By: Laura Ogg, Senior Counsel, Atlanta

Two important decisions came out from the Supreme Court of Georgia and the Court of Appeals of Georgia in October: Ocmulgee EMC v. McDuffie and Sanchez v. Carter. In Ocmulgee, the court found  that an employer need not show the availability of suitable employment to justify a suspension of benefits after establishing that an employee’s work-related aggravation of a preexisting condition has ceased to be the cause of the disability. In Sanchez, the court found that death benefits are not owed for meretricious relationships even where there is dependency in fact. Below, please find our recommendations for future handling of your claims in light of these decisions.

In Ocmulgee EMC v. McDuffie, the claimant applied for work with the employer and started in March 2007. When he applied for the job, he failed to disclose a right knee injury from 2002 while working for a prior employer. The injury resulted in three knee surgeries and permanent, sedentary work restrictions.

In September 2009, the claimant stepped in a hole and re-injured his right knee while working for the Employer. Indemnity benefits commenced. In March 2010, the employer discovered that the claimant provided false information on his job application when he stated he was physically capable of performing the job, and he was terminated. His indemnity benefits were suspended. Later, he was taken completely out of work after his doctor, Dr. Pope, recommended additional surgery, and indemnity benefits recommenced. In July 2011, Dr. Pope said that the claimant returned to his pre-injury baseline, and the employer/insurer suspended benefits. A second physician, Dr. Gupta, agreed that the claimant’s knee injury returned to its pre-2009 injury status.

The claimant requested a hearing seeking reinstatement of his indemnity benefits arguing that he had not undergone a change in condition because the employer/insurer did not show that suitable employment was available to the claimant. In denying the claimant’s request, the ALJ found that the employer/insurer proved that the claimant’s restrictions were the same as prior to the 2009 injury and that the claimant, “has no restrictions other than those he already was under at the time he was hired by the employer.”

The Appellate Division accepted the ALJ’s findings and said that if the employer/insurer can show by a preponderance of the competent and credible evidence that an employee no longer suffers any disability due to his work-related injury, then the employer/insurer need not show the specific availability of suitable employment to justify suspending temporary total disability benefits for change of condition. This is even where an employee has neither actually returned to work nor become capable of returning to work. The Superior Court affirmed the Appellate Division.

The case was appealed to the Court of Appeals. The Court of Appeals agreed that the claimant improved to the extent that he had no work restrictions other than the permanent sedentary work restrictions he was under when hired by the employer; however, they concluded that the ALJ erred when she failed to make factual findings regarding whether the employer met its burden of providing that suitable work was available for the claimant. The case was remanded for those additional findings.

The Supreme Court of Georgia accepted the employer/insurer’s petition and determined that the relevant question is whether the claimant returned to his pre-2009 injury condition; not whether he returned to full capacity. They found that where a claimant has a preexisting condition that limits his work capacity before the at-work injury, the employer/insurer’s responsibility for workers’ compensation ceases as soon as the effects of the injury cease. The employer/insurer is not responsible for compensating the employee until the preexisting condition improves or for showing that work exists suitable for an employee with that preexisting disability. Where the ALJ found that the claimant returned to his pre-2009-injury status, the employer/insurer was no longer required to pay workers’ compensation indemnity benefits.

The impact of this decision for employers/insurers is that we are not responsible for showing the availability of suitable work where we can establish that an aggravation to a preexisting condition ceases to be the cause of a claimant’s disability, and indemnity benefits may be suspended. If you know or learn later that a claimant has an injury that pre-exists his or her employment, try to take the following steps:

1. Collect evidence of the pre-existing condition. Are there medical records showing that the claimant had permanent work restrictions? Is there a prior settlement agreement stipulating that he was partially disabled and would not improve?
2. Send your evidence to the claimant’s treating provider and ask whether they believe the Claimant has returned to a preexisting condition. This may be accomplished by a letter, questionnaire, conference, or deposition depending on the circumstances. Ask your attorney for advice or guidance here if you have any question about the language or method that would be most effective.
3. If the treating provider believes the claimant has returned to his preexisting condition, then try to get a second, concurring opinion.
4. Call your attorneys at Eraclides, Gelman for assistance! We are happy to assist in helping you mitigate your exposure and resolve your claim.

In Sanchez v. Carter, Juan Martinez-Martin, the employee, suffered a fatal head injury when he fell from a roof during the course of his employment. The injury was accepted as compensable, and the employer/insurer paid the medical expenses. At the time of his death, Ms. Sanchez, the claimant, was living with the employee. Although the employee and the claimant were not married either ceremoniously or by common law, Ms. Sanchez lived with the employee continuously from 2002 until his death. The evidence showed that the employee paid for Ms. Sanchez’s living expenses including the rent and utilities for the home that they shared, and the ALJ found that the claimant was wholly dependent on the employee for support. In denying her claim for dependency benefits, the ALJ cited to prior Supreme Court decisions that held dependency benefits cannot grow out of a meretricious relationship. The Court of Appeals upheld the decision but said that the Supreme Court may choose to revisit this issue. Ultimately, however, they were not free to disregard the precedent established by the Supreme Court.

By saying that the Supreme Court may choose to revisit the issue, the Court of Appeals may be sending a message that they think the Supreme Court should overturn its prior decision, and that the standard for dependency benefits should be whether there is dependency in fact. Nevertheless, unless the Supreme Court accepts the case and overturns the decision, this is the law of the land, and claimants arising from meretricious relationships are not entitled to dependency benefits. Their claims should be denied.