The recent decision of the Western District Court of Appeals in Tillotson v. St. Joseph Medical Center (WD 72948, June 14, 2011) has generated a great deal of discussion in the workers’ compensation world. However, the Tillotson decision does not make new law. The decision does clarify the application of existing law to a particular type of fact situation.
What has excited comment is the court’s holding that the prevailing factor standard does not apply to the need for treatment. This is not new law. For an injury to be compensable, the work activity must be the prevailing factor in causing the disability and resulting medical condition. This is the only area where the prevailing factor applies. Where there is a compensable injury, the employer must provide whatever treatment is reasonably necessary to cure and relieve of the effects of the injury.
In evaluating this case, it is important to remember how the issues were framed to the Court. First, the parties agreed that a compensable injury occurred, resulting in a meniscus tear. The employer initially paid for treatment, up until the point when total knee replacement was recommended. The parties also agreed that a total knee replacement was reasonably necessary to relieve the claimant’s painful condition.
A 2008 decision by the Eastern District, Gordon v. City of Ellisville, 268 S.W.3d 454 (Mo.App. 2008), seems to have contributed to the confusion by using the phrase: “prevailing factor in causing his need for . . . surgery.” Id., 459. In the Gordon case, the claimant was thought to have sustained a rotator cuff tear. When the surgery was performed, no evidence of an acute injury was found and, therefore, no compensable injury existed.
In Tillotson, the claimant did sustain a compensable injury, a meniscus tear to the knee. The claimant also had preexisting arthritis of the knee. The physicians all agreed that repairing a meniscus tear in a patient with severe arthritis would make the overall condition worse. The only way to relieve the claimant’s pain was with a total knee replacement surgery. The witnesses for both sides agreed that performing the total knee replacement was reasonable. The employer refused to pay for the surgery, on the grounds that the meniscus tear was not the prevailing factor in the need for the knee replacement and the Commission agreed.
The Western District reversed the denial of benefits, holding that, since the total knee was reasonably required to treat the meniscus injury, the employer must provide it. “The fact that the medication or treatment may also benefit a non-compensable or earlier injury or condition is irrelevant,” citing to the 2006 decision in Bowers v. Highland Dairy, 188 S.W. 3d 79 (Mo.App. 2006).
In summary, the Tillotson decision does not effect a change in the existing law, but does clarify the process for analyzing whether an employer is responsible for providing certain treatment. 1. Was the work activity the prevailing factor in causing the injury? If the answer to this question is in the affirmative, there is a compensable injury. The next step is: 2. What treatment is reasonably necessary to cure and relieve the effects of the compensable injury?