MO Supreme Court Rules on Ambiguous Language in Doctor’s Report

confusedA worker who suffered a serious hypertensive condition at work sought workers’ compensation benefits for the medical bills accrued during his hospitalization. His employer argued that he had a history of heart problems and that his previous medical issues were the cause for his episode- and not an altercation at work which the employer argued was the cause. The Missouri Supreme Court ultimately decided that the worker should receive benefits, though the decision was a tight 4-3 opinion.

Ronald Malam worked as a corrections officer for the Missouri Department of Corrections. At work one day he took down an inmate who was out of order. At first Mr. Malam said he experienced only an adrenaline rush but later on he started to experience chest pains and was coughing up blood. He went to a hospital via ambulance and was unconscious for one week after being diagnosed with a “hypertensive crisis”.

The doctors who examined him said there were no signs of trauma from the altercation other than a bruised knee. They thought, but could not be sure, that maybe the incident triggered some underlying factors or added stress and ended up causing the heart failure. He had been in the hospital before for a myriad of heart conditions- congestive heart failure, hypertension, primary cardiomyopathy, pulmonary hypertension, left ventricular dysfunction, biventricular failure and morbid obesity.

In order for an accidental injury to be compensable, the accident has to be the prevailing factor in causing the resulting illness, injury or disability. The prevailing factor would be the primary factor, even in addition to other factors, that caused the resulting medical condition or disability.

He filed a claim for his medical bills, which totaled $138,010.15. His employer’s physician, Dr. Puricelli, examined him and said that his preexisting health problems were the main factors in his hypertensive crisis. His own doctor, Dr. Koprivica, said that the altercation was “the prevailing factor precipitating” his hypertensive issues. The Administrative Law Judge said that the takedown didn’t meet the requirements to be a prevailing factor and so could not be related to work events. His benefits were initially denied. When Mr. Malam appealed the court of appeals upheld that denial, agreeing with the earlier decision that Dr. Koprivica’s opinion was not clearly articulated so it was too vague to substantiate the claim that the takedown was the prevailing factor. The case went to the Workers’ Compensation Commission, who also upheld the denial. Dr. Puricelli’s report was discarded by the commission because the doctor did not have the correct facts of the incident so they relied only on Dr. Koprivica’s report. Even still his case was denied. Each court agreed that the language in Dr. Koprivica’s report was too vague to be considered evidence that the incident was the prevailing factor in his injury.

The Missouri Supreme Court decided that the Commission was being too technical in basing their denial on the doctor’s unclear report. They decided that even though the doctor’s report was a little ambiguous and maybe open to different interpretations, no court had ever followed up with the doctor to ask what he meant so it was not fair to base decisions on the fact that the report was too vague to establish what the prevailing factor was. The main point, they said, was that Dr. Koprivica had recognized and emphasized the accident’s role in Mr. Malam’s hospitalization and downplayed his pre-existing conditions as a major factor. The unexpected stress, both emotional and physical, was the greater factor at play here.

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