P. Vargas, Sr. v. WCAB (Pietro Industries, Inc.) ( 2016 )

IN THE COMMONWEALTH COURT OF PENNSYLVANIA
Ponciano Vargas, Sr., :
Petitioner :
: No. 2315 C.D. 2015
v. :
: Submitted: May 13, 2016
Workers’ Compensation Appeal :
Board (Pietro Industries, Inc.), :
Respondent :
BEFORE: HONORABLE MARY HANNAH LEAVITT, President Judge
HONORABLE PATRICIA A. McCULLOUGH, Judge
HONORABLE DAN PELLEGRINI, Senior Judge
OPINION NOT REPORTED
MEMORANDUM OPINION
BY JUDGE McCULLOUGH FILED: October 14, 2016
Ponciano Vargas, Sr. (Claimant) petitions for review of the November 3,
2015 order of the Workers’ Compensation Appeal Board (Board), which affirmed the
decision of the Workers’ Compensation Judge (WCJ) denying Claimant’s petition to
review compensation benefits and granting the termination petition filed by Pietro
Industries, Inc. (Employer).
Employer employed Claimant as a laborer at its mushroom farm. On
January 16, 2013, as Claimant was on scaffolding washing boards for seeding with a
pressure hose, his left foot slipped causing his right knee to bend and his body to
twist. Claimant did not fall to the ground but was left hanging from the scaffolding.
Claimant experienced immediate low back pain that radiated through his right leg and
down to his foot. Claimant also described his right foot as having fallen asleep.
Claimant was taken to the hospital and later had surgery on his back. (WCJ’s
Findings of Fact Nos. 7a-b, 8b.)
Employer issued a notice of temporary compensation payable (NTCP)
on February 4, 2013, which later converted to a notice of compensation payable
(NCP), recognizing Claimant’s injury as a lower back strain. On April 25, 2013,
Claimant filed a claim petition alleging that he sustained an injury to his lower back
with right lower extremity radiculopathy on January 16, 2013. Claimant sought
payment of total disability benefits and medical expenses, as well as counsel fees,
from Employer. Employer filed an answer admitting that Claimant sustained a lower
back strain, which it acknowledged by way of the NTCP that converted to an NCP,
but denying all other allegations. The matter was assigned to the WCJ. At a
subsequent hearing before the WCJ, Claimant amended his claim petition to a
petition to review compensation benefits alleging an incorrect description of his work
injury. (WCJ’s Findings of Fact Nos. 1-3.)
During the course of litigation, on February 10, 2014, Employer filed a
termination petition alleging that Claimant had fully recovered from his work-related
injury as of November 11, 2013, and was capable of returning to work without
restrictions. Claimant filed an answer denying this allegation and the matter was
consolidated with Claimant’s pending review petition. (WCJ’s Finding of Fact No.
4.)
Claimant submitted deposition testimony from October 24, 2013,
relating a history of his work injury and his ongoing complaints of pain. Claimant
stated that he underwent back surgery, but that the surgery did not relieve his
symptoms. Claimant noted that his attorney referred him to Daisy Rodriguez, M.D.
He described continuing numbness in his right leg and foot, which results in balance
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problems, and pain in his back. Claimant acknowledged that he suffered a prior work
injury to his knee in 2009 but denied any injury to his back. Claimant said that he
eventually agreed to settle his 2009 work injury for a lump sum and he returned to
work. (WCJ’s Findings of Fact, Nos. 7a-g.)
Claimant presented the October 7, 2013 deposition testimony of Dr.
Rodriguez, who is board-certified in internal medicine and in independent medical
examinations. Dr. Rodriguez testified that she first saw Claimant on May 23, 2013,
at which time he presented with a chief complaint of severe lower back pain that
radiated down his right side, as well as pain in his upper back and neck areas. Dr.
Rodriguez obtained a history of Claimant’s prior and current work injury and his
medical treatment, including a laminectomy on April 25, 2013. (WCJ’s Findings of
Fact Nos. 6a-c.)
With respect to the 2009 work injury, for which she also treated
Claimant, Dr. Rodriguez noted injuries to Claimant’s knees and back, including a
cervical and thoracic strain and sprain. She referenced a November 8, 2010 MRI that
documented an L5-S1 herniation and protrusions at L3-4 and L4-5 with canal stenosis
and narrowing of the bilateral foramina. She also noted a March 16, 2011 EMG that
documented bilateral radiculopathy at L4 and L5, left more than right. (WCJ’s
Finding of Fact No. 6c.)
Dr. Rodriguez testified that a February 14, 2013 MRI of Claimant’s
spine revealed severe central canal narrowing at L3-4 secondary to a right
central/paracentral disc protrusion and severe bilateral facet arthropathy, and that a
June 5, 2013 MRI revealed bulging discs at C3-4, C6-7, T5-6, T6-7, and T11-12. She
also noted that a later EMG revealed bilateral radiculopathy at L5 and S1, which she
described as slightly different from the 2011 EMG, which made no mention of S1.
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She opined that Claimant’s condition was causally related to his 2013 work accident
and that Claimant cannot return to his pre-injury job. On cross-examination, Dr.
Rodriguez explained that her causation opinion was based on Claimant landing
forcefully on his buttocks and experiencing immediate pain. (WCJ’s Findings of Fact
Nos. 6d-k.)
Employer presented the deposition testimony of Gene Salkind, M.D.,
who is board-certified in neurological surgery. Dr. Salkind testified that he examined
Claimant on November 11, 2013, at which time he obtained a history of Claimant’s
work injury and reviewed Claimant’s medical records. Dr. Salkind noted that said
history included Claimant bending his right knee and twisting his body, but not
falling to the ground. He also noted Claimant’s April 25, 2013 decompressive
laminectomy on the right at L3 with a right L3-4 discectomy. Dr. Salkind stated that
Claimant reported central lower back pain, but made no mention of neck pain or
complaints referable to his thoracic spine. Claimant also denied any prior history of
lower back pain or any prior work-related injuries. (WCJ’s Findings of Fact Nos. 8a-
c.)
Dr. Salkind described Claimant as exhibiting multiple instances of
symptom magnification and not being honest about his weakness or his sensory loss.
For example, Dr. Salkind testified that Claimant’s reflexes were symmetrical, which
meant that the nerve root arc of L4 through S1 was intact and was contrary to what
Claimant was attempting to portray during examination. Dr. Salkind reviewed a 2010
MRI which revealed degenerative disc disease, herniations at L3-4 and L4-5, and
canal stenosis at L3-4. He attributed these results to arthritic changes due to the
normal aging process. He also reviewed Claimant’s 2013 studies and noted that the
2013 EMG showed evidence of bilateral radiculopathy that did not correlate with the
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MRI which formed the basis for Claimant’s surgery. More specifically, Dr. Salkind
explained that L3-4 pathology would not give rise to radiculopathy at L5 or S1. He
also found no evidence of radiculopathy upon examination. He noted that none of the
2013 studies referenced an acute herniation and opined that Claimant suffered from
degenerative disc disease. (WCJ’s Findings of Fact Nos. 8d-i.)
Dr. Salkind further opined that, at most, Claimant sustained a lumbar
sprain and strain as a result of the January 2013 work incident, from which he had
fully recovered as of the date of his examination, and that Claimant’s condition,
including the April 2013 surgery, was not causally related to that incident. (WCJ’s
Findings of Fact Nos. 8j-k.)
In response, Claimant presented further deposition testimony from Dr.
Rodriguez obtained on April 21, 2014. Dr. Rodriguez continued to opine that
Claimant’s condition was work-related and that he was not fully recovered. Dr.
Rodriguez noted that Claimant was released to return to work with restrictions on
September 10, 2013. Dr. Rodriguez further testified that Claimant was last seen in
2012 for his 2009 work injury and that he had restrictions but was not released to
work. (WCJ’s Findings of Fact Nos. 9a-b.)
Claimant also testified before the WCJ at a May 13, 2014 hearing.
Claimant stated that he still experiences strong pain in his lower back and numbness
on his right side and that he continues to receive treatment for his condition.
Claimant indicated that he could not return to work because his job requires a lot of
walking in humid conditions, bending, and squatting. He further noted that Dr.
Rodriguez had never advised him that he was capable of performing any type of
work. (WCJ’s Findings of Fact Nos. 10a-c.)
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Ultimately, the WCJ issued a decision and order denying Claimant’s
review petition and granting Employer’s termination petition. The WCJ concluded
that Claimant failed to meet his burden of proving that he sustained a work injury
other than a lumbar strain as documented in the NCP. Conversely, the WCJ
concluded that Employer had met its burden of proving that all disability related to
the January 16, 2013 work injury had ceased and terminated as of November 11,
2013. The WCJ also concluded that Employer’s contest was reasonable.
In reaching these conclusions, the WCJ specifically rejected Claimant’s
testimony of ongoing complaints and disability as neither credible nor persuasive.
The WCJ noted that Claimant had significant injuries to his low back, with
radiculopathy, prior to the January 16, 2013 work incident. The WCJ referenced
Claimant’s 2009 work injury, which he was last treated for in 2012 and from which
he was never released to return to work. The WCJ also noted that Claimant provided
Dr. Salkind with an inaccurate history regarding this injury, describing only a knee
injury, when in fact he suffered a back injury with radiculopathy. Further, the WCJ
explained that his rejection of Claimant’s testimony was based on his observation of
Claimant’s demeanor while testifying.
The WCJ specifically credited the testimony of Dr. Salkind and rejected
any contrary testimony of Dr. Rodriguez. The WCJ noted Dr. Salkind’s expertise as
a board-certified neurological surgeon and his more thorough review of Claimant’s
records, studies, and MRI films, as compared to Dr. Rodriguez’ sole review of the
films from a single 2013 lumbar MRI. Moreover, the WCJ explained that Dr.
Rodriguez’ opinion on causation was predicated on her understanding that Claimant
landed forcefully on his right knee and buttocks on January 16, 2013, which was not
supported by Claimant’s testimony or the history he provided to Dr. Salkind. To the
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contrary, the WCJ stated that the record established that Claimant never landed on the
ground after he slipped. Furthermore, the WCJ found that neither Claimant’s
testimony nor the history provided to Dr. Salkind established injuries to his neck or
his upper back/thoracic spine.
Claimant appealed to the Board, but the Board affirmed the WCJ’s
decision and order.
On appeal to this Court,1 Claimant first argues that the Board erred in
affirming the WCJ’s decision because it was not supported by substantial evidence.
Claimant also argues that the WCJ failed to issue a reasoned decision because her
credibility determinations were arbitrary and capricious and so fundamentally
dependent on a misapprehension of material facts as to render those findings
irrational when the record is reviewed as a whole. However, before we reach the
merits, we must address Employer’s argument that Claimant waived his reasoned
decision argument by failing to raise it before the Board.
We agree with Employer that this issue was waived. In his appeal to the
Board, Claimant only alleged that certain findings by the WCJ were not supported by
substantial evidence and that certain conclusions of law were in error. Claimant
never alleged that the WCJ’s decision was not reasoned. The law is well settled that
issues not raised before the Board are waived and will not be heard for the first time
on appeal to this Court. Brown v. Workers’ Compensation Appeal Board (Knight
Ridder, Inc./Philadelphia Newspapers, Inc.), 856 A.2d 302, 308 (Pa. Cmwlth. 2004);
1
Our scope of review is limited to determining whether findings of fact are supported by
substantial evidence, whether an error of law has been committed, or whether constitutional rights
have been violated. Section 704 of the Administrative Agency Law, 2 Pa.C.S. §704; Meadow
Lakes Apartments v. Workers’ Compensation Appeal Board (Spencer), 894 A.2d 214, 216 n.3 (Pa.
Cmwlth. 2006).
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Mearion v. Workers’ Compensation Appeal Board (Franklin Smelting & Refining
Co.), 703 A.2d 1080, 1081 (Pa. Cmwlth. 1997).
We now turn to Claimant’s argument that the WCJ’s decision was not
supported by substantial evidence.
We begin by reviewing the applicable burdens. With respect to a review
petition, the party seeking to correct an allegedly incorrect description of an injury on
an original NCP “bears the burden to prove that a material mistake of fact or law was
made at the time the [NCP] was issued.” Young v. Workers’ Compensation Appeal
Board (Am-Gard), 816 A.2d 1236, 1240 (Pa. Cmwlth. 2003) (citations omitted).
With respect to a termination petition, the employer bears the burden of proving that
the claimant fully recovered from his work injury, that he can return to work without
restrictions, and that there are no objective medical findings that either substantiate
claims of pain or connect them to the work injury. Weismantle v. Workers’
Compensation Appeal Board (Lucent Technologies), 926 A.2d 1236, 1238 (Pa.
Cmwlth. 2007) (citing Udvari v. Workmen’s Compensation Appeal Board (US Air,
Inc.), 705 A.2d 1290, 1293 (Pa. 1997)).2
2
Our Supreme Court explained in Udvari as follows:
We must keep in mind that the employer bears the burden of proof in
a termination proceeding to establish that the work injury has ceased.
In a case where the claimant complains of continued pain, this burden
is met when an employer's medical expert unequivocally testifies that
it is his opinion, within a reasonable degree of medical certainty, that
the claimant is fully recovered, can return to work without any
restrictions and that there are no objective medical findings which
either substantiate the claims of pain or connect them to the work
injury.
Udvari, 705 A.2d at 1293.
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In the present case, Dr. Salkind testified that his physical examination of
Claimant was “fraught with dramatic signs of symptom magnification and
embellishment.” (Deposition of Dr. Salkind at 13.) While Claimant reported central
lower back pain and tingling, numbness, and weakness in his right leg, Dr. Salkind
stated that he did not feel that Claimant was being truthful about his weakness or his
sensory loss. Id. at 11, 15. Perhaps more importantly, he noted that Claimant denied
any prior history of lower back pain or any prior work-related injuries. Id. at 12. Dr.
Salkind did not believe that Claimant had “any concrete neurological deficits” as of
the date of his examination. Id. at 16.
Dr. Salkind noted that a 2010 MRI revealed degenerative disc disease,
herniations at L3-4 and L4-5, and canal stenosis at L3-4, which he attributed to
arthritic changes due to the normal aging process. Id. at 18-19. When comparing this
2010 MRI to a 2013 MRI, he described the two MRIs as “virtually identical,” with no
evidence of an acute herniation related to the January 16, 2013 work incident. Id. at
21. He also noted that a 2013 EMG showed evidence of bilateral radiculopathy that
did not correlate with the 2013 MRI which formed the basis for Claimant’s surgery.
Id. at 21-22. Additionally, Dr. Salkind stated that he found no signs of radiculopathy
upon examination. Id. at 29.
Based upon his physical examination of Claimant and review of
Claimant’s medical records, including the actual films of Claimant’s diagnostic
studies, Dr. Salkind opined that, at most, Claimant sustained a lumbar sprain and
strain as a result of the January 2013 work incident, from which he had fully
recovered as of the date of his examination. Id. at 24-25. He further opined that
Claimant could return to work without restrictions and that Claimant’s condition,
including the April 2013 surgery, was not causally related to that incident. Id. at 26.
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The WCJ specifically credited the testimony of Dr. Salkind. Because this credible
testimony constitutes substantial evidence in support of the WCJ’s decision, the
Board did not err in affirming the same.
Accordingly, the order of the Board is affirmed.
________________________________
PATRICIA A. McCULLOUGH, Judge
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IN THE COMMONWEALTH COURT OF PENNSYLVANIA
Ponciano Vargas, Sr., :
Petitioner :
: No. 2315 C.D. 2015
v. :
:
Workers’ Compensation Appeal :
Board (Pietro Industries, Inc.), :
Respondent :
ORDER
AND NOW, this 14th day of October, 2016, the order of the Workers’
Compensation Appeal Board, dated November 3, 2015, is hereby affirmed.
________________________________
PATRICIA A. McCULLOUGH, Judge