Why Causal Relationships Are Tricky in Workers' Compensation Cases


Causal relationships can be tricky.   There needs to be an in-depth investigation into any possible intervening events severing the causal link between the initial injury and the subsequent injury.   If the employee can prove the second event would not have occurred except for the original event (accident), the medical cost and associated indemnity disability cost is owed by the workers’ comp insurer.

A Hernia from a Spinal Cord Stimulator – Really?

Have you ever read a court decision on a workers’ compensation case and had the reaction . . . “WHAT?” 

Here is a court decision definitely creating a “WHAT?” reaction in most people.  A press release explained how the Wyoming Supreme Court overturned a lower court decision denying medical benefits to a man who claimed a spinal cord stimulator caused a hernia. (WcxKitz)

In 1993 Edward T. Pitkin* slipped while walking into a walk-in refrigerator to get some milk.  Mr. Pitkin claimed injury to shoulder, neck, back and right leg.  He was awarded permanent total disability.  “WHAT?”  Yes – Permanent total disability for a foot slipping.  The court description of the accident does not indicate Mr. Pitkin fell when he slipped.

Wyoming is a monopolistic state for workers’ compensation.  You have to wonder if the state employee/workers’ comp adjuster was asleep at the wheel on this one.  The location of the accident, the walk-in refrigerator, makes it most likely an unwitnessed event.  There is no mention in the press release if Mr. Pitkin’s accident was witnessed or if any investigation was done to confirm how Mr. Pitkin’s foot slipping would have injured his shoulder, neck or back.   A strain to the right leg is possible. 

QUESTION: As Mr. Pitkin had a spinal cord stimulator implanted in 2000, he definitely had an injury but, did the injury happen on the job?  Anyway, the claim was accepted.

In 2006 the original spinal cord stimulator failed and a new one was implanted.  In 2007, Mr. Pitkin states he was at home lying in bed when the second spinal cord stimulator caused him to experience a sensation causing him to stand up “real fast” then he fell down, causing a pain in the groin.  [Another unwitnessed event?].  Pitkin went to a Dr. Ted Styles* who ordered a CT scan that confirmed an inguinal hernia. 

Dr. Styles stated “I would consider this a work-related problem based off the origin of the fall.”   “WHAT?”  Inguinal hernias are normally caused (according to the medical book) by a

1). defect at birth;

2). prolonged wear and tear from lifting, straining or coughing;

3). age related weakness of the abdominal wall;

4). history of previous surgery in the area. 

Risk factors increasing the chances of the hernia developing include advancing age, straining to urinate or pass stools, severe or prolonged coughing and obesity.  

Mr. Pitkin’s description of how the hernia occurred does not fit the medical literature.  In rare cases a hernia can be caused by falling hard on a blunt object, but there is nothing in the press release stating Pitkin fell on any blunt object. 

While Pitkin claimed the spinal cord stimulator malfunctioned, there is no mention in the press release stating it was ever confirmed the stimulator malfunctioned.  If the spinal cord stimulator malfunctioned as claimed, there is no mention of Pitkin bringing a products liability claim against the spinal cord manufacturer. 

WHAT?”  You have to wonder why no products liability suit was brought if the spinal cord stimulator did malfunction. 

Wyoming’s Division of Workers’ Safety and Compensation denied payment for the hernia treatment on the basis it was not related to the original 1993 injury.  There is no mention in the press release whether or not the state employee/workers’ comp adjuster had an independent medical examination done to refute the doctor’s statement.  Also, there is no mention in the press release whether or not the Division of Workers’ Safety and Compensation did any investigation to determine if Pitkin was working somewhere else when the hernia occurred. 

WHAT?” You have to wonder why there was no investigation into other causes for the hernia.

Mr. Pitkin disputed the Division of Workers’ Safety and Compensation determination.  The matter was referred for a contested hearing.  At the hearing Pitkin contended he was entitled to medical benefits for the cost of the hernia treatment claiming the hernia in 2007 was causally related to the 1993 injury.  The hearing examiner ruled in Pitkin’s favor stating the hernia was caused by a fall, the fall was caused by the spinal cord stimulator, the spinal cord stimulator was implanted to treat Pitkin’s chronic back pain.


The adverse finding for the Division resulted in their appealing the matter to the District Court.  The District Court found the examiner was correct in its finding of fact, but ruled against Pitkin stating a hernia is a compensable injury only when it is the original injury.  The District Court considered the hernia a second compensable injury which was barred.  Pitkin appealed the District Court decision to the Wyoming Supreme Court. 

The Supreme Court reviewed the workers’ comp claim on whether the hernia occurred “in the course of employment” per the Wyoming workers’ comp statutes.  The Supreme Court ruled the position of Pitkin was in keeping with the language and context of the statute and with the legislative intent.  Pitkin therefore received the medical benefits for the hernia.


Almost all states treat injuries resulting from the original workers’ comp injury as part of the original injury.  Visit:  LowerWC.com Legal Library for your state’s law on workers’ compensation issues.

For example:  The employee had a verified work-related fall causing a leg fracture.  A week later the employee is on new crutches on his way to the doctor’s office for his leg fracture, when he loses his balance. He falls and breaks his arm.  The broken arm is causally related to the fractured leg.   In most jurisdictions this is referred to as a “compensable consequence of the injury.” (WcxKitz)

In a similar vein, in a very recent New York case, a Cornell University employee, William Smith*, had a compensable work-related back injury in 2001.  Smith suffered depression brought on by the chronic pain related to the back injury. In 2007 Smith committed suicide.  The New York State Appellate Court found “sufficient causal relationship” between the suicide, the depression, the chronic pain and the original workers’ comp injury.  The court has ruled Mrs. Smith is now entitled to death benefits under the New York workers’ comp law.

Fully documenting each and every workplace injury is essential at the time the injury occurs.  And, it’s not a bad idea to be aware of the employee’s current medical conditions – either to prevent causal relationships from a new injury or to be sure the employee is not assigned work task beyond his/her capability.

Visit LowerWC.com a premier Workers’ Comp Cost Reduction Resource Center for Employers.