Welcome to the first in a series of articles designed to be a refresher on various NC workers’ compensation presumptions. The first presumption we will be discussing is the presumption relating to an injured workers’ entitlement to medical compensation.
A common question is: “The claimant is at maximum medical improvement but wants additional medical treatment. Do we owe it?” Let’s explore the legal burdens and obligations on this question, shall we?
This very question came up in the seminal case of Parsons v. Pantry, Inc. case (126 N.C. App. 540 (1997)). In Parsons, the plaintiff, Effie Parsons, was working as an assistant manager when she was assaulted by two men. She was struck in the forehead and shot four times with a stun gun. This unfortunate incident occurred in 1991, and in 1993, the North Carolina Industrial Commission (NCIC), after a hearing, found that the plaintiff suffered a compensable injury by accident and awarded her medical compensation as a result of thereof. The Commission in its opinion specifically found and held that the plaintiff’s headaches were causally related to the compensable injury by accident. Neither party appealed from this decision.
The plaintiff continued to experience headaches and sought additional medical treatment which was denied by both the defendants and then by the NCIC, on the grounds that the plaintiff had failed to introduce evidence that her headaches as of the time of the second hearing were caused by her compensable injury. The Court of Appeals reversed, holding that the burden of proof rested not with the plaintiff but with the defendants. In short, the Court of Appeals established what is now known as the Parsons presumption: once compensability of an injury or condition is established, the plaintiff enjoys a presumption that any future or additional medical treatment (subject of course to the limitations set forth in N.C. Gen. Stat. 25.1) is related to the compensable injury by accident. Defendants can rebut this presumption by introducing evidence that tends to show that the current need for medical treatment is unrelated to the compensable injury but instead is due to some other reason or cause.
Thereafter, in response to a landmark NC Supreme Court case, Wilkes v. City of Greenville, 369 N.C. 730 (2017), which greatly expanded the Parsons presumption, the General Assembly amended NC Gen. Stat. 97-82(b) to specifically hold that an award of the Commission arising out of NC Gen. Stat. 97-18(b) or (d) (ie, a Form 60 or Form 63) “shall not create a presumption that medical treatment for an injury or condition not identified in the form … is causally related to the compensable injury” (emphasis added). While this statutory provision provides some protection to defendants, we nevertheless need to keep in mind that the presumption applies both in cases where there is a decision of compensability rendered by the Commission and also in cases where defendants admit a specific injury or condition by way of an IC Form 60 or 63.
However, while a workers’ compensation claimant enjoys a presumption that future medical treatment is related to a compensable injury or condition, it bears repeating that it is a rebuttable presumption and is not unlimited. While the plaintiff may not have to prove causation to obtain additional medical treatment, if defendants dispute this, the burden shifts to the employer to prove that the claimant’s need for medical treatment is unrelated to the compensable injury or condition. This will primarily be accomplished through expert medical testimony. For instance, in Miller v. Mission Hosp., Inc., 234 N.C. App. 514 (2014), the Court of Appeals agreed with the Full Commission that defendants had successfully rebutted the presumption that the plaintiff was entitled to additional medical treatment for a compensable back injury after reviewing surveillance evidence showing the plaintiff engaging in activities inconsistent with her complaints, and after a medical examination and medical testimony tending to show that the plaintiff’s initial compensable injury had resolved and she was no longer in need of medical treatment due to the injury.
If defendants rebut the Parsons presumption, the burden shifts back to the plaintiff to try to prove through competent medical evidence that the plaintiff’s claim for ongoing or additional medical treatment is related to the initial compensable injury.
Takeaway: injured workers enjoy a presumption that medical treatment for a compensable injury or condition is related to the workers’ compensation injury, even after maximum medical improvement, without having to prove causation but this presumption is rebuttable by defendants. Accordingly, consider obtaining surveillance to see if you can get evidence that the plaintiff’s medical issue or condition has in fact resolved, or try running an updated index to see if there have been any intervening accidents which may in fact be the reason for the renewed need and request for medical treatment.
