A recent South Carolina Court of Appeals decision may give employers and insurance carriers more reason to be thankful as we head into the holiday this week. Frampton v. South Carolina Department of Natural Resources confirms that, even after an employer has already admitted a claim and provided medical treatment, the employer may later deny benefits upon discovery of a claimant’s preexisting condition.
In Frampton, the claimant reported a neck injury to his employer, and the employer/carrier provided medical treatment. The claimant was ultimately released at MMI about three years after his accident. The treating physician assigned impairment ratings of 75% to the cervical spine and 26% to the whole person.
The claimant alleged permanent and total disability as a result of his injury. Shortly before a hearing, the employer/carrier obtained medical records showing the claimant had already been receiving treatment for a cervical spine injury before his work accident. At the hearing, the employer/carrier argued for the first time that the claimant could not prove a compensable aggravation of his preexisting condition under S.C. Code Ann. Section 42-9-35. This statute requires a claimant to present medical evidence in the form of a doctor’s opinion stated with a reasonable degree of medical certainty to prove aggravation of a preexisting condition.
The claimant apparently did not object to the fact that the employer/carrier was raising the preexisting condition issue for the first time at the hearing (even though the claim had been open for over three years by that time). He did not present the required medical opinion to prove an aggravation of his cervical spine condition. Additionally, the claimant did not ask for more time to get this evidence. Instead, he simply argued that the employer/carrier should not be permitted to deny benefits after it had admitted the accident and provided medical treatment for years.
The Single Commissioner found the claimant had not proven a compensable aggravation, but the Commissioner still ordered permanent disability of 20% to the spine. Upon review, the Full Commission agreed that the claimant had not proven an aggravation, and reversed the PPD award, denying the claimant was entitled to any further benefits under the Act.
The Court of Appeals affirmed the Full Commission, and held there was substantial evidence to support the Commission’s denial of benefits. It remains to be seen whether this case will be taken up by the South Carolina Supreme Court. In the meantime, employers and carriers in South Carolina may rely on the Frampton decision as further support for the notion that an employer may deny benefits upon discovery of a preexisting condition (or any other grounds that would support a denial), even after admitting a claim and providing treatment.
In spite of this result, employers should still try to gather all relevant medical records early in a claim and immediately assert any grounds for denial as soon as they are discovered. In the Frampton case, the Single Commissioner did not find the Claimant’s hearing testimony to be credible, which as a practical matter is probably a major reason he lost at the Commission level. In a case like this where a claimant is more forthcoming about his medical history, the employer would probably not get such a favorable result, especially after having arguably failed to do their due diligence early in the claim.