Thursday, April 24, 2014

Mental Claims & Boundaries

Mental injury claims have always presented some difficulty when they are disputed.

Different states vary greatly on what qualifies as compensable when a claim of psychiatric or psychological injury is alleged.

Some states have tight qualifying requirements, other states are more liberal.

Many states tie any claim for mental injury to a prerequisite physical injury first.

Florida has statutes of that nature - in general section 440.093 generally provides that mental injuries caused by "stress, fright or excitement only" will not be compensable. There was some confusion on how that statute applies, but the First District Court of Appeals has provided some guidance.

(Florida's 1st DCA is the initial reviewing appellate jurisdiction for all workers' compensation decisions issued by a Judge of Compensation Claims.)

Sharon McIntosh had worked at a CVS located at 1875 Capital Circle Northeast, in Tallahassee. An armed gunman burst into the store at around 3 a.m. on Oct. 19, 2010. The gunman ordered McIntosh to get on the floor, but she attempted to run. She was six months pregnant at the time, and she fell, landing on her stomach.

After the robbery, McIntosh went to the emergency room to make sure her baby was okay.

McIntosh had a small abrasion on her knee from the fall. She received treatment and went home.

Nearly two years later McIntosh sought psychiatric treatment. CVS authorized an evaluation, which took place July 11, 2012. The evaluating psychologist determined that McIntosh was suffering from PTSD from the 2010 robbery.

The doctor began a course of treatment, which CVS paid for, and McIntosh sought workers' compensation benefits for her PTSD.

The JCC found that McIntosh sustained a compensable physical injury to her knee when she fell while trying to run away from the robber.

However, he determined that McIntosh's PTSD was not compensable because her PTSD was not "the natural or unavoidable result" of her minor physical injury under section 440.093(2).

McIntosh appealed and the 1st DCA reversed the JCC.

Citing McKenzie v. Mental Health Care, the court said that Section 440.093(1) involves a different inquiry than Section 440.093(2), requiring a worker to establish a physical injury that required medical treatment as opposed to establishing a mental injury arising from a physical injury.

The matter is being remanded to the JCC to make some factual determinations in light of this interpretation.

Another issue to be determined by the JCC on remand is whether CVS should be estopped from denying the compensability of McIntosh's PTSD.

Florida Statutes Section 440.20(4) requires an employer to deny the compensability of a condition within 120 days of the date that it first provided treatment for the condition, otherwise it loses the right to do so.

Opinions obtained by WorkCompCentral to the courts ruling seem concerned with the vagueness of section 440.093 - some feel that the legislature was mandating a nexus between the physical injury and the mental claim, others feel that the section is "disturbing" because the law denies people who have witnessed horrible atrocities – but were physically unharmed – from receiving any kind of compensation.

To me the troubling aspect of any jurisdiction trying to segregate any mental injury claim from physical injury claims is that the brain is an organ - a biological organism that has physical characteristics: there's plenty of science documenting how neurons in the brain work, the chemicals involved, the synapses that physically generate electrical signals to the nervous system to produce either autonomous or voluntary actions.

While the manifestation of these biological actions in the brain may not be observed by traditional diagnostics used for overt physical injuries, I don't think that any reasonable medical opinion can deny that there is SOME physical activity in the display of psychiatric or psychological symptoms.

But at some point one has to draw a line because of the potential for abuse.

This Florida case highlights just how difficult defining the boundaries are.

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