One of the more difficult issues in Workers’ Compensation law in West Virginia is whether idiopathic injuries are considered compensable injuries for workers’ compensation purposes. This subject continues to provide ample opportunity for litigation as private insurers, self-insured employers, and third-party administrators continue to reject workers’ compensation claims that result from an injury of no known cause that occurs while at work. An example of this type of injury is an employee who is simply walking at work and either suffers a knee injury or an ankle injury unrelated to any type of accident or incident. Sometimes the injury results in a fall and sometimes it does not (and these facts must all be considered carefully). In recent decisions, the West Virginia Supreme Court of Appeals and the West Virginia Workers’ Compensation Insurance Commission Office of Judges have attempted to clarify the state of the law in regard to these issues. However, it does appear that the state is moving towards a general rule that provides that idiopathic injuries that occur at work will be considered compensable. These types of situations are very factually driven, so it usually is a good idea for employers and claims administrators to obtain as much factual and medical information as possible from the time of the initial report of injury to make sure that nothing outside of the scope of work, including a pre-existing medical condition, could have caused the injury.
For a claim to be held compensable under the workers’ compensation laws, the claimant must suffer a personal injury that is received in the course of employment and which results from employment. “In the course of” relates to time, place, and circumstances, while “resulting from” relates to the injury’s origin. Old case law indicates that the injury must appear to have resulted from something that the claimant was doing in the course of his work or from some peculiar danger to which the work exposed him. However, as explained below, the Supreme Court of Appeals has indicated in a memorandum opinion that the claimant is not required to prove an unsafe working condition for an injury to be held compensable. When a claim administrator is faced with a set of facts that show that the claimant simply fell or twisted an ankle or knee while walking at work, the West Virginia Insurance Commission Office of Judges is most likely going to consider that incident to be a work-related condition.
In 2015, the Supreme Court of Appeals issued two memorandum decisions regarding idiopathic injuries. In these decisions, the Court did not issue any new syllabus points, but did use language in the second decision that supports a general finding that idiopathic injuries at work will be considered compensable. In the first decision, the Court affirmed the denial of workers’ compensation benefits to an employee who suffered a dislocation of his left knee and a tear of the meniscal cartilage while at work, finding that the injury was idiopathic in nature and not the result of a condition of employment. All the testimony in the underlying litigation indicated that the employee was walking when he suddenly fell to the concrete floor. No one could identify any place where the employee slipped or tripped. He was not carrying any work materials at the time he fell, and the Office of Judges determined that the injury occurred while the employee was merely walking and his left knee gave out. The West Virginia Insurance Commission Board of Review and the Supreme Court of Appeals affirmed that decision. However, this decision seemed to be predicated on the finding that the claimant did not slip or trip; the claimant did not identify any work condition that precipitated his injury. The testimony revealed that the claimant was simply walking when his knee gave out.
Interestingly, approximately two months later, the Supreme Court of Appeals issued a new memorandum decision in which the Court was asked to consider whether an employee who twisted her ankle and fell while walking from one desk to another at work sustained a compensable injury. The claimant testified that the floor was in good condition and that she did not trip, slip, or fall over anything. However, the Court specifically found in this decision that the claimant credibly testified that she sustained a personal injury in the course of her employment and that such injury resulted from her employment. In its decision, the Court found that at the time the claimant was injured, she was walking from the back desk to the front desk to perform her job duties. The Court noted that the West Virginia workers’ compensation system is a no-fault system, meaning that the claimant is not required to prove unsafe work conditions for an injury to be held compensable. The Office of Judges has repeatedly relied on this decision to find idiopathic injuries to be compensable.
As indicated above, the determination as to whether an idiopathic injury is compensable in West Virginia clearly depends on the facts surrounding the injury. If the claimant has some sort of pre-existing, unrelated health condition which could have caused or contributed to such injury, it is reasonable to reject such an application for benefits because the injury cannot be considered to be work-related. However, if a claimant falls or suffers an injury at work while performing work-related duties that seem to be unrelated to the work, the resulting injuries will likely be considered compensable unless the injury resulted from a specific non-occupational factor. If a claimant cannot identify a work-related cause for the injury, the claim will likely still be held compensable if there are no contributing non-occupational factors or pre-existing medical conditions.