Direct and Natural Consequences Rule Remains Intact

By Jane Salem, staff attorney, Nashville

Last week, the Appeals Board issued its second opinion in two years in which it upheld the direct and natural consequences rule in workers’ compensation cases. Presiding Judge Timothy Conner wrote a concurring opinion, however, remarking that guidance from the Tennessee high court would be useful.


Natacha Hudgins injured her knee after tripping over a pallet at work. Global Personnel Solutions accepted the claim and provided medical benefits, including authorization of a partial knee replacement.

After that surgery, Hudgins began experiencing back and hip pain, prompting a referral for a neurosurgical evaluation that resulted in a recommendation for lumbar surgery. Global authorized decompression surgery but denied the recommended fusion.

After an expedited hearing, the trial court ordered Global to authorize the recommended surgery in full. The Board affirmed.

The case proceeded to a compensation hearing, where the parties introduced the experts’ opinions on causation.

Dr. Adam Caputo performed the back surgery. He agreed that factors other than the knee could have resulted in her back symptoms but ultimately concluded: “Based on the thorough medical history that I was provided with, including prior records, the only explanation that I have been presented with that plausibly explains her back condition would be the knee.”

The authorized physician, Dr. Carl Dyer, treated the knee. He testified that the back condition “indirectly maybe” resulted from the knee, but later said, “By virtue of the fact that she had the problem initially, we would have to say that all this was directly related to the injury based on the evolution of the whole symptom complex as it evolved over time.”

Dr. Dyer conceded that some people have knee injuries and don’t develop back problems. When asked if Hudgins’s back symptoms were the “natural result” of her fall at work, he stated that it wasn’t “natural or unnatural,” and, “I think what you can say is that’s the way it turned out to be because of the traumatic nature of her slip and fall injury, which brought her here in the first place.”

The trial court found that Hudgins’s spinal conditions were compensable, and Global appealed.

The Lead Opinion

The Board reminded that the direct and natural consequence rule “contemplates that certain injuries may be compensable even if they do not occur while the employee is at work, so long as they are the direct and natural consequence of a compensable injury.” The judges previously held that the rule, a “judicially-created doctrine,” survived the 2013 Workers’ Compensation Reform Act.

The most recent word on the rule from the Board (other than the appeal of the expedited hearing order in this case) came in Braden v. Mohawk Industries, Inc. last year. The Board held that an employee must offer evidence supporting a finding that the later injury “flowed from” or was a “natural consequence” of the original injury. They also observed in Braden, “If this common law rule is to be re-interpreted in light of the Reform Act to require a higher degree of proof from the employee to show a causal link between the original injury and the subsequent injury, it is for our Supreme Court, not us, to address.”

They then acknowledged that neither physician used the phrase “direct and natural consequence,” but the “totality of evidence” showed that the spinal condition was compensable.

Dr. Dyer’s opinion as the authorized physician was presumed correct. He ultimately testified that Hudgins’s back condition was “directly related to the injury.” Dr. Caputo similarly said, “the only explanation that I have been presented with that plausibly explains her back condition would be the knee.” In addition, Hudgins testified that she had no back symptoms or medical treatment for it before the knee surgery.

Judge Pele Godkin wrote the lead opinion, and Judge Meredith Weaver joined. They wrote: “While we agree that the parameters of this rule, post-reform, are questions for the Supreme Court to resolve, we conclude that the facts and medical proof in this appeal, reviewed in their totality, are more similar to those contained in Braden than our colleague has concluded.”

The Concurrence

Presiding Judge Conner wrote separately “to emphasize what I view as an unresolved legal issue” about an employee’s burden of proof with the direct and natural consequences rule. “The difficulty arises in determining how this common law doctrine applies in light of the 2013 Workers’ Compensation Reform Act,” he reasoned.

Under the Reform Act, an employee no longer shows that an injury “arose out of” work but now must prove by a preponderance of the evidence that the injury arose “primarily out of and in the course and scope of employment.” This means that “the employment contributed more than fifty percent (50%) in causing the injury, considering all causes.”

Judge Conner remarked that “it remains unclear how the addition of the word ‘primarily’ . . . impacted the direct and natural consequences rule, if at all.” For example, if a medical expert concludes that a work-related injury “contributed to, but was not the primary cause of,” a later medical condition, has the employee met the burden to show that it “flowed naturally from” or was a “direct and natural consequence” of the compensable work injury? He also noted that the statute no longer allows a remedial construction.

Judge Conner concluded by noting that in Braden, the treating physician testified that the later medical condition was “primarily related to” the work injury. But in Hudgins, Dr. Dyer said there was an “indirect” link between the knee injury and the lumbar condition but finally said the back was “directly related to the injury based on the evolution of the whole system complex as it evolved over time.”

Since Global didn’t introduce a contrary expert opinion, this was “just sufficient” to support application of the direct and natural consequences rule, he wrote.

Even on a somewhat gloomy day, Burgess Falls does not disappoint.

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