Workers’ Compensation Case Review: Second Bite at the Apple

Aug 21, 2014 | WC & Other Laws

Order that neither awards nor denies a benefit doesn’t bar insurer from challenging causation again.

Raul Sanchez suffered a serious motor vehicle accident in October 2005.  He treated with the company doctors, was placed at Maximum Medical Improvement without impairment.  He reopened his case in 2008 with the agreement of the insurance carrier.  When he had surgery for low back pain and right leg symptoms and sought to have his back surgery covered, the carrier refused.

Sanchez went to hearing and the Administrative Law Judge entered an Order determining that Sanchez had proven a change of condition, reopening the claim, and that the low back worsened condition was the  “a natural consequence of the claimant’s industrial injury rather than a pre-existing degenerative condition.”

After the order, Mr. Sanchez underwent additional medical treatment with Dr. Olson who eventually placed him at MMI with a 30% whole person impairment rating for the low back and left shoulder.  Sanchez underwent a Division Independent Medical Examination with Dr. Janssen.  Dr. Jannsen assigned a 24% impairment rating but stated that it was more likely than not that the need for the surgery was due to a pre-existing degenerative process instead of the motor vehicle accident.  Therefore Dr. Jannsen assigned a 0% impairment rating.

The insurance carrier requested a hearing, challenging the relatedness of the low back condition to the motor vehicle accident.

The claimant argued that the Order from the prior hearing prohibited the insurance carrier from litigating – again – causation.  The Administrative Law Judge disagreed.The Judge determined his prior order reopening the claim was not a final order since it neither awarded nor denied a benefit.  Thus the doctrines of issue preclusion did not prohibit the insurance carrier from challenging the relatedness of the lumbar impairment.

After a hearing, the Judge determined that Dr. Janssen was correct and upheld the 0% impairment rating.  The claimant appealed.

The Industrial Claims Appeals Panel affirmed.  Before reaching the merits, the Panel reviewed the three related, but distinct, legal arguments that are triggered whenever parties find themselves in front of an Administrative Law Judge on the same issues:

Issue Preclusion, also called collateral estoppel, bars parties from re-litigating issues thathave been previously decided in an earlier case between the same parties.  Issue preclusion completely bars re-litigating an issue if the following four criteriaare established: (1) the issue sought to be precluded is identical to an issue actuallydetermined in the prior proceeding; (2) the party against whom issue preclusion isasserted has been a party to or is in privity with a party to the prior proceeding; (3) there is a final judgment on the merits in the prior proceeding; and (4) the party against whom the doctrine is asserted had a full and fair opportunity to litigate the issue in the prior proceeding. Sunny Acres Villa, Inc. v. Cooper, 25 P.3d at 47.

Claim Preclusion, often referred to as res judicata, a judgment on the merits in a prior suit bars a second suit involving the same parties or their privies based on the same cause of action. Pomeroy v. Waitkus, 183 Colo. 344, 350, 517 P.2d 396, 399 (1973); see also McLane Western, Inc. v. Dep’t of Revenue, 199 P.3d 752, 756–57 (Colo. App. 2008). A claim in a second judicial proceeding is precluded by a previous judgment where the following factors are satisfied: (1) finality of the first judgment; (2) identity of subject matter; (3) identity of claims for relief; and (4) identity of or privity between the parties to the two actions. Loveland Essential Group, LLC v. Grommon Farms, Inc.,  11CA0722 (Feb. 2, 2012), 2012 COA 22.

The law of the case doctrine is a “discretionary rule of practice … based primarily on considerations of judicial economy and finality.” Brodeur v. American Home Assurance Co., 169 P.3d 139, 149 (Colo. 2007). Under this doctrine, although a court is “‘not inexorably bound by its own precedents, prior relevant rulings made in the same case are generally to be followed.”’ In re Bass, 142 P.3d 1259, 1263 (Colo.2006) (quoting People ex rel. Gallagher v. District Court, 666 P.2d 550, 553 (Colo. 1983)). “When a court issues final rulings in a case, the ‘law of the case’ doctrine generally requires the court to follow its prior relevant rulings.” Giampapa v. American Family Mut. Ins. Co., 64 P.3d 230, 243 (Colo. 2003).

At the earlier hearing, the claimant’s lawyer did not ask the Judge to order the payment of any particular treatment or medical.  Thus the parties proceeded to a hearing on reopening only, and the Order was not a “final judgment.”  Thus the Judge was free to change his mind.

As always, how this or any other case we discuss in this blog would apply to your case depends on many more factors.  We urge you to call us to see if you are entitled to workers’ compensation benefits.  Workers’ Compensation is difficult, confusing, and very complex.  Kaplan Morrell has helped thousands of injured workers since 1997 get the benefits they deserve.   Contact us here or call us at 303-780-7329 for your FREE CONSULTATION.