Self-Insured (SI) employer claim is allowed for shoulder conditions, claimant has surgery, and then four years later seeks authorization from SI employer Honda for another surgery for the allowed conditions as recommended by his doctor. SI employer videos the guy working out at a health club and shows the video to the Independent Medical Examination (IME) doctor who finds that the allowed shoulder conditions are totally resolved, that the claimant’s pain is due to a biceps rupture, and thus no need for shoulder surgery. IME doctor report contains errors and ambiguities (including incorrect dates, says there’s a lack of medical after discussing it in detail, states that the conditions resolved without stating when). Even so, the Industrial Commission (IC) accepts IME opinion and denies claimant’s request for surgery. Claimant files mandamus. Court of appeals reverses finding that the IME report is internally inconsistent and has troubling inconsistencies. Supreme Court, however, disagrees with court of appeals. The court explains the “ambiguous” versus “equivocation” distinction (ambiguous statements in report are fine, but equivocation disqualifies the report). As I read this opinion, the court is saying in effect (1) that it’s acceptable for the IC to rely on an employer IME report that contains multiple errors or “ambiguities”, (2) at the same time reject the claimant’s doctor’s opinion (the claimant’s doctor’s basis for requesting the surgery is not discussed in the opinion), and (3) essentially eliminate the claim by finding that the allowed conditions (which are not revealed in the court’s opinion) are resolved. The court stated that “the presence of inconsistencies within his [IME’s] report that do not contradict that critical opinion [that shoulder surgery was unnecessary] are harmless.”
If an employer can video a claimant, show it to a hired IME doctor, elicit an opinion that an injury has “resolved”, deny treatment, and thereby effectively eliminate the claim, the medical evidence relied upon should be held to a higher standard than stated by the court. I don’t know what really happened in this case. Perhaps the claimant’s shoulder problem (presumably a rotator cuff tear) had completely resolved (which is unusual with this type of injury), but the fact pattern of this case is common, which makes this decision even more disturbing. Also — Per Curiam – not a single dissent.