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Entitlement to IMEs: An Analysis of Section 12 and its Application under Card Dynamix, LLC v. Illinois Workers’ Compensation Commission
The Appellate Court’s decision in Card Dynamix, LLC v. Illinois Workers’ Compensation Commission, 2024 IL App (3d) 240319WC-U dissects the criteria for conducting Section 12 Independent Medical Examinations (IMEs), ultimately interpreting its scope of applicability as broader than just a determination of nature, extent, and degree of disability.
Background:
The Claimant, Marciela Throne, was a quality sample inspector for the plastic manufacturer and original Respondent, Card Dynamix, LLC. Claimant was injured on March 27, 2013 while pushing a several-hundred-pound cart. Claimant treated with orthopedic surgeon, Dr. Mark Sokolowski, from June 26, 2013 through arbitration on October 12, 2017, who diagnosed her with a disc bulge in her lumbar spine. Claimant underwent a laminectomy and spinal fusion surgery on March 19, 2014. Throughout treatment, Claimant’s pain worsened, and she was prescribed pain medications and an MRI by Dr. Sokolowski. This MRI was never performed as the Respondent-employer did not authorize it. Claimant was placed on permanent work restrictions by Dr. Sokolowski. The employer performed an IME on January 5, 2017, which placed Claimant at MMI and cleared her to return to work with no restrictions.
At trial, the issues disputed were causal connection, the nature and extent of the disability, and open medical rights. The arbitrator concluded that Claimant’s condition was causally related to her work accident and awarded PPD benefits for 35% of a PAW. Additionally, the arbitrator ordered the employer to pay unpaid medical bills and granted open medical rights. In doing so, the arbitrator adopted “the future plan and recommendations of Dr. Sokolowski”.
Following arbitration, the employer ceased to exist and Travelers Insurance Company (Travelers) became the Respondent. The Claimant continued treating with Dr. Sokolowski, who referred her to Dr. Kalina for long-term pain management. Travelers refused to pay the medical expenses accrued post-arbitration and demanded that Claimant undergo another IME. However, Claimant did not attend the IME, claiming she never received travel expenses and lost wages. Claimant argued that the IME was invalid, as she was attempting to assert her open medical rights rather than determine her degree of disability. The prescribed but unperformed MRI took place on January 19, 2021, through Claimant’s group insurance.
Commission Findings:
The Claimant filed a Section 8(a) petition to compel Travelers to pay all medical bills related to her work accident. Petitioner also sought Section 19(k) penalties and Section 16 attorney’s fees for unreasonable and vexatious refusal to pay the medical bills.
In its decision, the Commission ordered Travelers to pay the entire amount billed for medical expenses related to Dr. Sokolowski, rather than the fee schedule amount. They further imposed penalties and awarded attorney’s fees for Travelers refusal to pay.
The Commission also ruled that Travelers was entitled to an IME to determine causation. Additionally, the Commission interpreted the arbitrator’s adoption of Dr. Sokolowski’s future recommendations as specific to him [Dr. Sokolowski] and not inclusive of Claimant’s treatments from another doctor, even if referred to by Dr. Sokolowski.
The Commission denied the imposition of penalties and fees for refusal to pay for treatment with Dr. Kalina and did not assert a position regarding Travelers’ liability.
Commissioner Doerries’ partial Dissent stated that the penalties should have been calculated according to the fee schedule. She noted that Section 19(k) authorizes the Commission to impose penalties against an employer, “equal to 50% of the amount payable at the time of such award” and that only the fee schedule amount is “payable”. She concluded that the penalties imposed were double what was authorized and constituted an abuse of discretion.
Circuit Court Findings
The Claimant appealed the Commission’s decision to the Circuit Court of Will County. The Court reversed the decision and concluded that Travelers had no justification to deny Claimant open medical rights. The Court agreed with Commission’s imposition of fees and penalties but found that they should be based on the fee schedule. The Court remanded the case, instructing the Commission to award medical bills and penalties accordingly.
Appellate Court Holding & Reasoning
The Respondent appealed the Commission’s decision. The Appellate Court found that Travelers was entitled to an IME, that Travelers’ refusal to pay for Dr. Kalina’s treatments did not warrant penalties, and that Travelers’ refusal to pay for Dr. Sokolowski’s treatments did warrant penalties. The Appellate Court reversed the judgment of the Circuit Court and remanded the matter to the Commission with instructions to (1) determine penalties in accordance with the fee schedule and (2) assess the Claimant’s attorney’s fees and costs against Travelers at their discretion.
The Court held that because the Claimant’s post-arbitration symptoms were not obviously related to the work injury or within the scope of the award, Travelers retained the right to an IME to ensure such conditions and their treatment were causally related, necessary, and reasonable. The Court discussed the fact that medical treatment under Section 8(a) qualifies as “compensation”, and that Respondent is free to obtain an IME to assess whether the condition was related post-award.
The Court rejected the argument that Travelers had forfeited any right to an IME due to its failure to cover the Claimant’s lost wages and travel costs, as the Claimant failed to raise this argument prior. The Court noted that even if Travelers had organized an IME meeting all statutory requirements, Claimant’s counsel had already asserted Claimant’s refusal to attend due to her position that Travelers had no right to an IME.
Regarding penalties, the Court first concluded that Travelers’ refusal to pay for Claimant’s medical costs until after an IME was not unreasonable or vexatious. In doing so, the Court referenced Section 12 language warranting suspension of compensation for failure to attend an IME. The Court already ascertained that the IME was valid to establish causation and necessity of treatment with Dr. Kalina. Accordingly, the Court concluded that Travelers was not subject to penalties for refusal to pay post-arbitration expenses.
Despite the fact that Travelers’ refusal to pay for medical costs until after the IME was not deemed to be unreasonable or vexatious, the Court did impose penalties and fees for failure to pay for medical bills associated with Dr. Sokolowski’s treatment. The Court confirmed the Commission’s conclusion that Dr. Sokolowski’s treatment was within the scope of the arbitrator’s award and refusal to pay associated costs was unreasonable and vexatious.
The Court adopted Commissioner Doerries’ Dissent regarding penalties being subject to the fee schedule.
The Appellate Court’s holding in Card Dynamix establishes an expansion of the Respondent’s entitlement to an IME, offering the potential for more nuanced and precise determinations of the extent of open medical rights and other commonly awarded benefits. If you have any questions about this case, please reach out to our attorneys here.