiacgraphs,EMGgraphsandtreatmentnotesforunrelatedillnesses.Ifyouhaveastackofmedicalthatissolargethatyoudonotwanttobebotheredgoingthroughittoweedouttheirrelevantstuff,itisagoodbetthattheALJandappellatecourtsarenotgoingtowanttogothroughiteither,andtheymayendupmissingsomethingyoubelieveisimportant.Includeacoversheetdelineatingtheoutstandingmedicalbills.

10.Whenappealingtothehighercourts,theappealingpartypaysforthetransmittaloftherecordanditmustbedonewithin30days.Thecostis$10.00forthefirst10pagesand.50foreverypagethereafter.PursuanttoBoardRule105(f),youmayrequestawaiver.Upongoodcauseshown,theBoardmaywaivethecopyingandtransmittalcosts.Onlythetrialrecordissent–nottheentireBoardfile.Thiswouldincludethetranscript,exhibits,briefs,WC-14,ALJawardandAppellatedecision.Therecordissentinpaperviacertifiedmail.Theappealingpartymustrequestthatitbesenttothecountywheretheinjuryoccurredandifoutofstate,itisgenerallysenttoFultonCounty.

11.WhenappealingtotheAppellateDivision,bespecificwithyourenumerationsoferror.StateexactlyhowyouthinktheALJwasincorrectinhisorheraward.

12.BriefstotheAppellateDivisionshouldnotrehashthesameinformationthatisintheALJbrief.Ifyoudonothaveanynewarguments,justindicatetotheAppellateDivisionthatyouarerelyingontheALJbrief.ItiscertainlyacceptableandoftenpersuasiveforthebriefstobeshortandtofocusonaspecificissuethatyoucontendtheALJgotwrong.

13.EffectiveJuly1,2010,apartyscheduledfororalargumentisrequiredtonotifytheAppellateDivisionnolaterthan48(business)hoursbeforethescheduledappearanceifthepartydoesnotintendtoappear.TheAppellateDivisionallowsonlyoneresetanditmustbeforahighercourtconflictoraverygoodreason(deathinthefamily,seriousillness).Youmustfaxarequesttothe

Winter 2011 3

AppellateDivision48businesshourspriortothehearing.Keepinmindthatoralargumentisnotarightandiftheresetisnotgranted,theAppellateDivisionmaydecidethecaseontheargumentofthepartywhoappearsandthebriefs.

14.BriefsattheAppellateDivisionaredue20daysfromthedaytheappealisfiledandarelimitedto20pagesunlessotherwiseapprovedbytheBoard.BoardRule103(b)(4).Theappelleehas20daystorespond.Ifyouneedanextension,itmustberequestedinwritingevenifallpartiesagree.Ifanextensionisgranted,itwilllikelybeforoneweekonly.

15.IfyouwouldliketheAppellateDivisiontoholdtherulingonanappeal,becauseyouaretryingtosettletheclaim,theywilldosofor30daysonly.Thentheywillruleontheappeal.

16.Whenmakingyouroralargument,focusonthestrongestpoints.Bepreparedtoanswerquestionsfromthejudges.Youmaymakeanoralmotionforassessedattorney’sfees,butyoumustprovideevidenceofyourtimeandexpertise.

17.Ifyouareappealinganinterlocutoryissue,remembertoproperlyrequesttheALJtocertifyhisorherorderforappeal.Otherwise,yourappealwillbedismissedforlackofjurisdiction.BoardRule103(d).

18.Ifyouareappealingaclaiminvolvingmultipleaccidentdates,bespecificastowhatdatesofaccidentyouareinfactappealing.

19. IfyouwouldliketofileaMotionforReconsiderationofanALJaward,fileyourappealatthesametime.The20dayclockrunssimultaneouslyonboth.YoucanalwaysdismissyourappealiftheALJgrantstherequestedchange.Also,ifyoufileMotionsforReconsiderationdonotuseaWC-102(d).ThereisnotaformforaMotionforReconsideration,butthereisadoctypeinICMS.ThisappliesattheALJlevelandattheAppellateDivision.BesuretocalltheALJortheAppellateDivisionifyoufileaMotionforReconsiderationtomakethemawareofit,andtheAppellateDivisionwouldlikeacourtesycopyfaxedtothemaswell.FileMotionsforReconsiderationassoonaspossibletoallowtheALJsortheAppellateDivisiontimetoruleonthem.

20.Finally,thereisnowsecurityattheAppellateDivisioncourtroom.Planaheadandarriveearly.Youwon’twanttobelate!

4 Workers’ Compensation Law Section

I thasbeenalmosttenyearssincetheCentersforMedicareandMedicaidServices(CMS)releaseditsseminalpolicymemoranduminJuly,2001,

(knownasthe“PatelMemo”)1formallyintroducingtheMedicareSet-Aside(MSA)inrelationtoworkers’compensation(WC)settlements.TheWC-MSAistheagency’srecommendedcompliancemechanismtoprotectMedicare’s“futureinterests”undertheMedicareSecondaryPayerStatute(MSP).2

Onmanylevels,theWC-MSAhasrevolutionizedclaimspracticesandopenednewfrontsofpotentialexposure.Inadditiontoaddingachallenginglayerofcomplexitytoclaimshandling,theWC-MSAhassignificantlyincreasedcasevaluesandhascomplicated(and,insomeinstances,evenprevented)claimsettlement.

WhiletheindustryhascertainlymadestridesinbecomingbetterfamiliarizedwithCMS’everchangingpoliciesandprocedures,therestillremainsagooddealofconfusion,misunderstandingandmisapplicationofCMS’WC-MSAreviewthresholds.Likewise,howtohandle“non-threshold”cases(thosecasesthatdonotmeetCMS’WC-MSAreviewthresholds)continuestopresentformidablechallengesforpractitionersandtheclaimsindustryingeneral.

ThisarticledissectsCMS’WC-MSAreviewthresholds,highlightspotentialpitfallsregardingcertaindefinitionalcomponentsofthereviewthresholds(e.g.thepopular$24,999.99settlement),andaddressesthetroublingareaofMSPcomplianceinnon-thresholdcases.3

Part ICMS’ WC-MSA Review Thresholds: Understanding the Criteria & Avoiding the Pitfalls

A. Commutation v. Compromise Settlements

42C.F.R.§411.46istheregulationoftencitedbyCMSastheprimarybasisfortheWC-MSA.Subsection(a)ofthisregulationstatesasfollows:

Lump-sumcommutationoffuturebenefits.Ifalump-sumcompensationawardstipulatesthattheamountpaidisintendedtocompensatetheindividualforallfuturemedicalexpensesrequiredbecauseofthework-relatedinjuryordisease,Medicarepaymentsforsuchservicesareexcluded

untilmedicalexpensesrelatedtotheinjuryordiseaseequaltheamountofthelumpsumpayment.

Furthermore,subsection(b)(2)ofthisregulationprovidesthatifasettlement“appears to represent an attempt to shift to Medicare the responsibility for payment of medical expenses for the treatment of a work related condition, the settlement will not be recognized.”

UnderCMS’WC-MSAframework,theinitialscreeningtestindeterminingwhethertheagencydeemsaMSAappropriaterequiresanassessmentofthetypeofsettlementatissue.Inthisrespect,CMSclassifiesWCsettlementsascommutationorcompromisesettlements.4

CMSprovidesalengthyoverviewofcommutation vs. compromisecasesinitsJuly23,2001andApril23,2003policymemorandawhichtheauthorsuggeststhereadercarefullyreviewintheirentirety.Understandingtheagency’sapproachinthisrespectisimportantasitdictateswhetherornotconsiderationofaWC-MSAisnecessary.

PerCMS,aMSAisappropriateonlyinrelationtosettlementsthatpossessacommutation aspect.5Ingeneral,CMSviewsacommutation settlementasonethatcompensatesworkersforfuturemedicalexpensesrelatedtotheworkinjury;whileacompromise settlementisviewedasasettlementthatcompensatesonlycurrentorpastmedicalexpenses.6Asettlementcouldpossessbothacommutationandcompromiseaspect.7

CMSindicatesthatadmissionofliabilityisnotthesoledeterminingfactorofwhetherornotasettlementisconsideredacommutationorcompromise.8Alongtheselines,CMSstatesthatasettlementwhichdoesnotprovideforfuturemedicalscouldstillpossessacommutationaspectifthefactsindicateaneedforfuturemedicalcareinrelationtotheWCinjury.9

Onceitisdeterminedthataparticularsettlementisacommutation,containsacommutationcomponent,orcouldpossiblybeviewedbyCMSaspossessingacommutationaspect,thefocusshiftstodeterminingwhetherornotthecasemeetsCMS’WC-MSAreviewthresholds.

B. CMS’ Current WC-MSA Review Thresholds

CMShasestablishedtwospecific“reviewthresholds”forWCcases.IfaWCsettlementmeetseitheroneofthebelowthresholds,CMSdeemssubmissionofaWC-MSAproposalforitsreviewandapprovalappropriate.10

CMS’currentWC-MSAreviewthresholdsareasfollows:

Understanding CMS’ WC-MSA Review Thresholds & Addressing “Non-Threshold” Cases By Mark Popolizio, Esquire, NuQuest/Bridge Pointe

Winter 2011 5

Threshold #1à Medicare Beneficiaries

TheclaimantisaMedicarebeneficiaryatthetimeofsettlementandthetotalsettlementamountisgreaterthan$25,000;or

Threshold #2 à Non-Medicare Beneficiaries

TheclaimantisnotaMedicarebeneficiaryatthetimeofthesettlement,buthasareasonableexpectationofMedicareenrollmentwithin30monthsofthesettlementdateandthetotalsettlementamountisgreaterthan$250,000.11

Inordertodeterminepotentialapplicabilityofthereviewthresholds,itisimperativetounderstandhowCMSdefines(a)total settlement amountand(b)reasonable expectation of Medicare enrollment.

CMS’ Definition of Total Settlement Amount

Theconceptoftotal settlement amountrelatestohowCMScalculatesthemonetarycomponentofitsreviewthresholds.

CMSdefinesthetermtotal settlement amountasfollows:

Totalsettlementamountincludes,butisnotlimitedto,wages,attorneyfees,allfuturemedicalexpenses(includingprescriptiondrugs)andrepaymentofanyMedicareconditionalpayments.Payouttotalsforallannuitiestofundtheaboveexpensesshouldbeusedratherthancostorpresentvaluesofanyannuities.AlsonotethatanypreviouslysettledportionoftheWCclaimmustbeincludedincomputingthetotalsettlement.12

CMS’definitionoftotal settlement amountshouldbecarefullyexaminedtomakesurethatallrelevantfactorsarebeingconsidered.

Forexample,closeattentionshouldbepaidtohowtheagencycalculatesthetotal settlement amountwhenannuitiesareused.Inthiscontext,CMSstatesthatthetotalpayouttotheclaimantshouldbeusedinthecalculation--notthecostorpresentdayvalueoftheannuity.13

Furthermore,“any previously settled portion of the WC claim” isincludedincalculatingthetotal settlement amount.Unfortunately,theagencyhasnotprovidedanyfurtherguidanceastoexactlywhatmaybeconsideredtofallwithinthisconcept.Assuch,thiscouldverylikelycreateuncertaintyinparticularsituationsinlightofthewidearrayofpaymentarrangementsandoptionscommonlyusedinWCpractice.

Notwithstanding,thisfactorwouldatleastseemtohavespecificapplicationinthosejurisdictionswhereitiscommonpracticetosettleoutindemnity(leavingmedicalsopen)atonepoint,followedbyasettlementoffuturemedicalsatsomesubsequentpointintime.PerCMS’definition,theamountofthepriorindemnitysettlementwouldseeminglyneedtobeaddedtotheamountofthe

subsequentmedicalsettlementamounttodetermineifsaidsumexceedstheapplicablemonetarythresholds.

Anotherareaofcautionconcernsthe“repayment of any Medicare conditional payments”aspectofthetotal settlement amountdefinition.14Thiscallsintoparticularfocusthepopular$24,999.99settlement(orasettlementforsomeotheramountthatiscloseto,butdoesnotexceed,CMS’$25,000monetarythreshold)inrelationtosettlementsinvolvingMedicarebeneficiaries(Threshold#1).ThisapproachisoftenutilizedinanattempttokeeptheclaimbelowCMS’WC-MSAreviewthresholds.

However,despitetheparties’intentions,itispossiblethatthecasecouldendupmeetingCMS’WC-MSAreviewthresholdswhenconditionalpaymentsaretakenintoaccount.Unfortunately,CMShasnotprovidedmuchbywayofinterpretationalguidanceonexactlyhowconditionalpaymentsshouldactuallybefactoredfortotal settlement amountcalculationpurposes,and,thus,hasleftkeyquestionsunansweredregardingthepracticalapplicationofthisdefinitionalcomponent.

Forexample,CMS’useoftheword“repayment”isinterestinginthattakenliterallythiscouldbeinterpretedtomeanthattheincludableconditionalpaymentamountisthe“final”conditionalpaymentamountthatisultimatelydeterminedtobereimbursabletoCMS.However,underCMS’currentpolicy,thepartiesgenerallycannotobtain


CMS’“final”conditionalpaymentamountuntilaftertheclaimissettledandtheexecutedsettlementagreementissenttotheagency’scontractor.15

Thiswouldraisethequestionofhowdeterminingtheactualamountofconditionalpaymentstoberepaidcouldbeascertainedwithoutthepartiesfirstsettlingthecase.Thiswouldseeminglycreateanimpracticaland,perhaps,unworkablescenarioonmanylevels,andwouldlikelyinjectadditionaldelayandcomplicationtotheprocess.

AbsentclarificationfromCMS,practitionersarelefttowrestlewithhowbesttoaddressthe“repayment of any Medicare conditional payments” componentofCMS’definitionfromapracticalstandpoint.

Alongtheselines,addressingthisissuewouldatleastseemtoentailconsideringCMS’claimedconditionalpaymentamountatthetimeofsettlement,orperhapsfromsomeotherlogicalandacceptablemeasuringpointshortofactuallyobtainingCMS’“final”conditionalpaymentamount.Indoingso,itmaybediscoveredthatthisfigurebyitself,whenaddedtotheactualsettlementamounttobepaidtotheclaimant,couldendupyieldingatotal settlement amount greaterthanthe$25,000thresholdamount.

However,thesepracticalapproaches(assumingthatCMSwouldevenpermitsame)raisetheirownquestionsandissues.Forinstance,thefirstquestionthatsurfacesishowwouldtheconceptof“atthetimeofsettlement”bedefined?ThiscouldproveparticularlyproblematicgiventhatunderthecurrentprocessitcouldtakeafewmonthstoobtainaconditionalpaymentfigurefromCMS.Thus,shouldthepartiesbepermittedtousetheinterimconditionalpaymentamountthattheymayhavereceivedfromCMSduringthecourseoftheclaim?Ifso,howrecentshouldthisfigurebe?16

Assuminganacceptablemeasuringpointcouldbeestablished,additionalquestionsarise.Shouldthegrossfigureoftheclaimedconditionalpaymentamountbeused?Dependingonthespecificfacts,usingthegrossfiguremayverywellincreasetheprospectsthatthemonetarythresholdcouldendupbeingpierced.Or,shouldtheincludableamountbelimitedtotheamountthatwouldbe(orcouldbe)actuallyreimbursableundertheregulatoryreimbursementprovisionscontainedin42C.F.R.§411.24and42C.F.R.§411.37?

Limitingtheincludableamountofconditionalpaymentsinthismannercouldpreventaclaimincertaincircumstancesfromexceedingthemonetarythreshold.17

(Caveat: The above approaches are presented for illustrative discussion purposes only. In presenting same, the author is not stating or otherwise suggesting that these approaches represent, or could represent, a proper interpretation of CMS’ policy, or that same would necessarily be accepted by the agency).

Whilelegitimateinterpretationalquestionsremain,itisimportanttorecognizethelargerissues:(1)Thatthe“repayment of conditional payments” componentofthetotal settlement amountdefinitionmustbeconsidered,and(2)Thatindoingso,asettlementthatisseeminglybelow(andintendedtobebelow)the$25,000monetarythresholdcouldactuallyendupgettingtippedoverandintoCMS’WC-MSAreviewthresholds.

CMS’ Definition of Reasonable Expectation of Medicare

Theconceptofreasonable expectation of Medicare enrollmentdealswiththoseclaimantswhoarenotMedicarebeneficiariesatthetimeofsettlement.ThisrelatesdirectlytoCMS’WC-MSAreviewthresholdpertainingtonon-Medicarebeneficiaries(Threshold#2).

CMSdefinesreasonable expectationinitsApril23,2003,memorandumasfollows:

WhendealingwithaWCcase,whatis“areasonableexpectation”ofMedicareenrollmentwithin30months?

Answer:Situationswhereanindividualhasa“reasonableexpectation”ofMedicareenrollmentforanyreasonincludebutarenotlimitedto:

a)TheindividualhasappliedforSocialSecurityDisabilityBenefits;

b)TheindividualhasbeendeniedSocialSecurityDisabilityBenefitsbutanticipatesappealingthatdecision;

c)Theindividualisintheprocessofappealingand/orre-filingforSocialSecurityDisabilityBenefits;

d)Theindividualis62yearsand6monthsold(i.e.,maybeeligibleforMedicarebaseduponhis/heragewithin30months);or

e)TheindividualhasanEndStageRenalDisease(ESRD)conditionbutdoesnotyetqualifyforMedicarebaseduponESRD.

Winter 2011 7

Aswillbenoted,threeofthefactors(a-c)revolvearoundtheclaimant’ssocialsecuritydisability(SSD)status.Todeterminewhether(a-c)couldbeapplicable,directmeasuresneedtobetakentodeterminetheclaimant’sSSDstatus.Fromtheauthor’sviewpoint,bestpracticeswoulddictatethatthisdeterminationbemadeviadirectinquirytothesocialsecurityadministration(SSA)foravarietyofreasons.Importantly,itshouldbenotedthatCMS’QueryFunctionprocessestablishedtodetermineaclaimant’sMedicarestatusinthecontextofMedicare’snewnoticeandreportinglaw(Section111oftheMedicare,MedicaidandSCHIPExtensionActof2007)18willnotprovideanyinformationrelatedtotheclaimant’ssocialsecuritystatus.

Inaddition,specialattentiontofactors(b)and(c)isalsoinorder.Specifically,itshouldbenotedtheultimateapplicabilityofthesefactorscouldhingeontheclaimant’sintentionsandrepresentations.Forexample,assumetheSSAprovidesconfirmationthattheclaimant’sapplicationforSSDwasdenied,andthathe/shehasnotappealedorre-filedforSSD.Thisinformationisindeedimportant,butitisonlypartoftheanalysis.

PerCMS’definition,iftheclaimantinthissituation“anticipates appealing that decision”oris“in the process of appealing and/or re-filing” forSSD,CMSconsidershim/hertohaveareasonable expectation of Medicare enrollment.Thus,aspartofclaimspractice,practitionersshoulddevelopthenecessarypracticalapproachestoproperlyaddressthisaspectofCMS’definitionintermsofdocumenting(asbestaspossible)aclaimant’sintentionsandrepresentations.Defensepractitionersshouldconsultwiththeirclientstodetermineiftheyhaveanyspecificprotocolstobefollowedinthissituation.

Part IINon-Threshold Cases: Addressing Settlements That Do NotMeet CMS’ WC-MSA Review Thresholds

IfitisdeterminedthatthesettlementdoesnotmeetCMS’WC-MSAreviewthresholds,thefocusshiftstowhatobligationsthepartiesmayhavefromCMS’perspectivetoconsiderMedicare’sinterestsin“non-threshold”cases.

Onthispoint,CMSstatesasfollowsinitsJuly11,2005memo:

Q1 Clarification of WCMSA Review Thresholds – ShouldIestablishaWorkers’CompensationMedicareSet-asideArrangement(WCMSA)evenifIamnotyetaMedicarebeneficiaryand/orevenifIdonotmeettheCMSthresholdsforreviewofaWCMSAproposal?

A1 ThethresholdsforreviewofaWCMSAproposalareonlyCMSworkloadreviewthresholds,notsubstantivedollaror“safeharbor”thresholds

forcomplyingwiththeMedicareSecondaryPayerlaw.UndertheMedicareSecondaryPayerprovisions,Medicareisalwayssecondarytoworkers’compensationandotherinsurancesuchasno-faultandliabilityinsurance.Accordingly,allbeneficiariesandclaimantsmustconsiderandprotectMedicare’sinterestwhensettlinganyworkers’compensationcase;evenifreviewthresholdsarenotmet,Medicare’sinterestmustalwaysbeconsidered.(EmphasisbyCMS).

CMSrevisitedtheissueinitsApril25,2006,stating,inpertinentpart,asfollows:

TheCMSwishestostress[thatthe$25,000monetarythresholdrelatedtoMedicarebeneficiaries]isaCMSworkload review thresholdandnotasubstantivedollaror“safeharbor”threshold.Medicarebeneficiariesmust stillconsiderMedicare’sinterestsinallWCcasesandensurethatMedicareissecondarytoWCinsuchcases.(EmphasisbyCMS).

Fromthesestatements,important(andtroubling)piecesofthepuzzlefallintoplace:First,CMSdoesnotconsideritsWC-MSAreviewthresholdstobesafeharbors.Second,CMSexpectsitsintereststobeconsideredandprotectedinallWCsettlements,regardlessofwhetherornotthesettlementmeetsthereviewthresholds.Butwhatdoesthismeanexactly?

Unfortunately,CMShasnotreallyprovidedmuchbywayofguidance.Asaresult,CMShasessentiallyplacedtheindustryintheverypeculiarpositionofhavingtodevelopitsownpracticeprotocolsregardingwhen,andhow,toconsiderandprotectMedicare’sinterestsinrelationtonon-thresholdsettlements.

Inresponse,manyprimarypayershavedevelopedspecificinternalprotocolsregardinghownon-thresholdcaseswillbeaddressed.Theseprotocolstypicallyinvolveincludingsomeformoffuturemedicalallocationorprojectionaspartofthesettlement.Acommonmechanismusedinthiscontextisa“non-thresholdMSA.”(Forpurposesofthisanalysis,theauthorwilldiscusstheissueintermsofusinganon-thresholdMSA).Itisimportanttonotethatanon-thresholdMSA(orwhateverothermechanismthatmaybeused)isnotsubmittedtoCMSforreviewandapprovalastheclaiminthiscontextdoesnotmeettheagency’sreviewthresholds.19

Determiningexactlywhentoincludeanon-thresholdMSAinvolvesconsiderationofmanydifferentfactorsthatdifferfromprimarypayertoprimarypayer,andpractitionertopractitioner.Fromtheauthor’sexperienceandobservation,somefactorscommonlyconsideredbytheindustryweighinginfavorofincludinganon-thresholdMSAare:

1. AcaseinvolvingaMedicarebeneficiarywherethetotalsettlementis$25,000,orless.Inthisinstance,therationaletoincludeanon-thresholdMSAisthatMedicare’sinterestsarealreadyimplicatedastheclaimantisaMedicarebeneficiary.(CMS’April25,


2006memorandumcouldbeviewedassupportingthisrationale).

2. Asettlementinvolvinganon-Medicarebeneficiarywhereone,butnotboth,ofCMS’WC-MSAreviewthresholdsfornon-Medicarebeneficiariesismet.

Forexample,thesettlementisbelowthe$250,000monetarythreshold,butthefactsindicatethattheclaimanthasareasonable expectation of Medicare enrollment;orithasbeendeterminedthattheclaimantwillinfactbecomeaMedicarebeneficiaryatsomepointafterthesettlement(e.g.theclaimantwhoisaSSDbeneficiaryatthetimeofthesettlement,butwhoseMedicarebenefitsinconnectiontotheSSDawardarenotscheduledtocommenceuntilsomepointaftersettlement).Therationaletoincludeanon-thresholdMSAintheseinstancesispremiseduponthefactthatMedicare’sinterestscould be,orwill in fact be, implicatedafterthesettlement.

3. Adecisionmaybemadetoincludeanon-thresholdMSAinrelationtoasettlementthatexceedsthe$250,000monetarythreshold,eventhoughtheclaimantdoesnothaveareasonable expectation of Medicare enrollment.Therecouldbeseveraldifferentrationalesorconcernsatplaypromptingthisdecisionbaseduponthespecificfactualsituation.

Theaboveconsiderationsarebynomeansinclusive,andeachnon-thresholdcaseshouldbecloselyanalyzedtodetermineiftakingaffirmativestepstoconsiderandprotectMedicare’sinterestswouldbeappropriate.

Inaddressingthisissue,defensepractitionersshouldcontacttheirclientstodetermineiftheyhaveinfactestablishedspecificnon-thresholdprotocols.Ifso,thedefensepractitionershouldbecomefamiliarwiththeclient’sprotocolstoensurethathe/sheisproperlycomplyingwithsameaspartofhis/herclaimshandlingandsettlementpractice.Iftheclienthasnotestablishednon-thresholdcriteria,thedefensepractitionershouldconsultwiththeclienttoconfirmthattheyhaveacompleteandproperunderstandingoftheissue.

Asforclaimantpractitioners,itwouldbeprudenttoinquireastowhetherornottheprimarypayerinvolvedinyourcasewillrequireanon-thresholdMSA.Additionally,claimantpractitionersshouldindependentlyaddressthisissueandconsiderdevelopingtheirownnon-thresholdprotocolsandpracticeparameters.

ConclusionInmanyrespects,thereiscertainlymorethanmeets

theeyewhenassessingpossibleapplicabilityofCMS’WC-MSAreviewthresholds.Determiningwhetherornotasettlementmeets(ormaymeet)areviewthresholdrequirescarefulexaminationofthevariousdefinitionalcomponentsestablishedbyCMS.Thisanalysiscanbecomplicatedinparticularsituationsinlightofthefactthereremainseveralquestionsanduncertaintiesregardinghowspecificcomponentsofthereviewthresholdsaretobeinterpreted

(orcouldbeinterpreted).

Whenthedustsettles,itisimperativethatthepractitionerhasafirmunderstandingofCMS’WC-MSAreviewthresholdsandrecognizestheissuespresentedbynon-thresholdcasesinrelationtoeffectiveclaimshandling,protectingclientinterests,andminimizingpotentialexposure(forboththeirclientsandthemselves).

Mark Popolizio, Esquire, is the Vice President of Customer Relations for NuQuest/Bridge Pointe

Prior to joining NuQuest, he practiced workers’ compensation and liability legal defense for 10 years. During this time, he developed a national Medicare practice which included MSA and Medicare Compliance. Mark is very active on the national MSA/Medicare educational and training circuit. He is a regularly featured speaker on MSA/Medicare issues before carriers/TPAs, state bar associations and industry specific organizations.

Popolizio served as vice president of the National Alliance of Medicare Set-Aside Professionals (NAMSAP) from 2006-2008 and remains active with NAMSAP concentrating on educational and legislative matters. Mark is also involved with current MSP reform efforts in Congress (H.R. 4796). Mark has also published numerous articles on MSA/ Medicare issues.

He is licensed to practice law in Florida and Connecticut and can be reached at 786-457-4393 or via e-mail at [email protected].

(Endnotes)1. ParasherB.Patel,CMSMemorandumtoAllRegional

Administrators,Workers’CompensationCommutationof FutureBenefits,July23,2001.

2. TheMedicareSecondaryPayerStatute(MSP)iscodifiedat42U.S.C.§1395y,et.seq.Inaddition,pertinentprovisionsrelatedtoMSPcompliancearecontainedinSubpartsB,CandDof Title42of theCodeof FederalRegulations(42C.F.R.§§411.20through411.50,et.seq.)

3. Theauthorunderstandsthelargerargumentsraisedinsomequartersquestioningtheunderlyingvalidityandlegalauthorityof CMS’WC-MSAprocess,administrativeframework(orlackthereof),andpolicymemorandainregardtotheissueof whatever“legal”obligationsmayexist,orwhichmaybeconsideredappropriateundertheMSP.Whiletheauthoracknowledgestheseissuesandarguments,thatlargerdebateisnotthefocusof thisarticle.

4. ParasherB.Patel,CMSMemorandumtoAllRegionalAdministrators,Workers’CompensationCommutationof FutureBenefits,July23,2001,p.2-5andThomasL.Grissom,CMSMemorandumtoAllRegionalAdministrators,MedicareSecondaryPayer–Workers’Compensation(WC)FrequentlyAskedQuestions,April22,2003,p.2-3(FAQNo.4).

5. Patel,atp.2andGrissom,atp.2.

6. Patel,atp.3andGrissom,atp.2

7. Id.

Winter 2011 9

8. Patel,atp.2-3andGrissom,atp.2.

9. Patel,atp.2-3andGrissom,atp.2-3.ThefollowingstatementandexamplecontainedinCMS’April23,2003,memorandumhighlightstheagency’spositiononthispoint:Additionally,asettlementpossessesacommutationaspectif itdoesnotprovideforfuturemedicalexpenseswhenthefactsof thecaseindicatetheneedforcontinuedmedicalcarerelatedtotheWCillnessorinjury.Example:Thepartiestoasettlementmayattempttomaximizetheamountofdisability/lostwagespaidunderWCbyreleasingtheWCcarrierfromliabilityformedicalexpenses.If thefactsshowthatthisparticularconditioniswork-relatedandrequirescontinuedtreatment,MedicarewillnotpayformedicalservicesrelatedtotheWCinjury/illnessuntiltheentiresettlementhasbeenusedtopayforthoseservices.

10. Asstated,theWC-MSAandCMS’reviewprocessregardingsameistheagency’srecommendedmethodtoprotectitsfutureinterestsundertheMSP.Inthisregard,CMShasstatedthatitsreviewprocedureisavoluntarycomplianceprocess.WhileCMS’WC-MSAprocessistechnicallyavoluntaryprocess,fromtheauthor’sexperienceasignificantsegment(if notthemajority)of theclaimsindustryhasbeen,andis,complyingwiththeagency’sWC-MSAreviewprocess.IndustrycompliancewithCMS’reviewprocessisbasedprimarilyuponthebelief thatobtainingCMSapprovalprovidesadegreeof securityfromfutureliability.ThethoughtbeingthatthepartieswouldbeinafarbetterpositiontodefendanyfutureclaimbyCMSif theagencywasaffordedtheopportunitytoreviewthesettlementandapprovetheproposedWC-MSA.

11. CMSsetsforthanddiscussesitsWC-MSAreviewthresholdsinthefollowingagencypolicymemoranda:ParasherB.Patel,CMSMemorandumtoAllRegionalAdministrators,Workers’CompensationCommutationof FutureBenefits,July23,2001,p.4-6;ThomasL.Grissom,CMSMemorandumtoAllRegionalAdministrators,MedicareSecondaryPayer–Workers’Compensation(WC)FrequentlyAskedQuestions,April22,2003,p.1-2(FAQNos.2and17);GeraldWalters,CMSMemorandumtoAllRegionalAdministrators,MedicareSecondaryPayer(MSP)–Workers’Compensation(WC)AdditionalFrequentlyAskedQuestions,July11,2005,p.2(FAQNos.1and2);andGeraldWalters,CMSMemorandumtoAllRegionalAdministrators,Workers’CompensationMedicareSet-AsideArrangement(WC-MSAs)andRevisionof theLowDollarThresholdforMedicareBeneficiaries,April25,2006.ItshouldbenotedthatCMShasreservedtherighttoadjust,modifyoreveneliminatethereviewthresholds.

12. GeraldWalters,CMSMemorandumtoAllRegionalAdministrators,Workers’CompensationMedicareSet-AsideArrangement(WC-MSAs)andRevisionof theLowDollarThresholdforMedicareBeneficiaries,April25,2006.

13. Seealso,ThomasL.Grissom,CMSMemorandumtoAllRegionalAdministrators,MedicareSecondaryPayer–Workers’Compensation(WC)FrequentlyAskedQuestions,April22,2003,p.6(FAQNo.17).

14. A“conditionalpayment”canbedefinedas“aMedicarepaymentforservicesforwhichanotherpayerisresponsible.”See,42C.F.R.§411.21.

15. ForfurtherinformationregardingMedicareconditionalpayments,CMS’currentconditionalpaymentprocess,andrecentreformlegislationintroducedinCongressthatwouldrevisecertaincurrentagencypracticesinrelationthereto,seetheauthor’sarticleascontainedinSettlement News,April2010entitled:The Medicare Secondary Payer Enhancement Act of 2010 (H.R. 4796) ProposesAmendmentstotheMedicareSecondaryPayerStatute:MajorChangesAreProposedtotheMedicareConditionalPaymentProcess,Section111of theMMSEA&OtherGeneralMSPComplianceMattersThisarticlecanbeobtainedbyloggingontowww.NQBP.com(select“ResourceLibrary”andthenchoose“SettlementNews”).

16. Anotherpossibleconsiderationinthisregardishowandtowhatextent(if atall)conditionalinformationthatmaybeobtainedfromMyMedicare.govcouldpossiblybeused.Throughthissite,itmaybepossibletoobtainconditionalpaymentinformation.However,fromafewaccountsreceivedbytheauthor,thissitemaynotalwayscontainthemostcurrentinformationFurthermore,theremaybeissuesregardinginformationalaccuracyandsystemaccessinparticularsituations.

17.Thefollowingexamplesmayhelpbetterillustratethequestionsandpossibleissuesbeingraisedbytheauthor:Example#1:Thepartiesreachasettlementagreement(SA)involvingaMedicarebeneficiaryintheamountof $20,000.Atthetimeof thesettlement,ithasbeendeterminedthatMedicareisassertingconditionalpayments(CP)intheamountof $5,000.01.(Note:Forpurposesof theforegoingexamples,itisassumedthattheCPamountcouldinfactbeobtainedasof thetimeof thesettlementor,alternatively,thatsameisbasedonaninterimconditionalpaymentamountthatthepartiesmayhaveobtainedfromCMSduringthecourseof theclaim.Furthermore,theexamplesassumethatCMSwouldinfactbeagreeabletoevenconsidersaidapproaches.)Inthisexample,if CMStookthepositionthatitisthegrossamountof conditionalpaymentsbeingclaimedatthetimeof settlementthatshouldbeincludedincalculatingthetotalsettlementamount,thesettlementinthisinstancewouldmeetCMS’WC-MSAreviewthresholdasthecombinedtotalof thesefigureswouldequal$25,000.01[$20,000SA+$5,000.01CP=$5,000.01]whichexceedsthe$25,000monetarythresholdunderThreshold#1.Example#2:Thepartiesreachasettlementagreement(SA)involvingaMedicarebeneficiaryintheamountof $12,000.00.Atthetimeof thesettlement,Medicareisassertingconditionalpayments(CP)intheamountof $14,000.If,asinExample#1,CMStookthepositionthatitisthegrossamountof conditionalpaymentsbeingclaimedatthetimeof thesettlementthatshouldbeincludedincalculatingthetotalsettlementamount,thesettlementinthisinstancewouldmeetthereviewthresholdsasthecombinedtotalof thesefiguresequals$26,000[$12,000SA+$14,000CP=$26,000]whichexceedsthe$25,000monetarythresholdunderThreshold#1.However,adifferentresultcouldseeminglybereachedemploying42C.F.R.§411.24(c).Underthissection,if CMSdoesnotneedtotakelegalactiontorecoveritsconditional


paymentclaim,theamountof recoverableconditionalpaymentsisthelesserof either(a)theMedicareprimarypayment,or(b)theamountof thefullprimarypaymentthattheprimarypayerisobligatedtopay.AssumingthatCMSwouldpermitapplicationof thisformulaatthisjunctureof theclaim,thenMedicare’sconditionalpaymentrecoverywouldbelimitedto$12,000.Thisamountrepresentsthelesserof factors(a)and(b)above.Thus,inthisinstance,thesettlementwouldnotmeettheWC-MSAreviewthresholdsasthecombinedfigureswouldonlytotal$24,000[$12,000SA+$12,000CP=$24,000]whichisbelowthe$25,000threshold.Bywayof note,aninterestingquestionthatcouldariseusingtheseapproachesinvolveshow,if atall,shouldconditionalpaymentamountsthatthepartiesmayquestionordisputebetakenintoaccount?Also,towhatextent(if atall)wouldCMSpermitthedeterminationtobereducedby“procurementcosts”which,per42C.F.R.§411.37,arepermittedinreducingaparties’ultimatereimbursementobligation?(Note:Theabovearepresentedforillustrativediscussion

purposesonly.Inpresentingsame,theauthorisnotstatingorotherwisesuggestingtheseapproachesrepresent,orcouldrepresent,aproperinterpretationof CMS’policyonthispoint,orwouldotherwisebeacceptedbytheagency).

18. Section111of theMMSEAiscodifiedat42U.S.C.§1395y(b)(7)and(8).

19. Asasupplementtotheauthor’sdiscussionof non-thresholdcasesherein,thereadermayalsowishtoreviewtheexcellentoverviewof thistopic(whichincludesareviewof variousoptionsforconsideration)aspreparedbyPattyMeifertcontainedinSettlement News,March,2007entitled:MSP Compliance in Settlements NOT Meeting the CMS Review Thresholds: Options for Primary Payers.Thisarticlecanbeobtainedbyloggingontowww.NQBP.com(select“ResourceLibrary”andthenchoose“Articles”).

AswecloseinonthefirstyearofmytenureasChairmanoftheStateBoardofWorkers’Compensation,Iampleasedtoreportthatwe

attheBoardcontinuetomakeeveryefforttoserveourcustomersinafair,impartial,andefficientmannerineveryDivision.ItismypleasuretoupdateyouonseveralinitiativesthatDirectorsWarrenMassey,SteveFarrowandIhaveimplementedand/orwillhavecompletedintheverynearfuture.

First,theGeorgiaGeneralAssemblyrecentlypassedlegislation,whichtheGovernorsigned,allowing,forthefirsttimeinhistory,thepublicationofAwardsissuedatboththetrialandappellatelevels.Thisinnovationhasbeenlongrequestedbytheworkers’compensationcommunity,anditisnowavailable.WehavebegunbypublishingAwardsfromOctober,2009forward.WearestartingwiththosecasesheardbythecurrentAppellateDivision.Thus,ifacasewasappealedinorafterOctober,2009,boththeAdministrativeLawJudgeandAppellateAwardswillbepublished.Wewillbeaddingadditionalawardsasourresourcesallowus.

The2010sessionoftheGeneralAssemblyalsosawthepassageoflegislation,signedbytheGovernor,whichessentiallyrewroteandstrengthenedtheabilityoftheGeorgiaSelf-InsurerGuarantyTrustFundBoardofTrusteestopursueanon-compliantmemberwhichfailstofulfillitsobligationstocontinuepaymentoncompensableclaimsfiledbyinjuredworkers.

Inaddition,duringthepastyear,wehaveseenterritorychangesforadministrativelawjudges,whichtheAppellateDivisionbelieveswillenhancethedecision-makingprocessatthetriallevel.Ashasbeenmentionedpreviously,theturnaroundtimeforapprovalofStipulationsandAgreementsbytheSettlementDivisionhasimproveddramatically.Nowadays,approximately90to95%ofstipulationssubmittedforapprovalwillbeapprovedwithin10daysofsubmission.Also,Awardsatboththetrialandappellatelevelscontinuetobeissuedinatimelymannersoastoexpeditethedecision-makingprocessforallpartieswithregardtohandlingofaclaim.

ThemostthoroughandfarreachingchangepresentlytakingplaceistheICMSII“refresh”projectwhichwill,amongotherthings,seeareplacementofbothsoftwareandhardwareinthepresentICMSsystemandanupgradeandimprovementinthoseareaswhichwerefoundtobedeficientthroughtheICMSIprocess.

Finally,IwouldliketotakethisopportunitytothankallofthewonderfulpeoplewhoworkwithmeandtheotherDirectorsattheStateBoardofWorkers’Compensationandwhodevoteagreatdealoftimeandefforttoimprovingourworkers’compensationdeliveryservicestoyou,ourcustomerbase.IwouldalsoliketothankthemembersoftheChairman’sAdvisoryCouncilwhodevoteuntoldnumbersofhoursofunpaidtimetothecareandnurturingoftheGeorgiaworkers’compensationsystem.Withouttheirhelpandassistanceinguidingthesystem,Georgia’sworkers’compensationsystemwouldnotbeashiningexampleforotherstatestoemulate.

Message from the ChairmanBy Richard S. ThompsonChairman, State Board of Workers’ Compensation

Winter 2010 11

Inthisdayofupsidedownmortgagesand“201ks”,itiseasytogetanegativeattitude.Ourtrainingandworkaslawyersincreasesthatrisk,sinceitisourjobtoflyspeck

documentsandadversetestimony.It’snowonderthatlawyersexperienceahighlevelofdepressionandburnout.Sowhatcanwedotomakeitbetter?

Theanswerissimple–dowhatmatters.Boththedoingandthematteringareimportant.I’venoticedI’mmygrumpiestrightbeforeIbeginpreparingfortrial–atthetimewhenIamnotyetdoingit–Iamjustdreadingit.OnceIstartactuallydoingit,thedreadgoesaway.I’vealsonoticedthatIammuchhappierdoingtheworkiftheworkmatters.Winningonatechnicalityisnotnearlyassatisfyingaswinningonthemerits.

ButwhyamIwritingaboutthisinourtradejournal?Howdoesallthisapplytoworkers’compensationlaw?Itappliesbecausedoingwhatmatterswillmakeoursystemwork.Makingoursystemworkisworthwhile.Doingworthwhileworkisfulfilling.

Inarecentcase,opposingcounselcaughtupwithmeafterthehearingandsaid:“YouknowthatIMEIjustputinevidence–itisonadifferentclaimant.”WeagreedtosubstitutethecorrectIME.LaterthatsameclientwasreceivingTTDbutfoundajob.Therewasnothingnewordifferentaboutthenewemployer.Myclienttriedthejobforseveralweeks,butcouldn’tdoit.WhenIprovidedinformationshowingthosefacts,thedefenseattorneyandinsurervoluntarilyrecommencedTTDwithoutforcingmyclientthroughanotherhearing.

BothsubstitutingtheIMEandavoidinganunnecessary

hearingweretherightthingstodobecausetheymattered.Itmattersthatthejudgegetsthecorrectinformation,eventhoughitmighthavebeenkeptoutonatechnicality.Itmattersthattheinjuredworkergetspromptpaymentofbenefitseventhoughthedelayofahearingmighthavegiventhedefenseastrategicadvantage.ThatdefenseattorneyandIwillcontinuetozealouslyrepresentthoseclientsandothers.Hewillkickmytailsome,andhopefullyIwillkickhissometoo.Butregardlessofwhokickswhose,wewillbothenjoythefightmorebecauseitwasafairone.

IknowIammainlypreachingtothechoirwhenIwritethis.IthasbeensaidoverandoveragainwhatapleasureitistopracticeinthissectionofthebarbecausethelawyersdopracticewhatIampreaching.ButpreachinghappenseverySundayforareason–wehumansareterriblyforgetfuloflessonswehavelearned.Itneverhurtstoberemindedofwhatmatters.SoItakethisopportunitytogetuponmysoapboxandpreach.

Remembertodowhatmatters.Devoteyourtimetothejusticesystemaswellastoyourparticularclients.Encourageyourclientsandotherswhoworkinoursystemtodothesame.Makeyourfightsaboutthemeritsofthecase.Don’tappealeverycase–noteventotheappellatedivision.Astheappellatedivisiondirectorsmadeclearattheseminar,theywanttoreviewonlythecasesthatinvolveobviouserrorsoffactandfocusmoreonthefewcasesthatinvolverealissuesoflaw.Giveyouropponentthebenefitofthedoubt.Rememberheorshe,likeyou,istryingtodotherightthing,andthatbothofyouwilloccasionallyneedagentleassistwhenyoufallshortofthatgoal.Themorewefocusonthesethings,themorewewillloveourwork.

Message from the ChairBy Cliff PerkinsChair, Workers’ Compensation Section

Clifford C. Perkins Jr.PerkinsLawFirmLLP

Kelly Alyne BenedictBenedict&TorpeyP.C.

John G. Blackmon Jr.DrewEckl&Farnham,LLP

John Douglas Christy JohnD.ChristyP.C.

Gary M. Kazin

Lynn Blasingame Olmert CarlockCopeland&StairLLP

Gregg Mitchel PorterSavell&WilliamsLLP

Jo H. Stegall III McRaeStegallPeekHarmanSmithManning

A special thanks to the 2010-11 Workers’ Compensation Law Section Officers:


ICMS-2:We’vejustaboutgotthisthingfiguredoutasitis–whychangeanything?

Issues:WearehighlydependentupontheICMSandWCONLINEsystems.

• Softwaremustbeupgradedtotakeadvantageofnewfunctionality.

• Existingsoftwareishighlycustomizedandnoteasilyupgradeable.

• Accessforadditionaluserswithoutaffectingcurrentsystemperformance.

• Existinghardwareisnearingendoflifeandcoresoftwareisatendofsupport.

• ProjectScope:SBWCispartneringwithIBMandGTA(GeorgiaTechnologyAuthority)for:

• Theimplementationofnewinfrastructureenvironments(hardwareandsoftware).

• ApplicationupgradesandImplementationservices.

• SecurityforthesystematGTA’sNorthAtlantaDataCenter.

Project Objectives:• Newclassesofusers–

RehabSuppliers,ClaimsOffices/TPAs,Self-InsuredEmployers,andCarriers.

• HardwareandSoftwareupgrades–newer,faster,morereliable.

• Upgradedapplicationswithflexibledesign,whichareeasiertomaintainandenhance.

• Morerobustsystems–abletosupport1500newusers.

• SBWCshouldbeabletostandonourownformaintenanceandenhancements.

• Maintaincurrentsystemfunctionality

• Scalablesystem–createtheabilitytoaddmoreusersasneeded.

Some Items on SBWC’s Enhancement “Wish List”:• Provideaconsistentlooktoallformsviewedbyall

classesofusers.

• Improvethesettlementapprovalnotificationprocessforenhancedreliabilityandverifiability.

What Will Users Need?• Thenewsystem,likethecurrentsystem,willbe

windows-based.

• Accommodatemultiplebrowsers.

• HIPAA/HITECHCompliant(security,privacy,access,etc.)

• Intuitiveexperiencewithoutextensivere-training.

What is SBWC doing now, and when will ICMS-2 “Go Live”? • SBWC’sITstaffistraining

toenhanceandbroadentheirexistingskills;criticalskillshavebeenaddedasneededtofulfilladditionalrolesincludingProjectManager.

• AProjectTeamofkeySBWCstafffromvariousdivisionshasbeenmeetingtogettheprojectunderway.

• Developmentwilloccurinanisolatedsecureenvironmentwithoutrisktothecurrentsystem.

• Requirementsanddesigndetailsarebeingcaptured;thisprocesswillcontinuethroughsequentialrefinementscalled“iterations”.

• ThecurrenttargetforswitchoverisJuly2012.

• Asyoucansee,thisisalong-termprojectforSBWC.Ourgoalistocreateasystemthatwillprovideallthesamecapabilitiespresentinthecurrentsystem,buttomakeitmoresecure,morerobust,andfaster,friendlier,andeasiertouse.

ICMS UpdateBy Stan Carter

Winter 2011 13

Idiopathic Injuries and the Harris TestBy Robert Hendricks

RecentdecisionsintheCourtofAppealshavecloudedratherthanclarifiedthecompensabilityofidiopathicinjuries.Withoutclearguidanceonthis

issue,employers,insurers,andemployeeswillcontinuetolitigatecompensationforthesetypesofinjuries.Todate,theclearestandmostpracticaltesthasbeentheonelaidoutinHarris v. Peach County,296Ga.App.225,674S.E.2d36(2009).Inthatcase,acustodianbentovertopickapilloffthefloor,asrequiredbytheconditionsofheremployment.Intheprocessofpickingupthepill,herownbodyweightcausedherkneetodislocate.Shedidnotcomeintocontactwithanythingintheprocess.TheCourtofAppealsheldthatthisinjurywascompensablebecausetheactivitytheemployeewasengagedinwasinfurtheranceofherjobduties.Thistestofwhethertheactivityconstitutesanemploymentfunctionisaclearandeasydistillationoftherelevantlanguagefromapplicablecaselaw.

ThislanguagewasoriginallyimportedintoGeorgiacaselawin1923.TheCourtofAppealsinNew Amsterdam Casualty Co. v. Sumrell30Ga.App.682,118S.E.786(1923) addressedtheissueofwhetheraninjury“aroseoutof”theemployment.ThislanguagewasthenadoptedbytheGeorgiaSupremeCourtin Fried v.United States Fidelity and Guaranty Co.,192Ga.492,15S.E.2d704(1941).Specifically,incitingNew Amsterdam Casualty Co. v. Sumrell,theCourtinFriedstated:

TheCourtofAppealsofGeorgiahasveryaptlydefinedtheterm“arisingoutof”theemployment,asfollows:“It‘arisesoutof’theemployment,whenthereisapparenttotherationalmind,uponconsiderationofallthecircumstances,acausalconnectionbetweentheconditionsunderwhichtheworkisrequiredtobeperformedandtheresultinginjury.Underthistest,iftheinjurycanbeseentohavefollowedasanaturalincidentofthework,andtohavebeencontemplatedbyareasonablepersonfamiliarwiththewholesituationasaresultoftheexposureoccasionedbythenatureoftheemployment,thenitarises‘outof’theemployment.Butitexcludesaninjurywhichcannotfairlybetracedtotheemploymentasacontributingproximatecause,andwhichcomesfromahazardtowhichtheworkmenwouldhavebeenequallyexposedapartfromtheemployment.Thecausativedangermustbepeculiartothework...Itmustbeincidentaltothecharacterofthebusiness,andnotindependentoftherelationofmasterandservant.

Fouryearslater,theGeorgiaSupremeCourtinThornton v. Hartford Accident and Indemnity Co.,198Ga.786792,32S.E.2d816(1945)gaveaslightlyrewordeddefinition:

Thewords“arisingoutof”meanthattheremustbesomecausalconnectionbetweentheconditions

underwhichtheemployeeworkedandtheinjurywhichhereceived.Thecausativedangermustbeincidentaltothecharacteroftheemployment,andnotindependentoftherelationofmasterandservant.Theaccidentmustbeoneresultingfromariskreasonablyincidenttotheemployment.Andariskisincidenttotheemploymentwhenitbelongsto,orisconnectedwith,whataworkmanhastodoinfulfillinghiscontractofservice.“Ariskmaybeincidentaltotheemploymentwhenitiseitheranordinaryriskdirectlyconnectedwiththeemploymentoranextraordinaryriskwhichisonlyindirectlyconnectedwiththeemploymentowingtothespecialnatureoftheemployment.

Thislanguageiscitedinthemajorityofthemajorcasesaddressingidiopathicinjuriesandhasformedthebasisfordeterminingwhetheranidiopathicinjuryiscompensable.

AfterThornton,twocasesdealingwithidiopathicinjurieswereaddressedbytheCourtofAppeals:United States Casualty Company v. Richardson,75Ga.App.496,43S.E.2d793(1947) andOrkin v. Wright,92Ga.App.224,88S.E.2d205(1955).U.S. Casualty Co. dealtwithanemployeewhosufferedanepilepticseizureandstruckhisheadonatable,whileOrkin dealtwithanemployeewhosufferedaheartattack.Therewasevidenceinbothcasesthattheemployees’conditions(seizureandheartattack)hadbeeninducedbyworkrelatedexertion.Thisworkrelatedexertionwasenoughofacausalconnectiontosustaintheawardinbothcases.However,inaddressingtheissueofwhethertheawardwaslegallysustainableinU.S. Casualty Co.,theCourtofAppealsnotedthattheawardwouldbesustainableundereitheroneoftwotheories.Thefirstwasthattheworkrelatedexertionwasacausalconnectiontotheepilepticseizure.Thesecondwasthat“ifthefallisonastairwayorintoamachineoragainstanythingexceptthebarefloor,andespeciallyifthefallisfromaheight,astheriskofinjuryisincreased,orisa‘specialdangeroftheemployment’”itarisesoutoftheemployment.Thisadditionhascausedsomeconfusioninthecaselaw.

InPrudential Bank v. Moore, 219Ga.App.847,467S.E.2d7(1996),acomputerclerkapparentlyfaintedandstruckherheadonthebaseboardasshefell.SheclaimedthatunderU.S. Casualty Co. herinjuryaroseoutofheremployment.TheCourtofAppealsinPrudential Bankdistinguishedbetweenastructuralhazard(suchasthebaseboardorawall)andanincreasedrisk(anobjectspecificallyrelatedtotheworkplace).TheCourtalsodistinguishedthiscasefromU.S. Casualty Co. inafootnotestatingthattheinjurysufferedbytheemployeeinU.S. Casualty Co. wasduetoworkrelatedexertionandnotanidiopathicfall,aswasthecasehere.Thisdistinction


highlightsthenecessityofacausalconnectionbetweentheemploymentandtheinjury.InbothU.S. Casualty Co. andOrkin,theemployee’sinjurywasbroughtaboutbytheperformanceofajobfunction.InPrudential Bank,therewasnoevidenceofacausalconnectionbetweenthecomputerclerk’sjobandherinjury.

Prudential BankwassubsequentlyoverruledbyJohnson v. Publix,256Ga.App.540,568S.E.2d827(2002) andthenreinstatedbyChaparral Boats v. Heath,269Ga.App.339,606S.E.2d567(2004).TheCourtinJohnsonopinedthatPrudential Bank hadmisinterpretedU.S. Casualty Co. inthatPrudential BankstatedthatU.S. Casualty Co. standsforthepropositionthatanidiopathicfalliscompensableonlywhentheclaimantstrikesawork-relatedobject.WhiletheCourtinPrudential Bankdidbaseitsdecisiononthefactthattheemployeedidnotstrikeawork-relatedobject,italsonotedthattheemployee’sfallwasnotbroughtonbywork-relatedexertionasithadbeeninU.S. Casualty Co.Thus,theCourtinPrudential Bankseemstodistinguishbetweenaninjuryfromanidiopathicconditionandaninjuryfromanidiopathicfall.

Ifanemployeehassomesortofidiopathicconditionthatisinsomewayexacerbatedoractivatedbysomethingincidentaltohisorherwork,thatinjurywouldbecausallyconnectedtotheemployment,thusfallinginlinewithU.S. Casualty Co.However,iftheemployeeisinjuredinafallcausedbypurelyidiopathicreasons,thereisnocausalconnectiontotheemploymentandtheinjurywouldnotbecompensable,aswasthecaseinPrudential Bank.ThedissentinJohnson pointedoutthat“therewasnoevidencetoshowthat[theemployee’s]injuriesweretheresultofanythingotherthananidiopathicfall.”Additionally,therewasnoevidencetoconnectthecauseofthefalltoanyaspectoftheemployee’semployment.Thus,theCourtofAppeals’disapprovalofJohnson in Chaparralwasappropriate.

Despiteitseffortstothecontrary,theCourtinChaparraldidlittletoclarifytheissue.Indicta,theCourtdistinguishedbetweensituationsinwhichtheapplicationofthepositionalriskdoctrinewouldbeappropriatetoestablishacausalconnectionandsituationsinwhichitwouldnot.1Insituationswheretheapplicationofthepositionalriskdoctrinewouldbeinappropriate,thegeneralruleaslaidoutinFried, supra,wouldapply2.TheCourtwentontosaythatthe“peculiartotheemployment”analysisisnotareplacementfor“analyzingcompensabilityintermsofwhethertherewasacausalconnectionbetweentheemploymentandtheinjury.”TheCourtfurtherexplainedthatthe“peculiartotheemployment”analysisisessentiallyananalysisofwhethertheemployeewouldbeequallyexposedtotheriskapartfromtheemployment.Thisanalysiscontemplateswhethersomeconditionoftheemploymentwasrelatedtotheinjury.

CitingDavis v. Houston, 141Ga.App.385,233S.E.2d479(1977), theCourtattemptedtoillustratethispoint.InDavis,anurse’saidewasdeniedcompensationafterinjuringherbackwhileputtingonhercoattoleavework.

TheCourtaffirmedthefindingoftheALJandtheappellatedivisionthat“theriskofincurringsuchabackinjurywhileputtingonacoat‘wasahazardtowhichshewasequallyexposedapartfromheremployment.’Inotherwords,theriskwasnot‘peculiar’totheemployment,butcommontotheemployeeandthepublicatlarge.”TheCourtinChaparralfurtherexplainedthat“[b]ecausethecausativeriskwasnotpeculiarorincidentaltothecharacteroftheemployment,andtherewasnoevidenceofacausalconnectionbetweenaconditionoftheemploymentandtheinjury,Davisheldthattheinjurydidnotariseoutoftheemploymentandwasnotcompensable.”Thusindicatingthathadthecausativeriskbeenpeculiarorincidentaltothecharacteroftheemploymentorhadtherebeenevidenceofacausalconnectionbetweenaconditionoftheemploymentandherinjury,theinjurywouldhavearisenoutofheremploymentandbeencompensable.

AlthoughChaparralpresentedalengthydiscussionofthelawregardingidiopathicinjuries,itdidlittletocutbackonorreallyclarifythelanguageaddressingtheissueofwhetheraninjuryarisesoutofemployment.ThatstepwastakenbytheCourtofAppealsinHarris v. Peach County.Thefactsofthatcase,supra,wouldexcludetheapplicationofthepositionalriskdoctrineandtheincreasedriskdoctrine.Thusfortheemployee’sinjurytobecompensable,

Winter 2011 15

itmustfallwithintherequirementsofthegeneralruleaslaidoutinFried.TheCourtinHarrisdistilledthegeneralruletoaclearandeasytoapplytest:Didtheactivityconstituteanemploymentfunction?Thisdistillationlooksdirectlyatwhethertherewasacausalconnectionbetweentheinjuryandaconditionoftheemployment.BecausetheemployeeinHarriswasrequiredbyaconditionofheremploymenttopickthepilloffthegroundandbecauseshewasinjuredwhiledoingso,theCourtofAppealsfoundthattherewasacausalconnectionbetweentheconditionsofheremploymentandherinjury.

TheCourtofAppealsinHarrisalsoaddressedtheissueofwhethertheemployeemustsufferaninjurythatheorshewouldnotsufferoutsideofworktobecompensable.TheCourtexplainedthat“thefactthat[theemployee]couldhavebeeninjuredinasimilarmannerawayfromworkdoesnotrequireadifferentresult...[because]shewascarryingoutjobdutieswhenshewasinjuredinthatway.”Thisfallsinlinewiththediscussionofthemeaningof“peculiartotheemployment”inChaparral.TheCourtinChaparralusedtheinjurysufferedbytheemployeeinDavisasanexampleofaninjurythatwasnot“peculiartotheemployment”becausetherewasnonexusbetweenaconditionofheremploymentandherinjury.InHarris,theCourtprovidestheothersideofthatanalysisbyexplainingthataninjuryis“peculiartotheemployment”ifthereisanexusbetweenaconditionoftheemploymentandtheinjury.

ApplyingthetestlaidoutinHarristoU.S. Casualty Co.,Orkin,Prudential Bank,Davis,andChaparral,onewouldseethesameresults.Inthecaseswhereevidenceofanemploymentfunctioncontributingtoinjurywaspresented,thecourtsfoundacausalconnection(U.S. Casualty Co. andOrkin).Incasesthatlackedthatevidence,nocausalconnectionwasfound(Prudential Bank,Davis,andChaparral).Underthisanalysis,onlyJohnsonmighthavebeendecideddifferently.

Unfortunately,thecaseatissueinSt. Joseph’s Hospital v. Ward,300Ga.App.845,686S.E.2d443(2009)waspresentedtotheAppellateDivisionafterthepublicationofChaparralbutbeforethepublicationofHarris.WithouttheguidanceofHarris,theAppellateDivisionframedtheactivitytheemployeewasengagedinatthetimeofherinjury(turningtogetapatientaglassofwatersohecouldtakemedicine)initsmostbasicsense:simplyturning.TheAppellateDivisionfoundthatthiswasahazardthegeneralpublicwasexposedto,thusitwasnotacompensableinjury.ThatdecisionwasappealedtotheSuperiorCourtandreversed.TheSuperiorCourtheldthattheappellatedivisionmisappliedChaparralbynotconsideringthecausalconnectionbetweentheconditionsofthenurse’semploymentandherinjury.TheCourtofAppeals,however,notedthataccordingtothesufficiencyoftheevidenceruletheAppellateDivision’sfindingthatshe“wasnotexposedtoanyriskuniquetoheremploymentbystandingandturning”wassupportedbysomeevidence,andthustheSuperiorCourtandtheCourtofAppealswererequiredtodefertothatfinding.

ThedecisioninSt. Joseph’semphasizedthe“peculiartotheemployment”languagediscussedinChaparral,butseemstohavemissedtheinstructionthatthe“peculiartotheemployment”analysisisnot“agoodsubstituteforanalyzingcompensabilityintermsofwhethertherewasacausalconnectionbetweentheemploymentandtheinjury.”Ironically,thethreejudgepaneldecidingSt. Joseph’snoteinnonbindingdictathat“anystatementsinHarris, supra,thatmightbeconstruedascontrarytoourwholecourtdecisioninChaparral, supra,arenonbindingdicta.”Thiswasnotonlyunnecessarytodecidetheissueathand,butwasalsounnecessarysinceHarrissimplydistilledthetestthatwaslaidoutin Chaparralandis,infact,consistentwithChaparral.

WhileitisunclearhowtheCourtofAppealswilladdressthisissueinthefuture.ItseemsthatthereasoningappliedinSt. Joseph’sisunlikelytostandfortworeasons.First,ifitdid,thenwhenawarehouseworkerliftsafiftypoundboxandsuffersabackinjury,itwouldnotbecompensablebecausetheinjurywouldbearesultofliftingwhichwouldbearisktheemployeewouldhavebeenequallyexposedapartfromtheemployment.Second,thedecisioninSt. Joseph’salsocitesChaparraloutofcontextinregardtoitsunderstandingofthe“peculiartotheemployment”analysis.St. Joseph’ssawthe“peculiartotheemployment”analysisasrequiringthattheworkactivitybeanactivitythatthepublicdoesnotgenerallyengagein.However,Chaparralexplainedthatthe“peculiartotheemployment”analysisissimplyananalysisofwhethertheinjurywasrelatedtoorcausedbythepeculiarnatureofaconditionoftheemployment.Ultimately,themostlikelyresultseemstobeanaffirmationoftheprincipleslaidoutinChaparral,whichcanbeappliedeffectivelythroughtheHarristest.

A special thanks to Justin Lowery, a law student at Emory, for his assistance with this article.

(Endnotes)1. Essentially,thepositionalriskdoctrinewasmeanttoextend

protectiontoemployeesif adutyrelatedtotheemploymentplacestheemployeeinalocalewhichexposestheemployeetoarisk,evenif itisnotpeculiartotheemployment.However,itdoesnotapplywheretheriskwhichcausestheemployee’sinjurywouldoccurindependentlyof place,employment,orpursuit.

2. [Aninjury]‘arisesoutof ’theemployment,whenthereis...acausalconnectionbetweentheconditionsunderwhichtheworkisrequiredtobeperformedandtheresultinginjury....Butitexcludesaninjurywhichcannotfairlybetracedtotheemploymentasacontributingproximatecause,andwhichcomesfromahazardtowhichtheworkmenwouldhavebeenequallyexposedapartfromtheemployment.Thecausativedangermustbepeculiartothework...Itmustbeincidentaltothecharacterof thebusiness,andnotindependentof therelationof masterandservant.


TheWorkers’CompensationLawInstituteinOctobermarkedthetenyearanniversaryofthefirstDistinguishedServiceAwardtoaworkers’

compensationpractitioner.Thelistofrecipientsreadslikeawho’swho,andincludesBillGeorge,CharlieDrew,EarlMallard,JimHiers,JohnWilliams,JohnSweet,LamarGammage,CurtisFarrar,JoeSartain,LaviniaGeorge,CarolynHall,DonHartman,BobbyPotter,LeeSouthwellandJohnRoss.Criteriafortheawardarethatthenomineemust:(1)beatleast50yearsold,(2)hasbeenworkingintheworkers’compensationareafor20yearsand(3)hasbeenworkingforthegoodofthesysteminparticularandthecommunityingeneral.

Asyoumightexpect,itisadifficultdecisiontomakeconsideringthenomineessubmitted.JohnRosswasgiventheawardthisyearandwasastatesmanifthereeverwasone.Forthoseofyouwhocouldnotattendtheseminar,JohnFerguson,CarolynHall,StanCarterandJohnSweetspokeonhisbehalf.JohnpassedawayayearagoandpracticedlawinGeorgiaforalmost30years.HewascounselforCWMatthewsContractingCompany,an“asphaltman”ashedescribedhimselfandalong-termmemberoftheChairman’sAdvisoryCommittee.Hisspecialtywasbringingtwosidestothemiddleandhewasasskilledasanyoneindoingso.Johnwasaproblemsolver,anddevotedagreatdealofhistimeworkingtoresolveissuesinmannerthatbenefittedbothinjuredworkersandemployers.IfthereisonethingIrememberaboutJohn,itcamefromaspeechhegaveseveralyearsagoatanICLEseminar.HetalkedabouthisloveofGeorgia,thegreenpines,theredclayandthebluesky.Neverhavingbeenafanofredclay,hechangedmymindthatdayandwasamasteratgettingyoutoviewsomethinginadifferentlight.JohnRossneversoughtthelimelight,wasgenuineandhiscontributionswillbewithusforalongtime.

OneoftheotherindividualsnominatedthisyearwasMarvinPrice,andiftherewasanexampleofgoingaboveandbeyondthecallofdutyinrecentyears,itwasMarvin.Afterbeingtoldthatoneofhisclientswouldnolongerreceivebenefitsbecausetheinsurerwentoutofbusiness,Marvinfoughttirelesslytorightthatwrongandrestorebenefitstoagentlemanwhohadsufferedaseverebraininjury.Whilezealouslyrepresentinghisotherclients,andtryingtokeephispracticeafloat,Marvinworkedprobono

togetlegislationpassedthatwouldensurethathisclient,aswellasseveralotherssimilarlysituated,receivedlosttimeandmedicalbenefits.Thesewerecatastrophicallyinjuredworkerswho,forlackofabetterdescription,wereabouttobeturnedoutintothecold.ForthosewhoknowMarvin,thefactthathewouldundertakesuchanendeavorwouldcomeasnosurprise.

PerhapsthebestwaytodescribewhatqualitiesarecipientshouldpossessistolookatthecriteriafortheAlgernonSydneySullivanNationalAward.Itprovidesforrecognitionofanindividualwhohas“finespiritualqualities,practicallyappliedtodailyliving…theobjectof

eachoftheAwardsisnotsomuchtoencourageanyoneindividualasitistoreachandinfluencemany.”Competency,integrity,compassion,dedicationandservice.ThosequalitiesshouldbepossessedbyeveryindividualwhoisnominatedandwhoreceivestheDistinguishedServiceAward.

Overthelastseveralyearstherehasbeenquiteabitofdiscussionaboutwhetherweshouldhaveoneortworecipients.Suggestionhasbeenmade

thatthereshouldbeatleasttwoeachyear,onewhorepresentsinjuredworkersandtheotherfromthedefenseandperhapsathirdfromtheStateBoard.TheExecutiveCommittee,atleastthispastyear,didnotleanstronglyeitherway.Instead,thefocuswasongivingtheawardtoanindividualwhometthecriteria,anditwasnotadecisionhastilymade.Thefactofthematteristhatweareallinthistogether,andthesideyoupracticeonisirrelevantinthegrandschemeofthings.Ifapersonisdeservingoftheaward,heorsheshouldreceiveitwithoutregardtohisorherclients.However,thereismuchroomfordiscussiononthissubjectandifyouwouldlikegiveusyourideas,sendittoamemberoftheExecutiveCommittee,whichcurrentlyconsistsofCliffPerkins,LynnOlmert,GaryKazin,JohnChristy,JoStegall,KellyBenedict,GreggPorterandJohnBlackmon.

Whileallofthepastrecipientswereuniqueintheirownright,theircontributionstotheworkers’compensationpracticeandtotheircommunitywereextraordinary,whichiswhytheydeservedtheDistinguishedServiceAward.BecauseitisgivenattheannualseminarinlateSeptemberorOctober,nominationsshouldbesubmittedtotheExecutiveCommitteenolaterthanMay31.Ifyoudecidetosubmitaname,pleasetelluswhythatpersonshouldbehonored.Themoreinformationyouprovide,thebetter.

Distinguished Service Award By John G. Blackmon Jr. Drew Eckl & Farnham, LLP

As you might expect, it is a difficult decision to make considering

the nominees submitted.

Winter 2011 17

Discovering What Is In The Adjuster’s FileThe Injured Worker’s Perspective

Are theadjuster’sfileandtheadjuster’snotesdiscoverable?ThescopeofdiscoveryissetoutinO.C.G.A.§9-11-26(b)(1).“Partiesmayobtain

discoveryregardinganymatter,notprivileged,whichisrelevanttothesubjectmatterinvolvedinthependingaction….Itisnotgroundforobjectionthattheinformationsoughtwillbeinadmissibleatthetrialiftheinformationsoughtappearsreasonablycalculatedtoleadtothediscoveryofadmissibleevidence.”

Basedonthestatute,thefirstquestioniswhetherthefilesand/ornotesarerelevant.Whilethehearingissuesaregoingtodeterminewhetherthediscoveryrequestis“relevanttothependingaction”,thereareanumberofsituationswhereinformationcontainedintheadjuster’sfile,includingtheadjusternotes,arerelevant.Thefileandnotesshouldcontaininformationaboutwhethertheadjusterreceivedacertaindocumentordocuments,suchasaFormWC-205,ifthatisatissue.Ifassessedattorney’sfeesareanissue,thefileandnoteswilldocumenttheadjuster’sinvestigationand/orhandlingoftheclaimandwhetheritwasreasonableorunreasonable.IfO.C.G.A.§34-9-18civilpenaltiesareanissue,thefileandnoteswilllikelyprovidedocumentationofviolationofboardrulesand/orfalseormisleadingstatementsmadeforthepurposeofdenyingbenefits.

Thesecondquestioniswhethertheadjuster’sfileandnotesareadmissibleor,ifnotadmissible,reasonablycalculatedtoleadtothediscoveryofadmissibleevidence.Whiletheadjusternotesaremostlikelyreasonablycalculatedtoleadtothediscoveryofadmissibleevidence,theanalysisshouldnotevenneedtogothatfarbecausetheelectronic“adjusternotes”shouldbeadmittedatahearingasabusinessrecordpursuanttoO.C.G.A.§24-3-14.Underthatcodesection,“Anywritingorrecord…madeasamemorandumorrecordofanyact,transaction,occurrence,oreventshallbeadmissible…ifthetrialjudgeshallfindthatitwasmadeintheregularcourseofanybusinessandthatitwastheregularcourseofsuchbusinesstomakethememorandumorrecordatthetimeoftheact,transaction,occurrence,oreventorwithinareasonabletimethereafter.”Electronicadjusternotesclearlyfitwithinthisdefinition.TheyroutinelydocumenttheactionsoftheadjusterfromreviewofamedicalrecordtoassignmentofcasemanagementtounreasonableactionsandfailuretofileBoardRules.Theyarecreatedand

maintainedintheordinarycourseofaninsurer’sbusinessofclaimsmanagement.1

So,whataboutthosetwowords:notprivileged?Themostcommonlyassertedobjectiontothefilesand/ornotesisthattheyareprivilegedbecausetheywerepreparedinanticipationoflitigationandaretheworkproductoftheadjuster.Theinsurer,asthepartyassertingthisprivilege,willhavetheburdenofshowingthatthedocumentswerepreparedinanticipationoflitigation.2Itisnotsufficientthatthepartymakingtheassertionofprivilegesimplyobjectonthegroundsthatthematerialrequestedwaspreparedinanticipationoflitigation.Thepartymustpresentsomeevidencetoshowwhytheinformationisprivileged.

Theproperwaytobeginaddressingtheissueofanassertionofprivilegewithregardtotheadjuster’sfileand/ornotesiswithaprivilegelog.WithintheRequestsforProductionofDocuments,thepartyseekingdiscoverycanincludeinstructionsthatrequestaprivilegelogwithregardtoanydocumentclaimedtobeprivileged.Also,thepartyseekingdiscoverycanrequestaprivilegelogafterreceivingtheresponses.

Theprivilegelogshouldprovideageneraldescriptionofthedocument,thedateofcreationofthedocument,theidentityofthepersoncreatingthedocument,thesubjectmatterwithinthedocumentwhichiscontendedtobeprivileged,thespecificprivilegeasserted,andthelegaland/orfactualbasisfortheprivilege.Thepointisthatareasonabledeterminationcannotbemadeastowhethertheinformationisactuallyprivilegedwithoutthisinformation.Theinformationprovidedinaprivilegelogallowsthepartyseekingdiscoverytomakereasonableargumentsregardingwhytheinformationisnotprivilegedwithoutrequiringthepartyseekingtoprotectthedocumentstoactuallyrevealthosedocuments.

ThereisscarceGeorgialaw,especiallywithregardtoWorkers’Compensationclaims,aboutifandwhenelectronicadjusternotesarepreparedinanticipationoflitigation.Theevaluationofclaimsofpolicyholdersispartoftheordinarybusinessofaninsurancecompanyandsuchevaluationdoesnottakeplaceinanticipationoflitigationjustbecauselitigationoftenresultsfromadeniedclaim.3Activitiesroutinelyhandledbytheadjusteraspartofadjustingaworkers’compensationclaimwillbedocumentedintheadjusternotes.Becausemostoftheadjusternotesdocumentroutineactivities,theyshouldbediscoverablewhenotherwiserelevant.4Ifthereisdisagreementoverwhethercertainadjusternoteswerepreparedinanticipationoflitigationafteraprivilegeloghasbeenprovided,theadministrativelawjudgewilllikelyneedtoconductanincamerareviewoftheadjusternotes.

This and That in DiscoveryBy Jason Perkins

Theemployer/insurermaydemonstratethatsomeadjusternotesorotherportionsoftheadjuster’sfilewerepreparedinanticipationoflitigation.However,eveniftheemployer/insurerdemonstratesthatcertaindocuments/noteswithintheinsurer’sfilewerepreparedinanticipationoflitigation,theinjuredworkercanstillobtainthosedocumentsifitcanshowthatheorshehassubstantialneedforthematerialsinpreparationofitscaseandisunablewithoutunduehardshiptoobtainthesubstantialequivalentofthematerialsbyothermeans.O.C.G.A.§9-11-26(b)(3).Theinjuredworker,asthepartyseekingdiscovery,wouldhavetheburdenonthisissue.5Iftheadministrativelawjudgedeterminesthattheinjuredworkerhassatisfiedthisburden,thecourtshouldstillorderremovalofthementalimpression,conclusions,opinionsorlegaltheoriesoftheemployer/insurer.6

Whataboutsurveillance?Georgialawaddressingsurveillancehasheldthatprivateinvestigatorsthatareprovidingevidenceabouttheirobservations,asopposedtoinvestigativetechniques,aretestifyingasfactwitnessesinsteadofexperts.Assuch,theobservationsmadebyaninvestigatorarenotprivilegedandonlytheinvestigator’sconclusionsorotherworkproductshouldbeprotectedfromdiscovery.7Asurveillancetapeshouldsimplybearecordingofwhathappenedonaparticulardayordays.8Assumingthatitissurveillanceoftheinjuredworker,itisreallyjustastatementofthatinjuredworker’sactions.Asaresult,itisdiscoverablejustlikeanyotherstatementoftheinjuredworkerorrecordingofhowtheinjuredworkerwasfeelingonaparticularday.

Ontheotherhand,theactualreportoftheinvestigatorcouldcertainlycontainworkproductinadditiontothereportingoftheinvestigator’sobservations.Ifworkproduct,includingmentalimpressionsand

conclusion,ispresentinthereport,thentheanalysisoftheinvestigator’sreportbecomesadifferentissuefromprovidingthetape.However,wheninterrogatoriesaresenttotheemployer/insurerseekingfactsaboutwhattheinvestigatorobserved,theemployer/insurershouldanswerthoseinterrogatoriestotheextentthatitdoesnotrequirethemtorevealworkproduct(andmayneedtouseinformationfromthereporttodoso).

Shouldtheemployer/insurerbeabletowithholdtheotherwisediscoverableinformationuntiltheyhavetakentheinjuredworker’sdeposition?Theemployer/insurerwillarguethattheywillnotbeabletoimpeachtheinjuredworkerifthesurveillanceinformationhastobeproducedindiscoverypriortothedeposition.Firstofall,thelitigationprocessisnotanefforttowinthecasebytrickeryorconcealment.Itisanefforttoarriveatthetruth.Second,thereisastatutorilyenactedprocessforservingandrespondingtodiscovery.Ifdiscoveryhasbeenservedbytheinjuredworkerandtheanswerstothatdiscoveryareduepriortotheinjuredworker’sdeposition,itisnotproperfortheemployer/insurertoviolatethediscoveryrulesandwithholddiscoveryuntilafterthedeposition.

Partiesshouldnotbeencouragedtobenefitstrategicallyfromimproperobjectionsandthefailuretocomplywithdiscoveryrequirements.Infact,Georgiacourtshaverecognizedthatdiscoveryofotherwisediscoverableinformationshouldnotbepreconditionedonapartyfirstsubmittingtoadeposition.9Thisrulesupportsthepolicyoffullandtimelydisclosurethatisthebasisofourdiscoverystatutes.Ifitwereotherwise,partieswouldsimplywithholdalldiscoverableinformation10fromtheopposingpartyuntilafteradepositionwastaken.Ontheotherhand,if

thedepositionhasbeenproperlyscheduledbeforetheemployer/insurer’sresponsestodiscoveryaredue,thenthedepositionshouldcertainlytakeplacebeforethediscoveryhastobeprovided.

The Employer/Insurer’s PerspectiveOften,Ireceiverequestsforanentire

adjuster’sfile.Whilesomematerialsinthefilearecertainlydiscoverable(forexample,medicalrecords),othersclearlyarenot.Forexample,requestsareoftenspecificallymadeforadjusterfilenotespreparedbytheadjusterregardingthecase.Asdiscussedbelow,thereisnoGeorgiacaselawdirectlyonpointregardingthediscoverabilityofsomeofthesematerials,however,whenobjectionsaremadetotheproductionofsuchmaterials,theassertionshouldbethattheyareprivilegedundertheattorney/clientprivilegeand/ortheattorneyworkproductdoctrine.Inthesamevein,it

shouldbepointedoutthatadjuster’sfilecontentsvaryfrominsurertoinsurer,

Winter 2011 19

andthisisaverybroadapproachtothemostcommonelementsandcontentsofthesefiles.

Georgiahasnotbeenasclearasotherstatesindefiningwhatisandisnotgovernedbytheattorney/clientprivilege(“theprivilege”),butgenerallyspeaking,theprivilegeinGeorgiaincludesagentsandemployeesoftheattorneyandhis/herclient,actingunderthedirectionofeithertheclientortheattorney,infurtherance/tofacilitatethelegalrepresentation.OCGA§24-9-24;Eglin Fed. Credit Union v. Cantor, Fitzgerald Securities Corp.,91F.R.D.414(N.D.Ga1981).Theprivilegednetworkoftheattorneywouldincludepeoplesuchasadministrativeassistantsandlegalassistants,thelattercategorybeinganyonefromlawclerkstosecretaries.In re Fulton County Grand Jury Proceedings,244Ga.App.380,535SE2d340(2000).Theprivilegeisnotnecessarilyatooltobeusedtoexcludefacts,butrather,itmerelybarstheuseofcommunicationsbyonepartytoprovefactsnotyetinevidence.Gilbert v. State,169Ga.App.383,313SE2d107(1983).InGeorgia,theprivilegeismostbroadlyconstruedwhenanexpertorconsultantishiredbytheattorney;whenthisisdonecommunicationsbetweentheexpertandclientareprivilegedbecausetheyarebetweentheattorney’sagentandtheclient.G.M.C. v. Moseley,213Ga.App.875,447SE2d302(1994).However,itisimportanttorememberthatwhentheexpertishiredbytheclient,theexpertbecomestheagentoftheclient,nottheattorney,andthustheprivilegewillnotapply,eventosensitivemattersinvolvinglegalstrategy.Id.

Theattorneyworkproductdoctrine(“thedoctrine”)ismoreclearlydefinedinGeorgia.Thepurposeofthedoctrineissimple;itisinplacetoprotectagainsttheuseofdiscoverymethodstoobtainanotherparty’strialpreparationmaterials.Sturgill v. Garrison,219Ga.App.306,464SE2d902(1995).Theapplicationofthedoctrine,however,isn’tassimple.Thedoctrineisonlywaivedwhenanoppositepartycanprovesubstantialneedoftheotherwiseundiscoverablematerials,andthesamepartymustalsoprovethattherewillbeunduehardshipinacquiringsubstantiallyequivalentmaterials(whicharediscoverable)byothermeans.OCGA§9-11-26(b)(3).Itisonlyaftersuccessfullyarguingbothsubstantialneedandunduehardshipthatthemovantwillbegrantedaccesstothesematerials,butevenifthemovantcanprovethesetwoelements,theCourtmustguardagainstdisclosureofmentalimpressions,conclusions,opinionsand/orlegaltheoriesofanattorney/otherrepresentativeconcerningthelitigationatissue.McKesson HBOC, Inc. v. Adler,254Ga.App.500,562SE2d809(2002).Evenaftersuchanargumentissuccessfulbythemovant,thetrialcourtwillalmostalwaysperformanincamerainspectionofthematerialstosafeguardagainstthedisclosureofanyoftheaforementionedcategoriesofinformationwhichcouldgivethemovantanunfairadvantageinthelitigation.Id.

Theclaimant’srecordedstatement,whengiven,isdiscoverable.Itisnotastatementbyanagentoremployeeoftheattorney;itshouldnotcontainanymental

impressionsortrialstrategyoftheattorney.Assuch,neithertheprivilegenorthedoctrinewillbaritfrombeingdiscoverable.Whetherithasbeentranscribedoritistheoriginalrecording,thestatementitselfisadiscoverableportionofthefileasitistheclaimant’sownwords.Sincethestatementisnottakenunderoathithaslimitedtrialuseforanyoneonceitisobtained,however,itcouldbeausefuldiscoverytoolforeitherside.Ialwaystakethepositionthatthisisadiscoverableportionoftheadjuster’sfilematerialasitisnodifferentthantheclaimant’sdiscoverydepositiontranscriptandtestimonyexceptforthefactthatitisnottakenunderoathandcannotbeusedassuchinahearingortrial.Itcan,however,beusedasevidenceasfarasthereisapriorinconsistentstatementmadebytheclaimantastoamaterialfactorrelevantmattertotheissueinlitigation.O.C.G.A.§24-9-83.Itshouldbenotedthatbeforecontradictorystatementsmaybeprovenagainsttheclaimant,unlesssuchstatementsarewrittenandmadeunderoathwithsomejudicialproceedings,thecircumstances(time,manner,place,andpersonsstatedto)attendingtheformalstatementmustbecalledtotheclaimant’smindwithasmuchcertaintyaspossible.Thisusuallymeansthatarecordedstatementmustbeshowntothedeclarantorreadattheclaimant’shearing.

SurveillanceisanothertopicforwhichthereisnocaselawdirectlyonpointinthestateofGeorgia.Generallyspeaking,theStateBoardhastakenthepositionthatwhenthereisadisputeoverthediscoverabilityofsurveillance,theemployerandinsurerareentitledtotakeadiscoverydeposition,andfollowingthat,thesurveillancemustbeproduced.Thisseemstobeacompromisebetweenthepositionssomedefensecounseltake,thatthesurveillanceisattorneyworkproduct,therefore,privileged,orconversely,thepositionthattheclaimant’sattorneysometimestakes,thatthesurveillanceisantherrecordedstatementoftheclaimant,andassuch,iscompletelydiscoverable.

Themajorityofjurisdictionsthathavedeterminedtheissueastowhetherornotvideosurveillanceisdiscoverableholdthatitis.19ALR4th1236.Mostofthejurisdictionsfavoringdisclosureplacealimituponit,andthisissimilartothepositionthattheStateBoardhastakeninthepast,thattheproductionofthesurveillancetapewillnotberequireduntilaftertheemployerandinsurerhashadareasonableopportunitytoconductadeposition(post-surveillance)oftheclaimant.Therearetwocasesdirectlyonpointwhichoutlinetheintersectionbetweensurveillanceandworkproductdoctrine.Ranft v Lyons,163Wis.2d282(Wisc.App.1991)andHikel v Abousy,41FRD152(d)Md.(1966).TheCourtinRanftreasonedtherehadtobeabalancebetweentheworkproductdoctrineandtheneedtoconductdiscoveryinanopenmanner,findingthatthe“strategicdecisiontoinvestaclient’sresourceson…videosurveillanceisprotectedworkproduct.Thedecisionnotonlyreflectsthelawyer’sevaluationofthestrengthsorweaknessesoftheopponent’scase,butalsothelawyer’sinstructionstothepersonorpersonsconductingthesurveillancealsorevealsthelawyer’sanalysisofpotentiallyfruitfulareasofinvestigation.”Ranft,163Wis.2d301.


Interestingly,theRanftCourtrejectedthecompromisepositionofallowingpost-surveillance/pre-productiondepositiontestimonyfromtheclaimant(thepositiontheStateBoardhasadopted).Conversely,theHikelCourtfoundthesurveillancematerialstobenon-discoverableinsofarasrevealingtheirexistenceinresponsetoaninterrogatorywouldpreventeffectivecross-examination.

Ontheoppositeendofthespectrum,severalstateshavetakenthepositionthatsuchmaterialsarediscoverabledespitethefacttheyareworkproduct.Forexample,inCabral v Arruda,556A.2d.47(R.I.1989),theSupremeCourtofRhodeIslandheldsurveillancematerial,whileworkproduct,wasdiscoverableuponashowingofunduehardship.TheCourtreasonedthatthesematerialsbeingusedtosurpriseaplaintiffordefendantattrialpotentiallycreatedunduehardship,andassuch,thematerialswouldbediscoverableundertheunduehardshipdoctrine.AsimilarconclusionbydifferentreasoningwasarrivedatbytheNewJerseySupremeCourtinJenkins v. Rainner,69N.J.50(1976).TheJenkinsCourtreasonedthatwhilethematerialswereworkproduct,theinabilityofthemovanttofilmhisprioractivitiescreatedunduehardshipinacquiringsubstantiallythesamematerials,therefore,theexemptioncreatedbythedoctrinewouldbelifted.

Medicalrecordsfortheinjury/accidentinquestionintheadjuster’sfilesarealwaysdiscoverableunderBoardRule200,andbarelydeservementioninthisarticleotherthantostatethatallmedicalrecordsshouldbeproducedassoonaspossible,again,topreventunduehardship.ThisseemsimplicitintheRuleandintheGeorgiaCivilPracticeAct.Thisisespeciallysoinworkers’compensationclaimssincephysiciansarenotcompelledtotestifyaswitnessesathearings,therefore,therelianceupontheserecordsisevengreaterbybothparties.Thussaid,however,adifferentapproachmightbetakenwithrespecttomedicalrecordswhichdonotpertaintotheworkaccident/injuryinquestion.Certainlythisisatopicwhichremains“inplay”intermsofthescopeofamedicalrecordsrequestbyinsurersforaclaimant’smedicalrecords,andthesameprivacyconcernsmustbegivenconsiderationwhenanadjuster’sfileisrequested.Certainlyanyrequestingclaimantwhoseekstolimitthemedicalrecordsbydateandinjuryoforigincannot,atthesametime,demandallthemedicalrecordsintheadjuster’sfileoutsideofthatlimitation.Sucharequestmight,infact,opentheclaimantupforthediscoveryofhisorherownentiremedicalhistoryasheorshehassuddenly“openedthedoor”intermsofwaivingasupposedprivilege.

There,ofcourse,willbemultiplecorrespondencesfromattorneysandotheragentsintheadjuster’sfile.Thesematerialsareclearlyprotectedundertheattorneyworkproductdoctrine.Whiletheattorney/clientprivilegeisofteninvokedasaprivilegetothesematerials,itshouldberememberedthattheattorney/clientprivilegeonlyappliestotestimony.Tenet Healthcare Corp. v Louisiana Forum Corp.,273Ga.206,538S.E.2d441(2000);GeorgiaRulesofProfessionalConduct,Rule1.6(a).Whilenopartyorwitnessshouldberequiredtomakediscoveryofthe

adviceofhisprofessionaladvisorsorconsultationwiththem[O.C.G.A.§24-9-27(c)],becausethecommunicationsarewrittenandproducedwithstrategyusuallyinmind,theworkproductdoctrineisthemoreproperobjectiontoassert,andindeed,suchcorrespondenceshouldbeprotectedunderthesame.Ofcoursetheattorney/clientprivilegewouldlikelybartheproductionofthesematerialsaswell.Thussaid,attorneycorrespondenceintheadjuster’sfileclearlyisworkproductandnotdiscoverablewithoutunduehardship,andeventhen,portionsofsuchmaterialswilllikelyberedactedbytheCourtafteranin camerainspection.

Last,butcertainlynotleast,aretheadjuster’snotes.Thereisalotofconfusionandcontroversysurroundingtheirdiscoverability,andGeorgiacourtshavenotdeterminedonewayortheotherwhetherornottheyarediscoverable(notunlikesurveillance).Adjuster’snotesgenerallycontainabroadvarietyoftopicsincluding,butnotlimitedto,notesofconversationswiththeircounsel,excerptsofcorrespondencefromcounselandcommunicationswithemployerrepresentativesconcerningthefactsoftheclaimindispute.Itwouldcertainlyseem,therefore,thatatleastpartsthesenotesarebeingkeptinpreparationfortrialusebytheattorneyinvolved,andthereforefallundertheworkproductdoctrine.

Whilemanycounselseekingthesematerialswouldpointoutthatthisisnot“product”preparedbydefensecounsel,trialpreparationmaterialsfallingundertheprivilegealsoincludereportspreparedbythoseworkingfortheattorneyortheclientrelated to anticipated or pending litigation.InTobacco Road, Inc. v Callaghan,174Ga.App.539,330S.E.2d768(1985)(emphasisadded),theinvestigator’sreportofawitness’statementwasdeemedprivileged[See,also,Copher v Mackey,220Ga.App.43,467S.E.2d362(1996)]andstatementstakenbyaninsuranceinvestigatorinanticipationoflitigationwerepartofprotectedworkproduct.Adjuster’snotesarecertainlypartoftheprocessforpreparingforlitigationand/ortrial,anddocumentevidence,strategyandinformationtobeusedinthesame.Again,ifthemovantpartycanprovebothsubstantialneedandunduehardshipinacquiringtheequivalentmaterialselsewhere,itispossiblethatthenotesmighthavetobeproduced,buteventhen,thetrialjudgewilllikelyperformanincamerainspectiontoexcludeallotherwiseprivilegedandprotectedmaterialswithinthenotes.Suchaninspectionmightmakethenotesworthlesstothemovantafterredactionbythejudge.

ItwouldcertainlyseemundertheCallaghanandCophercasesadjusternoteswouldbeworkproduct.Thus,withoutashowingofunduehardshipbythecounselfortheplaintiff,thenoteswouldbedeemednon-discoverable.Evenifunduehardshipwereshown,theworkproductnotes,notunlikeattorneycorrespondenceasoutlinedabove,wouldlikelyfirstbesubjecttoanen camerainspectionbytheCourtunderthesamemandatescitedaboveinthattheCourtshallprotectfromdisclosureallmentalimpressions,etc.,inthegenerationoftheproduct.Inotherwords,and

Winter 2011 21

insumandsubstance,Georgiacourtshavenotbeenverygenerouswithrequestsforsuchreportsormaterials,andlikely,anAdministrativeLawJudgewouldnotbeeitherwithoutshowingofunduehardshipbytherequestingparty.

The Interaction of the Right to Discovery and the Right to PrivacyHowmuchinformationaboutherprivatelifeisaninjuredworkerrequiredtorevealsimplybecauseshegotinjuredatwork?ThestandardforadepositionissetbyO.C.G.A.§9-11-26thesameasitisforotherdiscoverymatters.Itisessentiallyathreeprongedtestinthatthemattermustbe“relevanttothesubjectmatterinvolvedinthependingaction”,“reasonablycalculatedtoleadtothediscoveryofadmissibleevidence”and“notprivileged.”Theissueofprivilegewillnotbediscussedspecificallyinthisportionofthisarticle,butitisobviouslyimportanttoconsiderwhetherinformationisprivilegedindepositionsorotherformsofdiscovery.

Itisoftendifficulttodeterminewhethersomethingisbothrelevantandreasonablycalculatedtoleadtothediscoveryofadmissibleevidence.However,itisimportanttorememberthat“relevance”and“reasonablycalculated

toleadtothediscoveryofadmissibleevidence”aretwoseparatestandards.UnderO.C.G.A.§9-11-26,theinformationsoughtmustberelevantandadmissibleorreasonablycalculatedtoleadtothediscoveryofadmissibleevidence.“Themostacceptabletestforrelevancyiswhethertheevidenceofferedrendersthedesiredinferencemoreprobablethanitwouldbewithouttheevidence.”11Ofcourse,onemuststartwiththecurrentlitigationissuestodeterminewhatisrelevant.Toooften,discoveryisnotnarrowlytailoredtothependingissues.WhiletheClaimant’spreviousinjuriestothesamepartofthebodyandfunctionalcapacityarecertainlyrelevantinadepositioninanallissuesclaim,theyarenotrelevantinaclaimwherethedeterminationofthecorrectaverageweeklywageistheonlyhearingissue.

Eveniftheinformationsoughtisrelevant,admissible(orreasonablycalculatedtoleadtothediscoveryofadmissibleevidence)andnotprivileged,theinformationstillmaynotbediscoverable.TheStateofGeorgiarecognizestherighttoprivacy.Infact,theSupremeCourtofGeorgiawasthefirstcourtofhighestresortinthecountrytorecognizetherighttoprivacy.TherightofprivacyinGeorgia“isfarmoreextensivethantherightofprivacyprotectedbytheU.S.Constitution…”12This

righttoprivacyaffectsdiscoverybecause“thecompetinginterestsinanindividual’srighttoprivacymustbeaccommodatedinthediscoveryprocess.”13

Howshouldthecompetinginterestsinanindividual’srighttoprivacybeaccommodated?Theremustbeabalancingtestbetweentheneedfortheinformationofthepartyseekingdiscoveryandtheprivacyinterestsofthepartyprovidingtheinformation.Withregardtoworkers’compensation,thefilingofaworkers’compensationclaimdoesnotforcesomeonetomakeherentirelifeanopenbook.Iftheemployee’sinterestinkeepingtheinformationprivateoutweighstheemployer’sinterestindiscoveringtheinformation,thentheinformationshouldnotbediscoverable.Injuredworkersareoftenstigmatizedbyemployers,co-workersandothersforfilingWorkers’Compensationclaims.Theyaresometimesmadetofeellikeitistheirfaultthattheygothurt.Theyhaveastronginterestinkeepingprivateinformationthatmayonlybemarginallyrelevant.

Thatprivacyinterestisespeciallyimportantindiscovery.Whenan


injuredworkerrevealspotentiallyembarrassinginformationtoherattorney,thatinformationwillnotberevealedelsewhere.Whenpotentiallyembarrassinginformationisrevealedinadeposition,theinjuredworkermustrevealthatinformationtotheotherattorney,someonesheknowsishiredtoworkagainsther.Thatinformationisalsorevealedtothecourtreporter.Itwilllikelytoberevealedtoemployeesoftheemployerandtheinsurerasclientsoftheattorney,anditcancertainlygoevenfurtherthanthat.ThestrongrighttoprivacyinGeorgiashouldprotectinjuredworkersfromhavingtorevealmarginallyrelevantinformationwhentheyhaveaninterestinkeepingthatinformationprivate.

Proper Subpoena UseGenerallyspeaking,subpoenasareanorderfroma

courtcompellinganindividualtoprovidetestimonyonamatterbeforeit.Asofficersofthecourt(s),itisincumbentuponusassuchtousethesubpoenapowerofthecourt(s)inamannerthatisjustandwillaidinthefurtheranceofthecasesbeforeit.UnfortunatelythereareanumberofattorneysinGeorgiawhoissuesubpoenasinanabusivemannerandcertainlydonotissuethemproperly.Outlinedbelowaretheproperproceduresfortheutilizationof

subpoenastosecuretheattendanceofwitnesses,toprocureandtopreserveevidence.

Title24,Chapter10,oftheCodeofGeorgiasetsforththeproceduresbywhichtouseasubpoenaforlitigationpurposes.O.C.G.A.§24-10-20(a)mandatesthateverysubpoenashallbeissuedbytheClerkundersealoftheCourtwhosepoweritisissuedfrom.Inworkers’compensation,we,ofcourse,haveourownsubpoenasinformthatcanbeacquiredfromtheStateBoard/ICMS.Whenserved,itisimportanttonotethatforwitnesses,thepowerofthesubpoenatocompeltheirattendanceonlyextendstothelinesofthestateofGeorgia.O.C.G.A.§24-10-21.Inotherwords,out-of-statewitnessescannotbecompelledbyuseofaStateBoardsubpoena.Subpoenasforproductionofdocumentaryevidencearegovernedby§24-10-22,andundersection(a),asubpoenaissuedtoapersonforwitness’testimonymayalsodirectsuchpersontoproducebooks,papers,documents,orothertangiblethingsdesignatedonthesubpoena.Section(b)oftheStatutenotesthattheCourtissuingthesubpoena,uponwrittenmotionfiledbytheopposingpartybeforethetimespecifiedinthesubpoena,mayquashormodifythesubpoenaifitis“unreasonableandoppressive,”orconditionallydenythemotionupontheadvancementbythepersoninwhosebehalfthesubpoenaisissuedthereasonablecostofthematerialsrequested.

Asubpoenamaybeservedbyanysheriff,deputy,orbyanyotherpersonnotlessthan18yearsofage,proofofwhichmaybeshownbyreturnorcertificateendorsedonacopyofthesubpoena.O.C.G.A.§24-10-23.Subpoenasmayalsobeservedbyregisteredorcertifiedmailorstatutoryovernightdelivery,andthereturnreceiptshallconstituteprima facieproofofservice.Id.Itisimportanttonotethatserviceuponapartymaybemadebyservinghiscounselofrecord.Id.

Wheresubpoenasareoftennotservedproperlyiswhenfeesandmileagearenotpaid.UnderO.C.G.A§24-10-24,awitnessfeeshallbe$25 per day.Thepaymentofthefeeshallnotbedemandedasaconditionprecedenttotheattendanceofawitnessresidingwithinthecountywheretestimonyistobegiven.Whenawitnessresidesoutsidethecountywherethetestimonyistobegiven,however,theserviceofthesubpoena,inordertobevalid,mustbeaccompaniedbythetenderofthefeeforoneday’sattendance($25)plusmileageof$0.20permilefortravelingexpensesforgoingtoorfromthewitness’placeofresidencebythenearestpracticalroute.Inotherwords,unlessthewitnessliveswithinthecountywherehisorherattendanceiscompelledbythesubpoena,non-paymentofbothoneday’switnessfeeandmileagewilldeemtheserviceofthesubpoenatobeinvalid.

Finally,practitionersmustconsidertheenforcementmechanismunderTitle24,Chapter10.UnderO.C.G.A.§24-10-25,subpoenasmaybeenforcedbyanattachmentforcontemptwhichcanresultinafinenotexceeding

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$300.00andimprisonmentofnomorethan20daysifthewitness,afterbeingproperlyserved,failstoattend.However,acaveattothissubsection(SectionA)isthatinallcasesunderthissectionoftheCode,theCourtwillconsiderwhetherunderthecircumstancesofthecasethesubpoenawasservedwithin“areasonabletime.”Whilethisvariesfromcasetocase,innoeventshallareasonabletimebelessthan24hourspriortothetimethatappearancewasrequiredbyserviceofthesubpoena.

Insum,practitionersshouldusesubpoenassparinglyandonlyinclearfurtherancetheirclient’scase.Forexample,subpoenasshouldnotbeissuedtotheentirestaffofanemployerorinsurerto“scare”themintosettlement,norshouldtheybeissuedtotheentirefamilyofanemployeeforthesamepurposes.Thediscoveryprocessleadinguptoahearingortrialshouldgivebothsidesampleopportunitytoexamineanywitnessesunderoath,anddeterminewhocanbestadvancetheirclient’sinterestsatahearingortrial.Surprisingtheothersidewithsubpoenaswhicharenotissuedwiththispurposeinmind,orevenservedproperly,doesn’tdoeithersideanygood,andrisksangeringthesittingjudge.

(Endnotes)1. SeeBurchv.TiogaManorNursingHome,649So.2d545

(La.Ct.of Appeals,3rdCir.1994)(adjusternotesinhearingonissueof assessedattorney’sfeesforunreasonabledefenseandpenalties);

2. GeneralMotorsCorp.v.Conkle,226Ga.App.34(1997).

3. AtlantaCoca-ColaBottlingCo.v.TransamericaIns.Co.,61F.R.D.115(NDGa.1972).

4. SeeDepartmentof Transp.v.HardawayCo.,216Ga.App.262(1995)(discussingLowe’sof Ga.v.Webb,180Ga.App.755(1986)andexplainingthatroutineactivitieswerenotdoneinanticipationof litigationbutactivitiesinresponsetounusualcircumstancesorthreatsof litigationqualifiedasanticipationof litigation)

5. Lowe’sof Georgia,Inc.v.Webb,180Ga.App.755(1986).

6. TobaccoRoad,Inc.v.Callaghan,174Ga.App.539(1985).

7. Jonesv.Scarborough,194Ga.App.468(1990).

8. If ithasbeenmodifiedorenhancedtobesomethingotherthanjustarecordingof theinjuredworker’sactivities,thenthisisacompletelydifferentproblem.

9. SeeTruittv.Mason,189Ga.App.24(1988)(itwasimproperfortrialcourttoenterorderrequiringdefendanttofirstbedeposedbyplaintiff beforeplaintiff producedtranscriptof trafficcourtproceedings).

10. Examplesof suchinformationthatcouldbewithheldcouldincluderecordedstatementsof anyparty,medicalrecords,correspondenceseekingpaymentof medicalbills,etc.

11. SouthernRy.Co.v.Lawson,256Ga.798,802(1987).

12. Powellv.State,270Ga.327(1998).

13. SouthernOutdoorPromotions,Inc.v.NationalBanner,Inc.,215Ga.App.133(1994).

Presort First ClassU.S. Postage

PaidAtlanta, GA

Permit No. 1447

State Bar of GeorgiaWorkers’ Compensation Law SectionKelly A. Benedict & Jo H. Stegall III, Editors104 Marietta Street NWAtlanta, GA 30303

In This Issue

Preparing the Record for Appeal and Tips for Appellate Practice at the Board ................................. 1

Understanding CMS’ WC-MSA Review Thresholds & Addressing “Non-Threshold” Cases ..................... 4

Message from the Chairman ................................... 10

Message from the Chair .......................................... 11

ICMS Update .......................................................... 12

Idiopathic Injuries and the Harris Test ................... 13

Distinguished Service Award .................................. 16

This and That in Discovery .................................... 17