Medical Benefits – Medical Evidence Required When Causation Not Clear To Lay Person

In Rivera, the claimant fractured a toe on her right foot. This claim was accepted. An orthopedic specialist later found the claimant was medical stationary with no permanent impairment and required no further treatment. The claimant objected to her claim closure and argued that she continued to have pain and cramping in her right foot and leg and this caused her to fall and injury her right shoulder and left leg. The claimant also attributed an ingrown toenail and blood clotting issues to her original injury. The claimant’s treating podiatrist disagreed. Additionally, medical records showed that the right shoulder and left leg injuries occurred when she slipped in a puddle and the ingrown toenail resulted from her poor care of these injuries.

The administrative law judge (ALJ) found that the claimant had failed to prove she required additional medical care or sustain any permanent impairment. The claimant appealed and the Court affirmed.

The Court noted that in order to prove compensability, a claimant must establish all the elements of his claim, including proof that the injury is causally related to his employment. Additionally, if the result of an accident is not clearly apparent to a layman, then the causal connection must be determined by expert medical testimony. The Court noted that a “lay person does not possess the knowledge necessary to make an accurate diagnosis or to describe a condition’s etiology. Even a logical interpretation of events surrounding the industrial incident and claimant’s ensuing complaints, when made by a layman, is no more than speculation. And, speculative testimony is insufficient to support an award.”

In this case, the claimant only presented “her own untrained, contradictory, and self-serving testimony” that there was a causal connection between her ongoing complaints and the original work injury. Due to that lack of conflicting medical evidence, the ALJ was bound to accept the undisputed conclusion that the claimant’s current complaints were unrelated to the work injury.

Rivera v. Indus. Comm’n of Arizona, No. 1 CA-IC 18-0044 (May 23, 2019).

Would you like to know more? Contact Ilene H. Feldmeier at or 877-259-5693.


From the September 2019 Newsletter