Understanding Idiopathic Claims and How to Prove the Defense

The term “idiopathic defense” is widely misunderstood.  Practitioners need to appreciate when the defense applies and who has the burden of proving an idiopathic defense.  In New Jersey, and in most states, the burden is on the employer to prove an idiopathic defense.  The word “idiopathic” comes from the Greek: “idios” meaning one’s own, and “pathos” meaning suffering or illness.  It is defined in medical dictionaries as a disease or condition that arises spontaneously or for which the cause is unknown.  In law it means more precisely a personal condition which in and of itself explains the injury or illness of the claimant.

At the outset, it is important to distinguish claims where there is no work connection at all: these are not idiopathic claims and petitioner has the burden of proof. The case of Meuse v. Egg Harbor Township Police Department, No. A-4553-90G5 (App. Div. May 6, 1992) involved a police officer who was walking down steps at the station when he felt pain in his knee.  Apparently, a piece of bone broke off in the knee but the officer did not fall or strike anything.  The respondent never proved that petitioner had prior treatment in the knee because there was no need to.  It was petitioner who had the burden of proving that his knee problem arose from work, but he could not do so.  There was really no connection at all with work other than the fact that this happened at work.  The Appellate Division stated that this could have happened at any time and at any place and was not compensable.

The burden of proof always rests on the claimant to show that his or her condition occurred during work and arose from work.  The first concept is one of time; the second concept is one of causation.  If there is no work connection, then the case fails on that test.  For example, if an employee were just sitting at a desk and began to feel back pain, this would be denied as having nothing to do with work.  The respondent would win this case not because the injury is idiopathic but because it does not arise from work.

Now let’s look at an example of an idiopathic claim. In McNeil v. Township of South Brunswick Police, No. A-0777-11T1 (App. Div. May 9, 2012), Officer McNeil was responding to a call and felt pain in his back while hurriedly exiting his vehicle.  He was not sure if he bumped the steering wheel on exiting the vehicle.  Later that day he went to the hospital for treatment and reported the incident. The workers’ compensation doctor thought he had at best a mild strain.  McNeil eventually brought a motion to compel surgery on his back for an extruded disc.

Respondent arranged an IME which revealed that the officer had a long history of low back problems including prior herniated discs and prior surgery, and in fact the very herniated disc at issue had been known for quite some time.  The Judge of Compensation found that the act of exiting the vehicle did not cause any of the pathology in petitioner’s spine, and the physical act of exiting the vehicle was not consistent with the MRI results.  The Appellate Division affirmed and found that that exiting the vehicle was not the causal origin of petitioner’s back condition.  It said that petitioner must show “whether it is more probably true than not that the injury would have occurred during the time and place of employment rather than elsewhere.”

In an idiopathic claim, the burden of proof shifts to the employer.  When an employee  presents enough evidence to show that some event happened at work causing an injury, then the employer has the opportunity to rebut the claim and argue that the real cause is a long-standing or prior medical condition.  This burden shift is discussed in Verge v. County of Morris, 272 N.J. Super. 118 (App. Div. 1994).  The facts in Verge involved an employee who tripped on a rug but did not fall down.  The petitioner argued that her knee injury was occasioned by this twisting motion, and that the trip on the rug was the work connection.

The Judge of Compensation dismissed the case saying that this could have happened anywhere, but the Appellate Division reversed on the grounds that the employer should have the obligation to prove that the knee condition was preexisting and that the prior knee condition caused the knee pain.  The Appellate Division criticized the trial judge for failing to put the employer to its proofs on the idiopathic defense. “We hold that if petitioner’s ‘slip’ is to be characterized as an ‘idiopathic event,’ it must be found to be one which was caused by ‘a purely personal condition having no work connection whatever.’”  The appellate court said that petitioner had discussed prior problems and surgeries with her left knee but had stated she had no problems with her left knee since 1985.  The court clarified, “If petitioner sustained an idiopathic injury because there was no slip to cause her knee to twist in the first instance, then she cannot recover, as there was no subsequent fall or impact capable of causing a secondary injury.”

In considering Verge, what the court was saying was that the employer had to prove that the petitioner did not really slip, but rather that her knee condition caused the event due to its preexisting condition. For instance, if the employer had been able to prove that petitioner’s knee had been buckling for weeks due to a prior condition and it just buckled once more, completely unrelated to the impact of the rug, then the injury would have been idiopathic.  Similar to Verge is Shaudys v. IMO Industries, 285 N.J. Super. 407 (App. Div. 1995).  There an employee arrived at work in the company parking lot, exited his car and then, as he turned to walk toward his building, took a step with his left leg while slamming his car door shut.  In that moment he felt knee pain and heard a pop.  The court ruled for the employee: “… IMO would have had to prove by a preponderance of the evidence that petitioner’s injury was caused by a pre-existing condition and that petitioner’s twisting step towards his workplace did not contribute causing his injury.”

The lesson is this to all workers’ compensation practitioners.  When you have a case where there is really no connection at all to the employment, you do not have an idiopathic defense case.  The burden is on the claimant, who will lose if she cannot show that the injury arose from work.  For example, when Mrs. Coleman got her permanent wave solution and came to work the next day and lit a cigarette, causing her hair to ignite in flames, that was not an idiopathic defense case.  Petitioner lost because the act of lighting a cigarette had no connection to work.  She could not show that the injury arose from work. Coleman v. Cycle  Transformer Corp., 105 N.J. 285 (1986).  The idiopathic defense only arises after the employee has articulated some work event, even a minor one, which then shifts the burden to the employer to prove that the medical condition was preexisting and in fact caused the minor incident.

In essence, there are two competing theories in workers’ compensation when it comes to causation.  An employer takes the employee as he finds him is a dominant theme in workers’ compensation.  That means that the employer cannot prevail just because an employee is shown to have prior knee problems or prior low back problems.  The reason for that rule is that virtually every employee has prior conditions that he or she brings to the workplace.  So if the work effort “aggravates” the prior condition (i.e., objectively worsens it), then the employer is liable to pay workers’ compensation benefits.  On the other hand, if the employer can show that the work effort did not really cause the injury but that the preexisting condition was already there and was the cause of the pain, then the employer is not liable.

The idiopathic defense is, in a very real sense, the antidote to the maxim that the employer takes the employee as he finds him.  To win such a defense, the employer must obtain prior family doctor records, prior surgical records, prior car accident history, and the like, because a workers’ compensation judge will not rule in favor of an employer with just proof that a person had prior arthritis. This information must then be transmitted to a medical expert for an opinion on whether the cause of the symptomatology was solely due to the prior medical condition, not the alleged work event.  Having a prior medical condition like osteoarthritis is not enough to win an idiopathic defense.  There must be proof that the prior condition was treated and significant enough to be an independent cause of the petitioner’s injury.  Informal discovery and use of ISO and other valuable resources can turn the tide on a workers’ compensation case.  This is particularly important in a state like New Jersey where there is almost no formal discovery. Only with aggressive informal discovery can employers prevail in workers’ compensation in New Jersey.

Tags: idiopathic defense, McNeil v. Township of South Brunswick Police, Shaudys v. IMO Industries, Verge v. County of Morris