THE UNEXPLAINED FALL - IDIOPATHIC? ACCIDENTAL? COMPENSABLE?
By: John H. Ruocchio
The standard definition of an injury by accident is something that is unlooked for, untoward, or unusual. The key is whether there was a slip, trip, twist or fall. A fall is typically based on being at an increased risk, i.e., on a ladder, a stool or some elevated surface. By way of being at an increased risk, one typically falls onto a desk, a wall or some other object causing injury. If those criteria are met, there is no question of compensability as it is an injury by accident.
What about the unexplained fall? A fall where there is no obvious basis for same. The claimant is not on an elevated surface. There is no water on the floor, so there is no slip. A person is walking and somehow ends up laying on the ground. They have not hit anything other than the ground, thus eliminating the issue of increased risk. Is this compensable? Is this an idiopathic fall or an accidental one? What is the difference?
Imagine the following fact pattern: Plaintiff has non-work related left knee meniscus surgery in February. Plaintiff returns to work in April and is still treating with her surgeon, undergoing physical therapy, and has not reached maximum medical improvement. Plaintiff is supposed to wear a brace while at work, but does not. Plaintiff returns to work and is walking across the office floor. Plaintiff falls, claiming her leg gave out. There was no water on the floor following an investigation. Plaintiff did not slip. The carpet was not in her way and she did not trip on anything. Her shoes were examined and noted to have good tread mark. The floor, if cleaned, had been done at 5:00 in the morning. The falls occurs at 11:30 a.m. Plaintiff did not fall on anything other than the ground. Is this unexplained fall compensable? Is it idiopathic or accidental?
The North Carolina courts have addressed this issue and distinguished the doctrine of unexplained falls or accidental falls from idiopathic falls. The Court indicated that “in a workers’ compensation case, if the cause or origin of a fall is unknown or undisclosed by the evidence, we apply case law of unexplained falls. When a fall is unexplained, and the Commission has made no findings that any force or condition independent of the employment caused the fall, then an inference arises that the fall arose out of the employment.” The Court went on to state that this inference is permitted because when the cause of the fall is unexplained such that “there is no finding that any force or condition independent of the employment caused or contributed to the accident, the only active force involved is the employee’s exertion and the performance of his duties” then the case is compensable.
The Court held that unexplained falls, however, are differentiated in the case law from falls associated with the idiopathic condition of the employee. An idiopathic condition is one arising spontaneously from the mental or physical condition of the particular employee. Unlike a fall with an unknown cause, where an inference that the fall had its origin in the employment was permitted, a fall connected to an idiopathic condition is not presumed to arise out of the employment. Instead, the compensability of an injury caused by a fall that is associated with an idiopathic condition is determined as follows: (1) when the injury is clearly attributable to an idiopathic condition of the employee with no other factors intervening or operating to cause or contribute to the injury, then no award should be made; (2) however, where the injury is associated with any risk attributable to the employment, compensation should be allowed even if an employee may have suffered from idiopathic condition, which precipitated or contributed to the injury. In other words, even if a plaintiff suffers from an idiopathic condition, i.e., other factors intervening or operating to cause the fall, if the plaintiff was on an elevated surface or in an automobile or in any other area that would increase his risk of injury, the injuries that flow from said fall or accident are compensable.
In the example above, despite the prior surgery to the knee, the Industrial Commission found that plaintiff’s fall was accidental, thus compensable, and not idiopathic. Therefore, to be successful in defending an unexplained fall, evidence of an idiopathic fall must be demonstrated clearly and convincingly from the testimony and medical evidence. Otherwise, defending these cases can create unforeseen pitfalls.
PRACTICE TIP:
The difference then between an accidental and idiopathic fall comes down to investigation and development of medical records. As such, the key test to defend a case appropriately is to determine if there was an intervening or other force operating upon the plaintiff at the time of the fall. If so, then it is not compensable. If not, the doctrine of accidental fall will be applied.