Opinion
BOARD No. 011835-93
Filed: November 6, 1996
REVIEWING BOARD DECISION
(Judges McCarthy, Maze-Rothstein and Smith)
APPEARANCES
Patrick C. Gable, Esq., for the employee.
Karen Bakos, Esq., for the insurer.
The employee appeals from the denial of his claim for compensation. The administrative judge adopted the insurer's proposed decision almost verbatim. Because we are unable to satisfy ourselves that the judge fully and fairly considered the claims of the parties and rendered a decision which articulated the basis for his decision, we recommit for further findings of fact.
The employee claimed an injury on April 2, 1993 arising out of and in the course of his employment. Pursuant to G.L.c. 152, § 7, the insurer made payments without prejudice from the date of injury until May 17, 1993, when it unilaterally discontinued the compensation pursuant to G.L.c. 152, § 8 (1). The employee then filed the pending claim for §§ 34 or 35 incapacity benefits from May 18, 1993 and continuing, § 30 medical benefits and § 13A legal fees. After the § 10A conference, the judge denied the claim. The employee then appealed for a § 11 hearing. He did not offer evidence of any unpaid medical bills. After hearing, the judge denied the entire claim.
452 Code Mass. Regs. 1.07 provides in pertinent part:
(2) Pursuant to the provisions of M.G.L.c. 152, § 7G, the following documentation must be attached to a claim for benefits . . . before it will be processed by the Office of Claims Administration:. . . .
(c) 1. Claims for payment for adequate and reasonable health care services shall, where applicable, be accompanied by the following:
a. the dates of service; b. the type of treatment or service and the itemized costs; c. office notes, hospital records, or a statement from the attending physician or medical vendor that such visit, testing, prescription drug, therapy, or ancillary medical service device or aid was reasonable, necessary, and causally related to the injury for which the employee is eligible for benefits. . . .
All bills presented shall, where possible, contain treatment codes, the percentage of reimbursement to which the hospital is entitled and the provider's tax identification number.
The decision recited testimony without making findings as to witness credibility or persuasiveness. It made no findings of fact about whether the claimed incident at work actually occurred or injured the employee. The decision recited the impartial medical opinion that as of the time of the § 11A medical examination, there was no causal connection between the employee's subjective pain complaints and any of the injuries described to him by the employee. (Dec. 4.) It stated that the claim was denied because the employee failed to produce medical evidence of causation. (Dec. 5.) It did not confront and adjudicate the issue of whether the employee had been hurt but had recovered at some time prior to the impartial medical examination.
An administrative judge has the obligation to fairly and impartially weigh the evidence, make determinations on all issues raised by the parties, both factual and legal, and to render a decision articulating his reasoning process with sufficient detail to allow proper appellate review. Lavoie v. Westfield Pub. School Systems, 7 Mass. Workers' Comp. Rep. 77, 78 (1993), citingCrawford's Case, 340 Mass. 719, 720-721, 166 N.E.2d 724, 725 (1960). General Laws, c. 152, § 11B requires the administrative judge to decide each issue in controversy and provide a brief statement of the reasons for each decision.
The decision raises many questions as to what the judge actually decided. It fails to address "liability", the first issue which must be decided in every original claim for compensation when raised by the insurer. See Tr. 5 (insurer's assertion of defense that there was no work injury). The judge was required to make clear and specific findings resolving what did or did not occur on the alleged injury date. Buonopane v. Vappi Company, 10 Mass. Workers' Comp. Rep. 88, 89 (1996). The decision merely recited the employee's testimony about what occurred without making any factual findings about whether the work activity caused a physical change in the employee's body resulting in the need for medical treatment or lost time for more than five calendar days. (Dec. 3.) Therefore it is appropriate to recommit for further findings of fact and conclusions of law. See Saracino v. Commonwealth of Massachusetts, 8 Mass. Workers' Comp. Rep. 422, 423 (1994).
See G.L.c. 152, § 29 (required period of incapacity) and § 30 (elements of proof for medical awards).
On recommittal, the judge must decide whether the employee has established by a preponderance of the credible and reliable evidence that: 1) an event occurred in April 1993 as alleged; 2) causing injury (if so, describe the injury and the diagnosis); 3) affecting the employee's ability to work on and after May 18, 1993 (if so, describe the injury-caused impairments and functional limitations). If the judge finds a partial physical disability, he should then consider the employee's physical limitations caused by the injury together with vocational factors, such as the employee's age, education, experience, and determine the amount which the employee was able to earn post-injury. See Carney v. M.B.T.A., 9 Mass. Workers' Comp. Rep. 492, 495-496 (1995); G.L.c. 152, §§ 35 and 35D; Scheffler's Case, 419 Mass. 251, 255 (1994) and Frennier's Case, 635 Mass. 635, 639 (1945). At every change in medical condition, the judge should reassess its impact on the employee's earning capacity. See Dawson v. New England Patriots, 9 Mass. Workers' Comp. Rep. 675, 677 (1995).
In summary, because the decision is inadequate for appellate review, it is appropriate to recommit the case for further findings of fact consistent with this opinion. See G.L.c. 152, § 11C. If the judge finds that justice so requires, additional evidence may be taken prior to the entry of the recommittal decision.
So ordered.
________________________ Suzanne E.K. Smith Administrative Law Judge
________________________ William A. McCarthy Administrative Law Judge
________________________ Susan Maze-Rothstein Administrative Law Judge
Filed: November 6, 1996