SUBROGATION – SALE OF THE LIEN

BACKGROUND

Colorado’s workers’ compensation subrogation statute, located at S 8–41–203, C.R.S., is poorly worded and has become more complex through legislative revisions over the years. At its heart, the statute allows payment of compensation under the Colorado Workers’ Compensation Act to operate as an assignment of a cause of action against another person or entity “not in the same employ” whose negligence or wrong produced injury or death for which benefits are paid. The right of subrogation applies to all compensation including medical, hospital, dental, funeral and other benefits. The assigned and subrogated case includes the right to recover future benefits. It extends to money collected from the third party that produced injury for all economic damages, physical impairment and disfigurement. The assigned and subrogated cause of action does not extend to money collected for non-economic damages awarded to the injured worker for pain and suffering, inconvenience, emotional stress or impairment of quality of life.

People familiar with workers’ compensation subrogation are aware of judicial apportionment between the injured worker and the carrier. Further, the carrier is responsible for any prorated share of fees and costs the injured worker incurred in obtaining a settlement or judgment from the third-party, should the carrier elect to not pursue the matter on its own. This can lead to significant uncertainty for the carrier in trying to determine whether to pursue the third-party on its own or come to an agreement with the injured worker for a percentage of gross or net recovery. In most circumstances the workers’ compensation case is open and moving forward while the third-party case is pending, whether filed or not. What to do with the third-party case is a complicated, multifaceted decision-making process; however, at least in some circumstances, the decision can be simplified by selling the recovery rights (although not technically a lien, I will refer to it as a lien in this article) to the defendant in the third-party case.

LIEN SALE EXAMPLE

I recently had a case where sale of the lien made sense. The injured worker’s claim had been closed by settlement. Therefore, the total amount of potential recovery was known. The case involved a car accident where the injured worker was hurt in a rear-end collision. The total amount of insurance to cover the loss and liability of the negligent driver was also clear. The injured worker was pursuing the negligent driver in the third-party case and the workers’ compensation carrier elected to not bring its own cause of action. In settlement discussions in the third party case, it was clear that the negligent driver’s carrier would offer little or nothing to settle the case despite clear liability. The third-party carrier was willing to go to trial over causation of injuries that were largely compensated under the workers’ compensation system. Given these circumstances, I spoke directly to counsel for the injured worker to try to broker a deal on a percentage of potential recovery. We could not come to an agreeable percentage. I advised counsel for the injured worker that I was in discussions with the negligent driver’s carrier to have it buy my carrier’s lien. Since I could not come to an agreement with the injured worker’s attorney, I simply sold my client’s subrogation lien to the defendant in the third-party case. This guaranteed recovery for my client. The third-party case went to trial and the injured worker recovered no damages. The defendant in the third-party case submitted trial briefs asserting some set-off against potential damages based on the lien it purchased. The trial court held off any determination of a set-off. In the workers’ compensation case we had paid approximately $100,000, split evenly between medical and indemnity benefits. We sold the lien for $30,000. At issue before the trial court in the trial briefs was the value of the purchased lien. Was the purchased lien worth $100,000 set-off against billed medical, lost wages and permanent impairment claimed as damages in the third-party case? In the alternative, was the lien worth $30,000 as some undivided lump sum that can be set-off against all awarded damages? It is clear why the trial judge elected to not answer these questions, but let the jury come back with a decision on damages. The trial judge would have a difficult time figuring out what the defendant purchased from the workers’ compensation carrier and what it was worth. The jury saved the trial judge that headache since they found liability, but no damages. Regardless of the trial judge’s ultimate conclusion, my client’s had successfully recouped 30% of their lien and halted their exposure for on-going litigation expenses.

RAMIFICATIONS OF THE SALE

Counsel for the injured worker tried mightily to argue that respondents should reimburse the injured worker out of the $30,000 sale proceeds to account for its share of attorney fees and costs in the unsuccessful attempt to recover against third-party. Counsel for the injured worker was unsuccessful in all of his attempts. There was simply no legal basis to require the workers’ compensation carrier to pay for a share of unsuccessful litigation by the injured worker. That stated there is an appeal to the argument that it is unfair for the workers’ compensation carrier that did not actively participate in the negligent third-party case, to derive benefit from selling its lien without paying for the work done in the third-party case, even though it was unsuccessful.

BOTTOM LINE

Sale of the workers’ compensation lien is a viable option of recovery for respondents holding a subrogation lien; nevertheless, sale of the lien should only be done in certain circumstances. Sale of the lien when the workers’ compensation case is still open would not be recommended. Sale of the lien, for practical purposes, reduces any amount that could be used to settle the third-party case. This makes it more likely that that case will go to trial where the lien value will be used against the injured worker. This is not a good position for the workers’ compensation carrier. The workers’ compensation carrier still has obligations to claimant under the workers compensation system and in an open workers’ compensation case it should probably not sell its lien to the defendant in the third party case.

As a result of the lien sale in my specific case, there are rumblings in the claimant/plaintiff bar that they may try legislatively to prevent the sale of liens generated from workers’ compensation cases. As of now, no such legislation has been introduced.

We always recommend discussing this legal strategy with your counsel prior to embarking on this path. Whether the sale of a subrogation lien is viable depends largely on the specific facts of each case.

The History of Workers’ Compensation Part II: The Rise of Workers’ Compensation Coverage

This second segment, of the three part series on the history of workers’ compensation law, briefly summarizes how the industrial revolution fueled the workers’ compensation system. The first resemblances of workers’ compensation insurance coverage primarily arose because of increased revolutionized industrial practices and socialist schisms in European political ideals. Around the 1860s, the industrial revolution was beginning to take hold in Europe; the American Industrial Revolution area would steam forward in the later part of the 1800s. Industrial imperial countries, specifically Germany, wrestled with growing the economics of their respective country while continuing to expand their empires. To achieve these goals, political leaders were required to balance the progressive social worker-centered ideals and traditional conservative business goals.

 

Observers credit Chancellor Otto von Bismarck of Germany as establishing Otto_von_Bismarckthe benchmark standards for workers’ rights in Germany in the early 1870s. Gregory Guyton explained that, although Bismarck was not a benevolent leader, the legislation passed under his tenure resulted from a compromise between traditional views on industry and the increasing pressures from the growing Marxist movement.  Bismarck spearheaded the Employer’s Liability Law of 1871 extending legal protection to workers in specific labor areas including mines and railroads. In 1884, Germany adopted the Workers’ Accident Insurance Act. It provided pensions to those unable to work because of non-occupational causes. The subsequent Public Aid Act provided disability benefits for workers unable to work as a result of an on-the-job injury.

 

By virtue of creating a monetary distribution system for injured workers, Otto von Bismarck’s movement also created immunity for employers from civil lawsuits. This was a divergent political and legal shift from the ideals of the popular socialist political camp. Hence, the early workers’ compensation laws contained the exclusivity of remedies similar to what can be found in today’s statutes. Alan Pierce, Workers’ Compensation in the United States: The First 100 Years (Lexis Nexis 2011).

 

As the industrial revolution grew in America in the 1880s, so did public awareness of the unsafe work conditions faced by the daily laborer. In 1906, a socialist political activist, Upton Sinclair, published the graphic novel expose’ The Jungle. The novel, which followed a family of immigrants working the Chicago slaughter houses and exposed the horrific working conditions, gained ubiquitous attention amongst progressives. In the wake of The Jungle, the U.S. Congress passed several federal laws aimed to protect the public working class and general consumers, including the Food and Drug Act of 1906.

 

Still, little was done in terms of workers’ compensation insurance coverage in America. Common law tort liability in civil courts was the only remedy available to a worker injured in the course of employment. The American legal system posed challenges to immigrant workers such as procedural and language barriers. An employer could still raise the defense of assumption of risk or contributory negligence as a bar to any momentary recovery an injured worker could be entitled to. In his article, Guyton points out that the federal Congress acted by passing laws such as the Employer’s Liability Act in 1906 and 1907. The Acts respectively mitigated the harsh contributory negligence laws.

 

Following this Congressional intervention into an otherwise laissez-faire American capitalism culture, several states including New York and Massachusetts attempted to pass state based workers’ compensation reform laws. These reformations ultimately failed. However, President, later Supreme Court Justice, Howard Taft acted upon entering office. Taft signed into law the Employer’s Liability Act of 1908. The purpose of the act was to protect railroad workers’ engaged in interstate commerce. Each state developed independent commissions on how to address the liability for an injury. Private agreements between employers and workers lead to contractual obligations for employers to pay medical expenses for on the job injuries while workers’ waived their right to sue in civil tort. It was in this climate that the workers’ compensation system based in state law arose in 1911, which will be the subject of the next article.

The Ongoing Dilemma of Intermittent FMLA Leave

Intermittent FMLA leave is a giant thorn in the side of human resource professionals Familyacross the country. The struggle is that not all intermittent leave requests are equal. Here’s a look at some of the most common scenarios, and how to handle them. The FMLA allows employers some flexibility in granting different kinds of intermittent leave. Employees are entitled to take it for serious health conditions, either their own or those of immediate family members. The law also allows use of intermittent leave for child care after the birth or placement of an adopted child, but only if the employer agrees to it. It’s the company’s call. It’s not always simple, however. If the mother develops complications from childbirth, or the infant is born premature and suffers from health problems, the “serious health condition” qualifier would likely kick in. As always, it pays to know the medical details before making a decision.

Eligibility Is Not Automatic

Companies can successfully dispute bogus employee claims to FMLA eligibility. Consider this real-life example:

A female employee in Maine said she suffered from a chronic condition that made it difficult to make it to work on time. After she racked up a number of late arrivals – and refused an offer to work on another shift – she was fired. She sued, saying her tardiness should have been considered intermittent leave. Her medical condition caused her lateness, she claimed, so each instance should have counted as a block of FMLA leave. Problem was, she’d never been out of work for medical treatment, or on account of a flare-up of her condition. The only time it affected her was when it was time to go to work.

The Court denied her claim for FMLA eligibility and indicated that intermittent leave is granted when an employee needs to miss work for a specific period of time, such as a doctor’s appointment or when a condition suddenly becomes incapacitating. That wasn’t the case here, the judge said – and giving the employee FMLA protection would simply have given the woman a blanket excuse to break company rules.
Cite: Brown v. Eastern Maine Medical Center.

Designating Leave Retroactively
In order to maximize workers’ using up their allotted FMLA leave, employers can sometimes classify an absence retroactively. For example, an employee’s out on two weeks of vacation, but she spends the second week in a hospital recovering from pneumonia. Her employer doesn’t learn of the hospital stay until she returns to work. But she tells her supervisor about it, who then informs HR. Within two days, HR contacts the woman and says, “That week you were in the hospital should be covered by the FMLA. Here’s the paperwork.” The key here is that the company acted quickly – within two days of being notified of the qualifying leave. The tactic’s perfectly legal, and it could make a difference in the impact FMLA leave time could have on the firm’s overall operation. It’s also an excellent example of the key role managers play in helping companies deal with the negative effects of FMLA.

Using Employees’ Paid Time Off
Employers should never tell workers they can’t take FMLA leave until they’ve used up all their vacation, sick and other paid time off (PTO). Instead, companies can require employees to use their accrued PTO concurrently with their intermittent leave time. Employers can also count workers’ comp or short-term disability leave as part of their FMLA time – but in that case, employees can’t be asked to use their accrued PTO.

The Transfer Position
Companies can temporarily transfer an employee on intermittent leave, to minimize the effect of that person’s absence on the overall operation. The temporary position doesn’t need to be equivalent to the original job – but the pay and benefits must remain the same. And, of course, the employee must be given his old job – or its equivalent – when the intermittent leave period’s over.

There is one large restriction – the move can’t be made if the transfer “adversely affects” the individual. An example would be if the new position would lengthen or increase the cost of the employee’s commute. This would adversely affect the employee. Instead, such transfers need to be handled in such a way as to avoid looking like the employer is trying to discourage the employee from taking intermittent leave – or worse yet, is being punished for having done so.

Cooperation
Although FMLA is certainly an employee-friendly statute, employers do have some rights when it comes to scheduling intermittent leave. For instance, employees are required to consult with their employers about setting up medical treatments on a schedule that minimizes impact on operations. Of course, the arrangement has to be approved by the healthcare provider. But if an employee fails to consult with HR before scheduling treatment, the law allows employers to require the worker to go back to the provider and discuss alternate arrangements.

The Firing Question
Yes, companies can fire an employee who’s on intermittent FMLA leave. Despite the fears of many employers, FMLA doesn’t confer some kind of special dispensation for workers who exercise their leave rights. Obviously, workers can’t be fired for taking leave, but employers can layoff, discipline and terminate those employees who violate company policies or perform poorly. When an employee on FMLA leave is terminated, the DOL decrees that the burden’s on the employer to prove the worker would have been laid off, disciplined or terminated regardless of the leave request or usage.

Reductions in Force
When an employer has a valid reason for reducing its workforce, the company can lay off an employee on FMLA leave – as long as the firm can prove the person would have been let go regardless of the leave. However, companies again should be prepared not only to prove the business necessity of the move, but to show an objective, nondiscriminatory plan for choosing which employees would be laid off.

Misconduct or Poor Performance
Employees on FMLA leave – of any type – are just as responsible for following performance and behavior rules as those not on leave. However, companies that fire an employee out on FMLA will be under increased pressure to prove that the decision was based on factors other than the worker’s absence. As such, courts might well pose employers a key question: Why didn’t you fire this person before he/she took leave? This is not an easy answer to explain before a jury if liability is threatened at trial. The good news is that a number of courts have upheld employers’ rights to fire employees on FMLA leave, even when the employee’s problems were first discovered when the employee went off the job. Nevertheless, companies should move cautiously if they are to terminate an employee currently out on leave due to misconduct or poor performance existing prior to the leave, but discovered after the leave begins.

History of Workers’ Compensation Law: Part 1, Ancient Beginnings

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The modern day workers’ compensation system has a long, and often dark, history. The concept of an individual’s right to recover monetary compensation for sustaining an injury caused by another is one of the oldest legal concepts in recorded human history. One observer has pointed out that “the history of workers’ compensation begins shortly after the advent of written history itself.” Gregory Guyton, “A Brief History of Workers’ Compensation,” Iowa Orthop. J, 1999, 19: 106-110. Guyton argues that, regardless of how professionals involved in the system “lament the difficulty” of its administration, understanding the history of the workers’ compensation system lends valuable perspective to its critical importance in the work place. This three part series, Ancient Beginnings, Industrial Revolution, and Modern America, will deliver the basic historical framework underpinning the workers’ compensation profession.

The first historical recording of law requiring payment of monetary compensation for bodily injury dates back to the Code of Ur-Nammu, which is the oldest surviving set of written laws. The Code of Ur-Nammu, which is written on stone tablets and currently on exhibit inHammurabi_Code Istanbul, originated in Mesopotamia sometime between 2100-2050 B.C, while under the reign of King Namma of Ur. The overarching goal of the code was to establish “equity in the land.” In doing so, King Ur dictated laws such as “if a man knocks out the eye of another man, he shall weigh out ½ of mina in silver” or 30 silver shekels. The code itself implies that the payment of compensatory awards applied to all aspects of daily life. The code also reflects the ubiquitous use of labor slaves, as it only provided for and only awarded monetary compensation awards to the slave owner, rather than the laborer, if the slave in the case sustained the injury.

The Code of Hammurabi, famously known for the harsh eye-for-an-eye decree, adopted the compensation-for-disability concept when instituted sometime between 1795-1750 B.C. Neither the codes of Kings Ur or Hammurabi appear to give an employer special exempt privileges. According to the Code of Hammurabi, if a man committed an unintentional assault or bodily harm against another free man, he need only be charged the value of doctor’s fees as a penalty. Rev. Claude Johns, “Babylonian Law”, 11th Ed. of Encyclopedia Britannic, (1910-1911). There were harsh penalties for careless and neglectful behavior on the part of those providing public services. For example, if an unskilled surgeon caused loss of life or limb, the surgeon’s hands were cut off. Scholars point out that the code also contained instances when compensation could be awarded based upon a schedule if the underlining injury was a result of neglect conduct. One can use their own imagination to lament on how this code was applied to individuals who engaged in careless actions that caused harm to their employees. The monetary compensation and respective legal codes only applied to free citizens. One explanation for the lack of specific work-place laws certainly is that the workers’ in the high intensity jobs, such as construction, were not entitled to legal protections due to their social position as property slaves.

Contemporary observers are part to turn of the century Greek, Roman, Arabic, and Chinese legal codes as the next step in the evolution of workers’ compensation law. Gregory Guyton notes that the ancient legal systems provided for compensation schedules for the loss of a specific body part based upon the schedule on compensation for the injury itself. The compensation given to an individual for loss of a body part was only based upon the scheduled award. The value of an impairment disability did not exist in antiquity. See Geerts, Achille, et. al., Compensation for Bodily Harm: A Comparative Study, (1977). For example, in Ancient Rome, the civil liability for causing physical impairment to another citizen was contained in the civil law delict codes. Whether one was held liable for damages, based upon the schedule, depended on the degree of fault of the offending party. The Roman delict provided the early foundations for negligence based personal injury compensation systems. By all accounts, these legal systems did not include remuneration for physical impairments (disability affecting an individual’s ability to perform a task or job), but only provided compensation for an actual injury.

Payment for an actual impairment, equivalent to modern impairment benefits, subtly arose in the pre-Renaissance feudal system. The payment of quasi-impairment compensation occurred when landlords would provide impaired feudal serfs compensation for disabling physical conditions. See Gayton, Supra. One not need think too hard on whether a serf was providing services to a lord at the time of the injury. The arbitrary award to a loyal serf stemmed from the feudal lords’ culturally imposed sense of honor and benevolent obligation to care for his servants. There is no definitive evidence to suggest that the royal elites in the time of Kings Ur or Hammurabi engaged in similar practices.

The Middle Ages and pre-industrial Renaissance Europe gave way to the birth of the English common law system. The slow reduction of enslaved and indentured laborers correlated to an increased number of persons (protected under the laws) entering into more labor-intensive jobs. The law needed to respond in turn. Guyton notes that early English Common law established three principles known as the “unholy trinity of defenses” to determine whether work place injury was compensable. First, the contributory negligent principle held that if a worker was in “anyway” responsible for an injury, the employer was not liable. Second, the “fellow servant” rule exempted an employer from liability when the workers’ injury arose out of the negligent conduct of a co-worker. Third, the “assumption of risk” rule permitted employers to enter into contracts with workers whereby the worker would waive the right to sue the employer for damages. Since employers would often enter into these agreements with workers when a job required exceptionally dangerous work, the waiver agreements became known as “death contracts.”

Hundreds of years later, the modern American workers’ compensation system eviscerated the three early English compensability laws. The lessons gleaned from antiquity reflect the slow growth of the compensation for injury system, which was born out of necessity to address growing disputes amongst those protected under the respective legal system. The next edition of Cup O’ Joe will discuss Part II, how the industrial revolution shaped the modern workers’ compensation system.

THIRD-PARTY RECOVERY (2 – 4 – 6 – 8 Let’s Go Subrogate!)

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As you are probably aware, the Colorado Workers’ Compensation Act has a statute giving a subrogation right to the payer of workers’ compensation benefits. This statute is § 8-41-203, C.R.S. Although referred to as a subrogation lien, it is actually a right of recovery that operates as an assignment. Once benefits are paid under the Act, that payment also assigns a right of recovery to the payer against a third party that may be responsible for the injury that generated a claim for which benefits are paid.

The right of recovery is independent of the injured worker’s right against the third party, meaning that the payer can bring its own cause of action, but the action is still derivative of the underlying workers’ compensation claim. This situation creates tension between the payer and injured worker relative to potential liability of a third party.

This short article gives an overview of what can be recovered along with some data over recoveries. Future articles will flesh-out workers’ compensation recovery problems.

What Can Be Recovered?dollar

The statute outlines what can be recovered. It states that the right to recovery exists to “all compensation and all medical, hospital, dental, funeral, and other benefits and expenses to which the employee or, if the employee is deceased, the employee’s dependents are entitled … for which the employee’s employer or insurance carrier is liable or has assumed liability.” The payer gets a right to recover future benefits paid and the right of recovery “…extends to money collected from the third party causing the injury for all: economic damages, physical impairment and disfigurement damages.” There are certain specific limitations to these recovery categories, but the statute makes a special exemption from recovery for amounts collected for “…noneconomic damages awarded for pain and suffering, inconvenience, emotional stress, or impairment of quality of life.” These amorphous damage categories cannot be subject to recovery by the payer in a workers’ compensation case.

As you can imagine, the struggle in subrogation in workers’ compensation is determining a fair distribution of any third party settlement or judgment between the injured worker and the payer of benefits since there is rarely, if ever, enough in settlement or judgment to fully compensate the injured worker and the payer. One mechanism to determine some of the allocation issues is known as a Jorgensen hearing, named after the case where this method of allocation was set forth. These hearings will be covered in greater detail in newsletters to come.

How Much Recovery Can Be Expected?

Colorado is not a very favorable state for third-party recovery of workers’ compensation benefits. Other states allow the payer to get paid first from any third party recovery, before an injured worker gets paid. Colorado does not allow this, but there are other reasons for low third party recovery. For instance, it is rare that an injury results entirely from the fault of a third-party. There is usually some degree of fault that can be assigned to the injured worker and to other potential non-parties that reduce the overall recovery, and sometimes even to the employer. If a carrier is pursuing a third party claim either with or without the injured worker, the worker’s and employer’s actions can reduce recovery. Further, to the extent that benefits were potentially overpaid, those amounts may not be successfully claimed as damages against a third party. A payer’s failure to mitigate its loss in the workers’ compensation claim by overpaying can also reduce recovery. Finally, and most importantly, judges and/or juries are not receptive to a payer (usually an insurance company) that paid benefits under a limited benefit package, trying to seek those amounts back from a third party.

A survey of the Jury Verdict Reporter from 2002 through present day shows that when a payer went as far as a jury verdict to try and recover against a third party, the amount claimed in recovery vs. the amount actually recovered was only 21%. Please note this is a limited sampling of recovery cases. In these cases defendants obviously felt strongly enough about their position to take the case to trial. Further, the Jury Verdict Reporter is not comprehensive of all cases taken to trial and the facts of each case are different. Taking all of these issues into account, this still demonstrates a less than favorable environment for recovery. If you would like a breakdown of this data, case by case, please email fcavanaugh@leekinder.com and I will forward it to you.

Bottom Line

Workers’ compensation is complicated and recovery of benefits paid only compounds the complication. It requires someone who understands workers’ compensation and liability matters. We have handled all aspects of recovery cases, including defending against them. Watch for future recovery topics in future newsletters. In the meantime, if you have any questions about this topic, please do not hesitate to call or email us.

Colorado Supreme Court Tackles Medical Marijuana

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The Colorado Supreme Court, one-week ago, issued a highly anticipated decision implicating employment law related decisions as they pertain to employees using lawful medical marijuana for activities outside the course and scope of employment. In the decision of Coats v. Dish Network, the Colorado Supreme Court, for the first time, provided its position on whether employers could make adverse employment actions against its employees who are lawfully using medicinal marijuana away from work. The Court held that even though medical marijuana is “lawful” activity in Colorado, such activity is not “lawful” under the federal law. As a result, employees may not assert protections under the Colorado Lawful Activities Statute.

In Coats, the Plaintiff filed a lawsuit against Dish Network for discharging him for his use of medical marijuana, green-cross-thmbR medical marijuana to treat painful muscle spasms caused by his quadriplegia.   Between 2007 and 2009, the Plaintiff worked for Dish Network as a telephone customer service representative. In May 2010, the Plaintiff tested positive for tetrahydrocannabinol (“THC”) during a random employee drug test. The Plaintiff informed Dish Network that he was a registered medical marijuana patient. Dish Network terminated the Plaintiff for testing positive for THC as a violation of the company’s drug policy.

The Plaintiff alleged a wrongful termination claim against Dish Network, pursuant to C.R.S. 24-34-402.5, which generally prohibits employers from discharging an employee based on his or her engagement in “lawful activities” off the premises of the employer, during nonworking hours. The case was dismissed by the trial court finding that, while medicinal marijuana was legal under state law, it was still illegal under federal law and thus, not a lawful activity. The Colorado Supreme Court has affirmed this decision and agrees with this conclusion.

Accordingly, the take away for Colorado employers is simple. Colorado employers may continue to enforce their drug policies against their employees who use medicinal marijuana and any adverse employment actions taken against them will not violate Colorado’s Lawful Activities Statute. It should be noted that this decision specifically did not address use of recreational marijuana, which Colorado has also made lawful. Nevertheless, it would be anticipated that the Court would treat recreational use no differently.  In other words, because both medical and recreational uses are still illegal under federal law, such activities still will not be “lawful” to support a claim under the Lawful Activities Statute.

For those interested in reading the opinion, please click the link below:

https://www.courts.state.co.us/userfiles/file/Court_Probation/Supreme_Court/Opinions/2013/13SC394.pdf

Researching Narcotic Prescription Information In Colorado

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A ubiquitous problem in workers’ compensation patient care, as well as in the general clinical healthcare setting, is an individual patient’s use, and potential abuse, of controlled prescription narcotics.  The Prescription Drug Monitoring Program (PDMP) is the State of Colorado’s secure, central electronic informational data base that records and tracks each pharmacist’s dispensement of controlled narcotics. In an effort to curb narcotic prescription abuse, as well as to improve overall clinical care, the state of Colorado recently revised its PDMP guidelines with the goal of promoting more accessibility to the PDMP’s recording and research functions.

Currently, medical professionals use the PDMP to track a particular patient’s use, prescription quantity, frequency of prescriptions, and procurement of controlled substances. The PDMP is frequently used in the workers compensation system to reference whether an injured worker is obtaining narcotics prescriptions from more than one physician, or whether an injured worker has a history of narcotic dependency. The PDMP is considered a medical record, and protections of HIPPA apply to PDMP information. This information can be used to evaluate a specific course of treatment unique to the injured workers’ clinical history; however, a long-standing issue has been the quality and quantity of the information available to physicians.

Prior to October, 2014, PDMP users were only permitted to upload data twice every month. As of October 15, 2014, the revised PDMP regulations, Rx_keyadministered by the Division of Professions and Occupations, require that all in-state and non-resident pharmacies registered by the state’s Pharmacy Board submit controlled substance dispensing data to the PDMP on a daily basis. Most of these changes are contained in House Bill 14-1283. Any pharmacist or physician possessing a Drug Enforcement Agency registered narcotics prescriber permit is required to register with PDMP and follow rules and regulations of the State Board Pharmacy. The new regulations also contain tools to help ease the burden of having to enter massive amounts of patient data in real time. As of January 2015, each prescriber and pharmacist registered as a user with the PDMP may delegate access to the PDMP to three agents by way of creating sub-accounts with the PDMP under the corresponding prescriber or pharmacist’s account.

Granting broader access to the PDMP is an important step for purposes of controlling and containing medical costs in workers’ compensation. Based upon the new revisions to the PDMP guidelines, a workers’ compensation authorized provider may delegate authority to access the PDMP database to three designees acting for the provider. Large and small facilities treating patients will now be able to utilize nurses, or other health care professionals who did not previously have access to the PDMP, as delegated agents authorized to research an injured workers’ narcotic prescription history. The regulatory changes will give busy pharmacists the opportunity to input data on a daily basis. Physicians practicing in workers’ compensation can then obtain real time data about an injured worker’s prescription history by using their staff to obtain and process the clinical information.

Under the applicable rules, physicians performing independent medical examinations may not access the PDMP for information on an injured worker. However, it is recommended that, after obtaining a HIPPA compliant release, the authorized physician be asked to check the PDMP to evaluate an injured worker’s narcotic prescription and compliance history. It is also recommended that insurance representatives adjusting a workers’ compensation claim make repeated requests for PDMP information throughout any claim when narcotic prescription management is an issue. More information about Colorado’s PDMP can be found at

http://www.hidesigns.com/copdmp.

Recent U.S. Supreme Court Decision – Is there Now a Duty to Accommodate Pregnant Employees?

In a pattern of ongoing protections for employees, the Equal Employment Opportunity Commission (EEOC) along with the United States Supreme Court has taken head-on the issue of pregnancy discrimination. For the first time in over 30 years, the EEOC in July 2014 issued Enforcement Guidance regarding pregnancy disability.  In general, the Guidance explains Title VII’s prohibition against pregnancy discrimination, describes individuals to whom the Pregnancy Discrimination Act (PDA) applies and discusses how the expanded definition of “disability” under the Americans with Disabilities Act (ADA) applies.
In sum, the Guidance advises employers to apply the same work place accommodation policies, leave of absence policies, medical benefits, and seniority/retirement benefits to all employees, regardless of whether a request for leave of absence, workplace accommodation, or medical benefit is due to a medical condition related to pregnancy or any other disability. The EEOC concedes that pregnancy is not a “disability” under the ADA, but points out those pregnant workers may have impairments related to their pregnancies that qualify as disabilities under the ADA, even though these disabilities are temporary.

Most recently, the U.S. Supreme Court in Young v. United Parcel Service, articulated a high legal burden that employers would have to meet in order to justify policies that provide accommodations to some categories of employees, but not to pregnant women. The Court stated that it was not persuaded by, and noted a number of problems with, the EEOC’s July 2014 guidance, stating “[w]ithout further explanation, we cannot rely significantly on the EEOC’s determination.” The Court ultimately decided employers need to offer the same or similar accommodations to its pregnant employees as it does to its disabled employees.

The Court held that “a plaintiff alleging that the denial of an accommodation constituted disparate treatment under the Pregnancy Discrimination Act’s second clause may make out a prima facie case by showing, as in McDonnell Douglas, that she belongs to the protected class, that she sought accommodation, that the employer did not accommodate her, and that the employer did accommodate others ‘similar in their ability or inability to work.’” In other words, the Court determined that a Plaintiff can get to a jury trial and avoid summary judgment by providing sufficient evidence that the employer’s policies impose a significant burden on pregnant workers and that the employer’s “legitimate, nondiscriminatory reasons” are not sufficiently strong to justify the burden, but rather give rise to an inference of intentional discrimination.    ​

The ultimate take away from this recent decision is that while an employer is not automatically required to provide all pregnant workers the same accommodations it offers to others 100% of the time, employers should be prepared to justify any differences in their accommodation decisions, which may be difficult to do. Employers should also keep the ADA in mind, given that the Court specifically referenced the expanding definition of “disability” under the 2008 amendments to the ADA.

Practical Pointers for Guidance Compliance:

  • Review policies related to light duty and reasonable accommodation requests to ensure they are in line with legitimate business needs and not based on cost and convenience.
  • Examine accommodation requests granted and denied over the recent past, and on an ongoing basis, to determine if pregnant women are being treated disparately.
  • Train managers and HR professionals on the need for individualized inquires in granting or refusing requests for accommodation.

Reimbursement and Recovery

LetsBeFrank

Reimbursement and Recovery – Medical Care Providers

Increasing costs of medical care have created reimbursement and recovery incentive for providers. Often times medical care secondary to an injury, whether work related or otherwise, becomes the subject of recovery and reimbursement attempts by the providers, as the providers are not inclined to provide care that is not their liability. This article explores and discusses the various means healthcare providers can assert and recover liens, including intervening in workers’ compensation claims.

Workers’ Compensation
Under the Colorado Workers’ Compensation Act, Sec. 8-42-101, C.R.S., an injured worker cannot be responsible for bills or reimbursement to a medical care provider, so long as the medical care was received for a work injury. The workers’ compensation carrier or self-insured employer also has an automatic assignment of any amounts paid in a workers’ compensation claim that allows it to recover amounts directly against any third party responsible for the injury.

A problem arises when treatment is received for a work injury, but the claim is denied, meaning the carrier or self-insured employer are contesting liability. Often in these cases, the carrier or self-insured employer may try to settle on a denied basis, meaning that they are not admitting liability for the claimed injury. If medical care has been provided for the injury, the provider may seek reimbursement against the injured worker, making such a settlement a risky proposition for the injured worker and his attorney. In addition, the medical care provider has an arguable ability to intervene in the underlying workers’ compensation case as an interested party. Recent statutory changes that make the injured worker not responsible for medical bills also make the workers’ compensation insurer liable for medical care for treatment to the injured worker in the event that the claim is ultimately deemed compensable. I have successfully intervened in workers’ compensation cases on behalf of a large hospital where it was undisputed that the injured worker was hurt working, but the employer was uninsured. This created statutory employer liability for a general contractor that was denying the claim and attempting to settle the case on a denied basis. Obviously, the carrier for the statutory employer was attempting to settle the case without regard for medical treatment the injured worker received. I managed to intervene in the matter and attend a settlement conference. In this way, I was able to get some reimbursement for medical care provided to the injured worker. Therefore, be cautious in settling a claim on a denied basis when you are aware that there are medical care providers that expect reimbursement.

Hospital Liens
Hospitals have a lien on any third party recovery, when the lien is properly perfected with the Secretary of State. It is simple to determine if a medical lien exists on a claim by simply accessing the Secretary of State’s website and checking for any UCC filings by known medical care providers to any plaintiff or claimant. If a case is settled without regard to the hospital lien, the hospital can collect reimbursement against the individual or entity that ignored its lien. Further, the hospital can receive attorney’s fees paid if the statutory lien is violated. Historically, hospitals have not been very efficient in filing a lien with the Secretary of State; however, I strongly recommend that the status of liens be determined prior to any settlement of a workers’ compensation case or liability suit.

Assignments
Medical care providers often require a patient (or representative of the patient) to sign a document before receiving care. This document is in the form of a guarantee for payment; however, this document will also include an assignment from the patient to the medical care provider for any rights or proceeds asserted or collected against a third party responsible for the injury. Sometimes these assignments include assignments of any claim to workers’ compensation benefits. Such an assignment is ineffective as workers’ compensation benefits cannot be assigned to a third party. Regardless, if an injured worker settled the workers’ compensation case on a denied basis, or for amounts that were not yet realized as workers’ compensation benefits, payment of this amount to the injured worker rather than to a medical care provider may be a breach of an assignment. In fact, recent case law has recognized that there is an entirely new cause of action for breach of an assignment. This cause of action is similar to a breach of contract in that the assignment arises out of a contract. The individual or entity that breaches an assignment has to be made aware of the potential assignment before a breach can be claimed. Therefore, to the extent that any medical care provider has supplied a treatment document signed by the injured individual, that document should be examined for any assignment from the injured individual to the medical care provider. Keep in mind that this problem is not unique to workers’ compensation claims, but to any liability claims as well.

Other Methods of Recovery – Spousal Necessity Doctrine
Medical care providers have other potential avenues of recovery for treatment supplied to an injured individual. In particular, there is an old statute in Colorado, as well as in other States, that makes a spouse individually responsible for payment for necessities of the other spouse. Case law interpreting this statue has made a spouse responsible for legal fees, housing costs and other bills that have been incurred by the other spouse. Although there is no case directly on point, I have managed to obtain a judgment against a spouse for medical treatment as a necessity under this particular statute.

Other Methods of Recovery – Custodial Care
Custodial responsibility is a mechanism by which a medical care provider can obtain reimbursement. For instance, individuals in the custody of a law enforcement agency are not primarily responsible for medical care. Instead, the entity that has placed the individual in custody is responsible for medical care. There are instances when an individual may be in custody, but not under arrest. If medical treatment is needed while that individual is in custody, but not under arrest, the entity placing the individual in custody is responsible for the medical care. I have successfully obtained a judgment against a law enforcement agency for treatment a hospital provided to a criminal that was not yet arrested, but that I argued was in custody.

Bottom Line
Any carrier or employer has to be conscious of medical care providers that have provided treatment for any claimed injury. With medical care costs continuing to rise, medical care providers are much less likely to write-off, or ignore, avenues for reimbursement and they are growing more aware of any potential for reimbursement through possible insured losses.

The 180 Day Ticking Time Bomb

The Colorado Governmental Immunities Act: The 180 Day Ticking Time Bomb for Filing a Subrogation Personal Injury Lawsuit
– Joseph W. Gren, Esq.


Professor Alan Dershowitz, a hailed legal commenter and constitutional scholar, once remarked that “every lawsuit results from somebody doing something wrong. If everybody did right, we wouldn’t need laws.” In Colorado, the Workers’ Compensation Act provides an employer and insurance carrier the right to sue a “third party” when that respective third party causes injuries to an employee. Section 8-41-203, C.R.S. Though most insurance carriers and claims examiners are generally familiar with the “right of subrogation,” there are several areas of workers’ compensation subrogation that are often times thorny, especially when the government becomes involved.

When the “somebody” who caused an injury to an injured employee is a state governmental entity, a workers’ compensation insurance carrier must take specific measures at the onset of the injury in order to protect their respective subrogation rights. A party’s failure to follow the specific statutory timeframes established by the Colorado Governmental Immunities Act (“CGIA”), section 24-10-101, C.R.S., will result in any personal injury claim being time barred: Maestas v. Lujan, 351 F.3d 1001 (10th Cir. 2003). The most important step an insurance carrier or employer can take at the onset of a subrogation claim is to file the appropriate notice of claim with a governmental entity.

Generally, the CGIA permits the government to be sued for damages arising out of personal injury claims in limited circumstances. This concept is known as a waiver of governmental immunity. Though the jurisprudential theory underpinning why the government enjoys such a unique perk is significant, it is more important to understand how this law practically works. The first step in determining whether the CGIA applies to your case is to determine whether a governmental agency or employee caused, or was involved in causing, the injury to an insured’s employee.

Commonplace examples of personal injury claims involving a governmental entity include injuries caused by dangerous conditions, such as slip and falls on ice found on the grounds of governmental facilities – schools or parks maintained by a municipality, city or state. See, also Reynolds v. School District No. 1 Denver, 69 F.3d 1532 (10th Cir 1995). More subtle instances of entities who may claim protections under the CGIA include physicians whom are associated with state teaching intuitions, but work at medical facilities conducting surgeries. Rudnick v. Ferguson, et. al., 179 P.3d 26 (Colo. App. 2007). State hospitals and its employees also enjoy the protections of the CGIA. Injuries caused by a federal governmental entity or employee implicate the Federal Tort Claims Act. 28 U.S.C., Chapter 17. It is important to distinguish between state and federal entities at the onset of the claim to determine which notice provisions apply in your case.

Once the governmental entity or employee is identified, any party seeking damages, including damages provided under the subrogation statute, must provide the entity notice consistent with the CGIA. Notice of a claim must be sent in writing within “one-hundred and eight-two days” after the “discovery of the injury, regardless of whether the person then knew of all elements of claim or of a cause of action for such injury.” Section 24-10-109(1). As a general rule, most familiar with the CGIA use 180 days as the notice deadline. It is critical to file the written notice within 180 days after the employer or carrier has reasonable or actual notice of a workers’ compensation injury. Failure to provide a claim notice within the 180 day window will result in the claim being barred by the CGIA, as has happened in a number of cases. Once a trial court dismisses a claim as a result of untimely notice, the appeals courts usually provide no sympathy to a CGIA claimant.

The case of The City and County of Denver v. Crandall, 161 P.3d 627 (Colo. 2007) is illustrative of the harsh realities of not meeting the 180-day notice deadline. In that case, customer service agents working for an airliner at DIA alleged an environmental exposure injury caused by the poor air quality in Concourse B. The employees manifested symptoms consistent with the exposure in 1999 through 2002. In 2002, one employee filed a workers’ compensation claim alleging a 1999 date of injury. Multiple injured employees then filed notice of a CGIA claim with the City of Denver. The city claimed that the notice should have been filed within 180 days from the 1999 date of injury as noted on the workers’ compensation claim form. Although the employees demonstrated recurring symptoms in 2002, the Colorado Supreme Court barred the claim against the city on the grounds that the notice should have been filed in 1999. The employees were unable to recover damages against the city. The case, however, does not address whether a workers’ compensation carrier would be able to file a timely CGIA claim if the carrier found out about the injury in 2002. However, it does imply that the 180-day requirement starts ticking when a party, perhaps even the employer, has reasonable evidence that an injury has occurred.

The CGIA also requires that the notice contain specific language. Section 24-10-109(2)(a)-(e), C.R.S. provides that the claim notice requires: (a) the name and address of the claimant and the name and address of his attorney, if any; (b) a concise statement of the factual basis of the claim, including the date, time, place, and circumstances of the act, omission, or event complained of; (c) the name and address of any public employee involved, if known; (d) a concise statement of the nature and the extent of the injury claimed to have been suffered; (e) a statement of the amount of monetary damages that is being requested. As a workers’ compensation carrier, the carrier or employer who carries the loss can be considered the “claimant,” as described in section (a). Since the exposure for a workers’ compensation claim may be unknown until several years after the injury, the notice of damages should contain a statement of generalized monetary figures or allegations. The courts often times strictly enforce what is statutorily required to be in the notice. Hamon Contractors, Inc., Carter and Burgess, Inc., 229 P.3d 282, (Colo.App.2009). Though you may serve the written notice within 180 days, failure to include a statement of circumstances of the event, for example, can result in a bar to the claim.

Finally, the written notice must be served with the proper governmental entity. According to the CGIA, “[i]f the claim is against the state or an employee thereof, the notice shall be filed with the attorney general. If the claim is against any other public entity or an employee thereof, the notice shall be filed with the governing body of the public entity or the attorney representing the public entity. Such notice shall be effective upon mailing by registered or certified mail, return receipt requested, or upon personal service.” Section 24-10-109(3)(a). Additionally, subsection (b) states that a “notice required under this section that is properly filed with a public entity’s agent listed in the inventory of local governmental entities pursuant to section 24-32-116, is deemed to satisfy the requirements of this section.” Each governmental agency may have a different division or department designated to receive CGIA claims notices, such as a city attorney or a county clerk. It is advisable to contact the agency several weeks before the notice due date to obtain the name, address and division for the department designated to accept claim notices.

This article only scratches the surface of the CGIA’s complexities. But the most critical aspect of the CGIA, and the greatest obstacle in governmental subrogation recovery, is filing a claim against a government with the 180-day timeframe. Claims against the government can be won and lost depending on whether the timely notice has been met. If the timeframe is not met, the governmental “somebody doing something wrong” entity or employee will be granted immunity under the law even if the government is 100% at fault.

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