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Case Name: January 2017 – Maldonado, Maria v Caraustar
Handling Attorney: 
Joe Needham
Case No.: 
08 WC 34400
Date of Accident:  
July 2008
Potential Exposure: Seven-figure permanent total disability.
Arbitrator Findings: $12,300 award; 6% of the person, 3.5% of the leg.

 

Dear Clients:

 

We are pleased to share with you our most recent victory in front of the Illinois Workers’ Compensation Commission:

 

Case Summary & Background:

 

Petitioner’s claim for permanent total disability benefits denied, a half-million dollars in medical treatment denied as excessive leaving the medical providers without recourse for payment against either party, and a seven-figure exposure reduced to a $12,300 total award.

Petitioner suffered a knock-down fall to the ground resulting in a laceration to the lower leg and minor spinal complaints. She returned to regular work duties for roughly one year before resuming treatment and eventually received lumbar and cervical spinal fusion surgeries. Upon Petitioner’s resumption of care for spinal complaints, Respondent secured Section 12 opinion evidence and Section 8.7 prospective Utilization Review evidence establishing Petitioner was MMI for her injuries, and that any form of treatment including surgical spinal intervention was unnecessary and unwarranted for Petitioner’s condition, regardless of cause. Respondent’s Section 12 expert cautioned against surgical intervention in that surgery would not improve a non-surgical condition and normal is a condition that cannot be improved upon. Following each surgery Petitioner failed to improve, and post-operative Sections 12 and 8.7 evaluations again found surgical intervention unwarranted and unnecessary, with Respondent’s Section 12 expert characterizing as “unconscionable” the treatment to which Petitioner was unnecessarily subjected.

 

Legal/Claim Strategy:

 

Accepting Respondent’s medical evidence over Petitioner’s surgeon while reciting several factual errors made by the surgeon in support of his treatment, the Arbitrator found Petitioner reached MMI for work-related spinal strains and a lacerated lower leg shortly after returning to unrestricted work duties several weeks after the occurrence, and denied all subsequent claims for benefits. Relying on prospective and retrospective Section 8.7 UR denials of certification for Petitioner’s multiple spinal surgeries and finding the treatment excessive and unwarranted, the Arbitrator denied payment of Petitioner’s surgical bills against either party, leaving the surgeon and corollary treaters without recourse for $489,583.48 in medical treatment and reducing seven-figure global claim exposure to a comfortable five-figure settlement.

 

Significance:

 

The result was no accident. Detailed initial investigation into the occurrence by the employer, years of diligent claims handling by the adjuster and prudent defense strategy make possible securing the right result in the face of potential overreach. Solid Section 8.7 Utilization Review evidence including prospective denial of certification is the best evidence in denial of treatment, and in this instance provided insulation for both parties against payment of unnecessary/excessive medical treatment expenses. Section 12 IME evidence was critical to defense success – it starts with not allowing conventional wisdom to choose the Section 12 expert because of popularity before the Commission. Respondent’s Section 12 opinion evidence was science-based, unassailable under cross-examination, and fully consistent with Section 8.7 Utilization Review protocol, even if not provided by one of the Commission’s favored experts. It was simply the better evidence because it was factually and medically accurate.

Defend your cases with a detailed accident investigation, a diligent claims handler, quality experts and skilled defense counsel. A truly objective IWCC Arbitrator will reach the right result.
Thank you for allowing us to share with you our latest successful trial result.  If you have any additional questions or thoughts about this decision, please do not hesitate to contact the undersigned or the handling attorney, Joseph R. Needham.