City of Sacramento v. WCAB

Citation: Not availableDocket: C072944

Court: California Court of Appeal; January 14, 2014; California; State Appellate Court

Original Court Document: View Document

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In a workers’ compensation case involving Arthur Cannon, who suffered from plantar fasciitis after an injury while employed as a police officer for the City of Sacramento, an agreed medical examiner concluded that Cannon's condition resulted in a 7 percent whole person impairment, analogous to a limp with arthritis. The City of Sacramento contested this finding, arguing that such a rating by analogy was impermissible in the absence of objective abnormalities and should only apply in complex or extraordinary cases, which they claimed Cannon's situation was not.

Cannon's injury led to treatments including physical therapy and cortisone injections, and while his primary physician deemed him permanent and stationary with no impairment in daily activities, Dr. William Ramsey later acknowledged the condition's impact on Cannon's gait and recommended an impairment rating based on the analogy to a limp. Despite the lack of objective abnormalities and the challenges of fitting subjective pain into the AMA Guides, Dr. Ramsey maintained that the pain affecting Cannon's weightbearing activities justified the rating.

At trial, the workers’ compensation judge sided with the city, asserting that Cannon's case did not meet the criteria for a departure from the strict application of the AMA Guides due to its non-complex nature. In response, Cannon filed a petition for reconsideration, arguing that the rating by analogy was valid regardless of the case's complexity. The appellate court ultimately found no merit in the city’s arguments and affirmed the decision.

The board re-evaluated the case involving Cannon, agreeing with his position to rescind the judge’s earlier findings and award. It directed the judge to issue a new permanent disability rating based on Dr. Ramsey’s assessment, noting dissent from one board member. The board criticized the judge's interpretation, stating that his restriction to 'complex or extraordinary' medical conditions was misleading. Instead, it affirmed that physicians should be allowed to rate impairments by analogy within the AMA Guides, especially when strict application does not accurately reflect the impairment. Cannon's condition, plantar fasciitis, lacked a standard rating in the Guides, necessitating an analogy-based evaluation or assessment of its impact on daily living activities. The board validated Dr. Ramsey’s analogy-based assessment as compliant with the Almaraz/Guzman standard for conditions not explicitly covered by the AMA Guides.

The city then sought a writ of review, arguing that it is inappropriate to use analogy-based ratings when there are no objective findings and that such ratings should only apply to complex cases, referencing the Milpitas Unified case. The board disagreed with both arguments, outlining the statutory context established by the 2004 reform of California's workers' compensation system under Senate Bill No. 899. This reform mandated the development of a rating schedule to enhance consistency and objectivity, which was implemented through the new permanent disability rating schedule effective January 1, 2005, incorporating the fifth edition of the AMA Guides. The revision emphasized that the assessment of physical injuries must include criteria from the AMA Guides, which define impairment as a loss or dysfunction of any body part and focus on functional limitations rather than disability itself.

Permanent disability is characterized by a significant impairment of earning capacity, the normal use of a body part, or a competitive disadvantage in the labor market. A condition is deemed permanent when an employee reaches maximal medical improvement, indicating stabilization and minimal likelihood of substantial change within the following year, regardless of medical treatment. Permanent disability is quantified as a percentage, with less than 100 percent (total disability) entitling the injured worker to a specific number of weeks of indemnity payments based on that percentage. These payments are designed to compensate for both physical loss and diminished future earning capacity.

In assessing permanent disability percentages, factors such as the nature of the physical injury, the injured employee's occupation, and age at the time of injury are considered, particularly in evaluating future earning capacity. The 'nature of the physical injury' pertains to impairment, represented as a percentage that indicates the severity of the medical condition and its impact on daily living activities, excluding work. Impairment ratings are combined to yield a whole person impairment (WPI) rating, which reflects the overall effect of the injury on daily living capabilities, adjusted for future earning capacity, occupation classification, and age.

The controversy in this case centers on the 'nature of the injury' regarding impairment ratings. In the Almaraz/Guzman case, it was determined that the WPI component of any scheduled permanent disability rating must align with the AMA Guides, prohibiting reliance on physician opinions that deviate from these guidelines. While the WPI component must derive from the AMA Guides, physicians retain the discretion to evaluate WPI without being confined to a strict methodology, as per Section 4660(b)(1). The AMA Guides allow for the application of clinical judgment alongside objective measurements, emphasizing the physician's role in providing an independent assessment of the medical condition and its functional impact, as well as the need for comprehensive clinical expertise in evaluating impairments.

Medical evidence may be deemed insufficient to confirm the existence of an impairment of a certain severity, prompting a physician to adjust the impairment rating and provide a written explanation for this modification. In cases lacking specific impairment ratings, the AMA Guides recommend that physicians employ clinical judgment to compare the measurable impairment from the unlisted condition with similar conditions affecting daily living activities. Physicians should base their assessments on their experience, training, and thorough clinical evaluations, ensuring that their impairment ratings are appropriate and reproducible. Each physician, whether a treating doctor or a medical-legal evaluator, must provide expert opinions on the injured employee’s whole person impairment (WPI) using the most relevant assessment method from the AMA Guides. The assessment must not be arbitrary; a detailed, accurate report is essential to substantiate a rating of permanent impairment, including clear reasoning behind the conclusions drawn. Opinions not grounded in the AMA Guides are not considered substantial evidence and violate section 4660(b)(1).

In the case of Milpitas Unified, the court reviewed the board’s decision in Almaraz/Guzman, addressing whether section 4660 allows deviations from the strict application of the AMA Guides post-2004 revisions. The court affirmed that the Guides should be applied as intended but recognized the need for a flexible interpretation. Section 4660(b)(1) requires the integration of the Guides' descriptions and measurements without rigidly adhering to them, acknowledging the complexity and variability of medical conditions. The term "incorporate" suggests that not all injuries can be precisely categorized by the predefined classifications, indicating that the Legislature did not intend for every complex case to conform strictly to a preset measurement framework.

A narrower interpretation of the Schedule, which incorporates the Guides, is deemed inconsistent with its rebuttable nature and the legislative intent to liberally construe workers’ compensation statutes for the benefit of injured employees. The Guides acknowledge limitations in anticipating all impairments and emphasize the necessity for clinical judgment in assessing complex cases. The City argues that legislative intent behind Senate Bill No. 899 aimed for consistency based on objective findings, asserting that ratings based solely on subjective pain complaints are impermissible without objective abnormalities. However, there is no legislative mandate that precludes finding impairment from subjective complaints in the absence of objective findings. A strict application of the AMA Guides would suggest that conditions without objective manifestations cannot be rated, but the Legislature’s language does not compel such adherence. Dr. Ramsey's rating of Cannon’s condition by analogy to the AMA Guides was compliant with legislative directives. The City also contends that ratings by analogy under Almaraz/Guzman are only permissible in complex cases, arguing that plantar fasciitis does not qualify as such. The board majority disagrees, interpreting that the Sixth District's decision allows for ratings in cases where conditions are poorly understood and manifest subjectively.

The excerpt discusses the application of clinical judgment in evaluating complex cases of impairment, specifically referencing a legal precedent (Milpitas Unified) that identifies certain conditions, like plantar fasciitis, which are not adequately rated by the AMA Guides due to their subjective nature. Cannon's plantar fasciitis, characterized solely by his pain experience, aligns with these 'complex or extraordinary cases.' Dr. Ramsey assessed Cannon's condition and determined it resulted in a 7 percent whole person impairment, comparable to a limp caused by arthritis. The city did not demonstrate any error in this assessment or the board’s decision based on it. The board’s opinion was affirmed, and the court ordered costs to the respondents on review. The opinion was also certified for publication following the court's order.