Linda Green suffered a compensable workplace injury in August 2005 and received workers’ compensation benefits through Zurich American Insurance Company, her employer’s workers’ compensation provider. However, in 2009, Zurich contested the continuation of her benefits, arguing that her medical condition had worsened due to noncompliance with treatment rather than the original injury.
According to Zurich, Green’s medical records showed that she had been treated by over 45 doctors or facilities, many of whom dismissed her as a patient due to her behavior or failure to follow medical instructions. The insurance company also cited incidents such as Green demanding the premature removal of her surgical cast, which allegedly led to an infection, and evidence suggesting that she may have tampered with her wound.
A contested case hearing before the Texas Department of Insurance, Division of Workers’ Compensation (the Division), ruled in favor of Zurich, finding that Green’s condition after July 29, 2009, was not a result of her original workplace injury. The division's appeals panel later upheld this decision.
Following the D=division's ruling, Green filed a lawsuit in district court seeking judicial review of the decision and a declaratory judgment that would prevent Zurich from asserting what she called an "injurious practices" defense. However, the trial court granted summary judgment in favor of Zurich, effectively dismissing her case.
On appeal, Green argued that the trial court erred in granting Zurich’s no-evidence summary judgment motion, claiming that the insurance company had not conclusively proven that her current condition was unrelated to her 2005 injury. She also challenged Zurich’s argument that her case was barred by the statute of limitations.
The Texas Court of Appeals rejected Green’s arguments, ruling that she had failed to provide sufficient evidence linking her current medical condition to her original injury. The court noted that while Green had initially suffered a compensable injury, she did not present any expert testimony or medical records establishing that her condition in 2009 was still caused or aggravated by that injury.
Furthermore, the court emphasized that expert testimony was required to establish medical causation in cases like this, where the relationship between the original injury and later medical conditions is complex. Since Green did not provide such evidence, the court affirmed the lower court’s ruling.
Additionally, the appeals court dismissed Green’s declaratory judgment claim, stating that the trial court lacked jurisdiction over her request to prevent Zurich from using the "injurious practices" defense. The court held that Green’s declaratory judgment claim was redundant since she had already pursued the issue through the proper statutory channels.
With this ruling, Zurich is no longer responsible for covering Green’s medical expenses related to her condition after 2009. The decision reinforces the burden of proof on workers seeking extended benefits under Texas workers’ compensation law, particularly when insurers argue that claimants' own actions contributed to their ongoing medical issues.
The case highlights the importance of compliance with medical treatment in workers' compensation claims, as well as the role of expert testimony in proving ongoing disability. It also underscores the limitations of seeking judicial review when administrative processes have already ruled against a claimant.
This ruling sets a precedent for similar cases in Texas, affirming that workers’ compensation insurers can successfully challenge continued benefits if they can demonstrate a break in the causal link between an original injury and a claimant’s current medical condition.
