In Longshore claims, once a claimant establishes a prima facie case, he is afforded the Section 20(a) presumption that his alleged injury is causally related to his employment. This is a relatively low burden to meet and once met, the burden then shifts to the employer to rebut that presumption through substantial evidence that the claimant’s condition is not work-related. If an employer rebuts the presumption, the issue of causation may be resolved by an Administrative Law Judge (ALJ) using the evidence in the record as a whole with the claimant bearing the burden of persuasion by preponderance of the evidence.
To determine causation, medical opinions from a claimant’s treating physician have long been considered a crucial factor as courts have held that a treating physician’s medical opinion may be given special and deferential weight, especially when there is no substantial evidence to controvert the treating physician’s opinion.
However, the credibility of a claimant can diminish the weight of this opinion, especially when that provider relies on information from the claimant to form that opinion. This opens the door for another provider’s opinion to carry greater weight as illustrated in two recent decisions by the Benefits Review Board (BRB).
Salaam v. Ceres Marine Terminals, Inc.
In Salaam v. Ceres Marine Terminals, Inc., Claimant sustained injuries to his left hand, knee, and ankle when he slipped and fell exiting a van in June 2021. Claimant was immediately taken to a hospital to receive treatment and an x-ray of his left knee. Based on that x-ray and Claimant’s self-reported complaints, his treating provider found that Claimant required a left knee surgery for a meniscal tear as a result of the work incident.
Employer obtained a physiatrist who opined that the work incident only temporarily exacerbated a pre-existing degenerative meniscal tear. Employer also obtained an orthopedic surgeon, who had previously evaluated Claimant for left knee pain in January and April 2019 and opined that the meniscus tear was unrelated to the work incident based on prior x-rays and evaluations. These opinions sufficiently rebutted the Section 20(a) presumption. Further, Claimant testified that he did not have left knee pain prior to the June 2021 accident despite evidence of two left knee evaluations in 2019.
Because Claimant’s physician relied on Claimant’s inaccurate reporting of no prior knee pain, the ALJ gave greater weight to the opinions of the physiatrist and orthopedic surgeon obtained by Employer. The BRB affirmed the ALJ’s decision that Claimant did not establish his left knee meniscus tear was a work-related injury.
Kkunsa v. Constellis Group/Triple Canopy, Inc.
In another case, Kkunsa v. Constellis Group/Triple Canopy, Inc., an Ugandan Claimant filed a claim for psychological injury following his employment in Iraq. Claimant testified that he was exposed to traumatic events and as a result, he became violent towards his wife and child when he returned home in August 2010 and they left him. Claimant did not seek treatment until 2019 and testified that he had no recollection of becoming violent towards his family or his family leaving him until his treating provider informed him after months of treatment.
The ALJ noted that Claimant’s own alleged amnesia undermines his claim as Claimant’s treating provider’s reports are clearly based on Claimant’s own reporting. Further, despite testifying to nine years of memory loss, Claimant’s records made no mention of amnesia or memory loss. The ALJ found several other inconsistencies between Claimant’s testimony and medical reports.
In addition to these credibility issues the treating provider relied upon, the ALJ found that the treating provider’s records were frequently illegible and/or unsigned, contained little to no background information, and lacked specifics of Claimant’s treatment or progress. The notes followed a basic formula which offered little insight into the source, extent, or nature of symptoms. One note from a different provider, stated that Claimant’s symptoms “followed working in Iraq.” The ALJ found that this statement was temporal in nature and did not establish a definitive causal connection without further explanation.
In contrast, the neuropsychologist obtained by Employer, through her report and testimony demonstrated that she reviewed all records, spent considerable time interviewing the Claimant, and conducted significant testing. Her opinion was well reasoned and offered more than mere conclusions. The BRB found that the ALJ rationally weighed all the evidence and affirmed his finding that Claimant failed to carry his burden of proof that he suffered a work-related psychological condition.
Evaluating Medical Evidence
These opinions provide key takeaways when evaluating a claim. First, if there are any inconsistencies between what a claimant has stated or evidence suggests and the medical records of a treating provider, these inconsistencies should be explored to determine whether the findings of a treating provider are based on credible information.
Second, it is important when obtaining a second medical opinion, to ensure that the opinion is well supported with objective testing, review of all available medical records, and evaluation of the claimant. This combination of evidence could prevent a claimant from proving that their alleged injury is work-related.