Navigating Recent Legal Decisions: Impacts on Adjusters in Idaho Workers’ Compensation Claims

Boise, ID (WorkersCompensation.com) -- The Idaho Industrial Commission Annual Seminar on Workers' Compensation, held in Boise, Idaho, featured a highly anticipated session titled "The Impact of Recent Decisions on Adjusting Claims." This segment aimed to give adjusters in-depth insights into how recent Industrial Commission and Idaho Supreme Court decisions practically affect their work. The session, conducted by Mark Peterson and Nikki O'Toole from the law firm Hawley Troxell, took place on May 25, 2023.

Several critical legal cases that have significant implications for adjusters in Idaho were discussed by Peterson & O’Toole. The following summaries provide an overview of each case and highlight the key takeaways for adjusters:

Thompson v. Burley Inn:

In Thompson v. Burley Inn (IC No. 2019-013978), the Industrial Commission accepted a hip replacement surgery request by a younger claimant, despite the defense expert's opinion that the injury was unrelated to the accident. The Commission awarded the claimant all benefits without applying an offset for self-employment income due to insufficient evidence from the defendants. Adjusters were advised to rely more on medical expert opinions than on a claimant's subjective report of the mechanism of injury. It was also recommended that adjusters request evidence of self-employment income to reduce time loss benefits appropriately.

Sharp v. Thomas Brothers Plumbing:

The case of Sharp v. Thomas Brothers Plumbing (170 Idaho 343) involved a claimant who experienced weight gain after a compensable spine injury. The defense expert argued that the weight gain resulted from the claimant's conduct, not the accident. However, the Idaho Supreme Court disagreed and considered the weight gain a compensable consequence of the accident. Adjusters were advised to prioritize medical expert opinions regarding the causal connection between the injury and any subsequent conditions or symptoms. It was also emphasized that adjusters should consider the claimant's subjective pain when assigning permanent restrictions and ensure that the expert's opinion adequately addresses this aspect.

Herrera v. State of Idaho, ISIF:

Building upon the principles established in the Sharp case, the Industrial Commission cited Sharp in the case of Herrera v. State of Idaho, ISIF (IC 2016-004230). The Commission held that the claimant failed to definitively establish the required causal connection between an ankle injury and the accident. Adjusters were advised to recognize the importance of establishing a clear causal relationship between the accident and the treatment being sought by the claimant.

In addition to the case discussions, the seminar provided adjusters with best practices in various areas of their work:

Requesting IC § 72-433 Medical Examinations:

Adjusters were reminded of the requirement for injured workers to submit to medical examinations requested by the employer/surety at reasonable times and places. To establish "reasonableness" when requesting these examinations, adjusters were advised to provide options for a reasonable time and location. Additionally, it was recommended that adjusters ensure the physician's qualifications conducting the examination and request confirmation from the worker regarding their availability.

Establishing "Good Cause" in IME Requests:

When requesting multiple independent medical examinations (IMEs), adjusters were informed that in addition to demonstrating reasonableness, they might need to establish "good cause" for these examinations. This could include conflicting opinions, complicated injuries, conflicting treatment recommendations, newly asserted body parts, or significant changes since the last IME. Adjusters were encouraged to provide the necessary information to support the "good cause" for the requested IMEs.

Stopping or Curtailing Time Loss Benefits Under IC § 72-403:

Adjusters learned that under Idaho Code Section 72-403, they could only pay time loss benefits if reasonably suitable work is offered to the injured worker in compliance with physician-imposed restrictions and the worker unreasonably refuses the job offer. Adjusters were advised to issue written "bona fide" job offers with specific details such as the job title, description, pay rate, benefits, hours, reporting instructions, and contact information. It was recommended to request the injured worker's signature and establish clear instructions regarding restrictions and reporting any changes.

Establishing Burden of Proof in Job Search Efforts:

The seminar addressed the issue of establishing the burden of proof when an employer/surety claims that an injured worker has unreasonably failed to seek suitable work, potentially allowing the suspension of time loss benefits. While no specific case law or statutory authority exists on this matter, adjusters were provided with suggestions to support their burden of proof. This included submitting a written request for a list of job applications within a specified timeframe and referring the injured worker to the Idaho Commission on Human Rights.

Workers' Comp. 101: In Idaho, once an employer has shown that a kind of suitable work exists, then the employer must introduce evidence that there is an actual job within a reasonable distance from the claimant's home that he is able to perform or for which he can be trained. See Rodriguez v. Consolidated Farms, LLC, 390 P.3d 856 (Idaho 2016).

Impairment and the 'Averaging Rule'

This presentation highlighted the "averaging rule" mandated by IDAPA (Idaho Administrative Procedures Act) 17.01.01.402.02. This rule requires that when multiple impairment ratings are assigned to a body part on an accepted claim, the ratings must be averaged unless "good cause" to deviate is shown. Adjusters were advised to be aware of the "averaging rule" and the exception to its application in "manifest injustice" cases under IDAPA 17.01.01.402.03.

Peterson and O'Toole concluded their presentation with a discussion of the Damien Order (issued October 13, 2022) that clarified the application of the "averaging rule." It emphasized that the rule is mandatory in undisputed compensability cases and outlined the process for relief if an aggrieved party seeks to deviate from the rule. Adjusters were reminded that failure to apply the "averaging rule" appropriately might result in liability for attorney's fees and that the burden of proof lies with the claimant during a hearing.

The segment aimed to equip adjusters with the knowledge and practical recommendations necessary to navigate the legal landscape in workers' compensation claims. By addressing recent legal cases and providing best practices, the session empowered adjusters to make informed decisions while adhering to the legal precedents set by the Industrial Commission and Idaho Supreme Court. Adjusters left the seminar with a clearer understanding of their roles and responsibilities in adjusting claims in Idaho.

Share This Article: