Waugh v. Workmen's Compensation Appeal Board

737 A.2d 733, 558 Pa. 400, 1999 Pa. LEXIS 2885
CourtSupreme Court of Pennsylvania
DecidedSeptember 29, 1999
StatusPublished
Cited by22 cases

This text of 737 A.2d 733 (Waugh v. Workmen's Compensation Appeal Board) is published on Counsel Stack Legal Research, covering Supreme Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Waugh v. Workmen's Compensation Appeal Board, 737 A.2d 733, 558 Pa. 400, 1999 Pa. LEXIS 2885 (Pa. 1999).

Opinion

OPINION OF THE COURT

CASTILLE, Justice.

This Court granted allocatur in the above-referenced matter in order to address whether an insurance company is entitled to set aside a Notice of Compensation Payable (“NCP”) on the grounds that an employer’s intentional misrepresentation as to the claimant’s residency at the time of the injury constituted a material mistake of fact. For the reason that follow, we reverse the Commonwealth Court and conclude that an insurance company is entitled to set aside the NCP in these circumstances.

The facts relevant to this appeal are that on December 18, 1993, John Waugh (“Claimant”) sustained a multiple trauma, closed head injury in the course of his employment for Blue Grass Steel, Inc. (“Blue Grass”), a Kentucky company, when he fell twenty-five feet off a building in the State of Indiana. Claimant remained hospitalized for his injuries until February 1994.

At the time of the accident, Blue Grass did not maintain workers’ compensation insurance in Indiana. Subsequently, a claim for workers’ compensation benefits was made to the State Workmen’s Insurance Fund (“SWIF”), with whom Blue Grass did maintain workers’ compensation insurance. SWIF contends that it provided workers’ compensation insurance to Blue Grass only for workers who were injured while either working or residing in Pennsylvania at the time of the injury, and claimant does not dispute this fact in his brief. The claim form completed by SWIF when it was informed on December 23,1993, of Claimant’s injuries listed Claimant as residing at a Clearfield, Pennsylvania, address. The claim form listed Ronald E. Golias as SWIF’s claim investigator, T. Rodgers as SWIF’s supervisor who would approve the claim, and Amanda Jacobs, the wife of Blue Grass’s owner, as the employer *403 contact. 1 The general remarks section of the form provides that Blue Grass was contacted and interviewed by SWIF and that Blue Grass alleged that the claim for benefits was valid. After the initial interview, Blue Grass never responded to further requests by SWIF for respondent’s personnel records. On January 3, 1994, SWIF issued a Notice of Compensation Payable to Claimant by which he would receive weekly workers’ compensation benefits in the amount of $337.61. Also, SWIF began paying Claimant’s medical bills related to the injury. The Notice of Compensation Payable, however, listed a Kentucky address for Claimant, and SWIF mailed all of Claimant’s benefit checks to this Kentucky address. On April 22, 1994, SWIF filed a petition to review compensation benefits. On May 12, 1994, SWIF amended the petition, alleging that an investigation revealed that the Notice of Compensation Payable issued to Claimant should be set aside because it contained a material mistake of fact.

At the hearings before the workers’ compensation judge (“WCJ”), SWIF presented the testimony of a claims adjuster for an independent company that routinely reviewed catastrophic claims for SWIF. The claims adjuster testified that on January 14, 1994, she noticed a discrepancy in Claimant’s address. The claims adjuster then stated that she contacted Claimant’s wife with questions regarding Claimant’s residency at the time of the accident. The claims adjuster stated that Claimant’s wife said that Claimant never resided in Pennsylvania and that Amanda Jacobs instructed her to say that Claimant lived in Pennsylvania since Blue Grass had no workers’ compensation coverage in Indiana (the site of the accident) or Kentucky (the site of the company and Claimant’s place of residence).

The claims adjuster also testified about her conversation with Jacobs regarding Claimant’s benefits claim. The claims adjuster stated that Jacobs told her that Claimant was a Pennsylvania resident at the time of the accident because of his separation from his wife. However, the claims adjuster *404 stated that Jacobs became increasingly defensive when the claims adjuster informed her that Claimant’s wife admitted that Claimant never resided in Pennsylvania.

Claimant’s wife’s deposition testimony was also presented at the hearing. Claimant’s wife stated that Jacobs told her that her failure to verify that Claimant resided in Pennsylvania at the time of the injury would result in Claimant having no medical coverage to pay for Claimant’s medical care.

Finally, Claimant’s deposition testimony was also presented at the hearing. Claimant admitted that he never resided in Pennsylvania. Claimant, however, never spoke with SWIF before he began receiving benefits.

After considering this evidence, the WCJ refused to set aside the Notice of Compensation Payable because he believed that SWIF had sufficient information in its file at the time that the Notice of Compensation Payable was issued to question, at a minimum, as to whether Claimant was a Pennsylvania resident. The Board reversed the. WCJ because it believed the facts showed that the Notice of- Compensation Payable was issued on the erroneous assumption that Claimant was a Pennsylvania resident and that SWIF took immediate steps to set aside the Notice of Compensation Payable once the evidence demonstrated that it had become aware of the misrepresentations. The Commonwealth Court, in an unpublished opinion, reversed the Board, determining that, although misrepresentations were made, SWIF had failed to meet its burden of proof since it failed to present the testimony of the claims investigator who issued the Notice of Compensation Payable. The Commonwealth Court held that the claims investigator should have been presented to testify as to why he issued the Notice of Compensation Payable in spite of conflicting residency information and that his failure to testify created an adverse inference against SWIF on the assumption made when it issued the Notice of Compensation Payable. Thus, in the view of the Commonwealth Court, SWIF could not establish a material mistake of fact based on the case that it had presented before the WCJ. This Court granted allocatur in order to further address the legal standards that govern *405 when a party seeks to set aside a Notice of Compensation Payable based upon an alleged material mistake of fact.

Appellate review of a workers’ compensation order is limited to determining whether a constitutional violation, an error of law or a violation of Board procedure has occurred and whether the necessary findings of fact are supported by substantial evidence. Pieper v. Ametek-Thermox Instruments Div., 526 Pa. 25, 31, 584 A.2d 301, 303 (1990). Section 413 of the Workers’ Compensation Act provides that:

A referee of the department may, at any time, review and modify or set aside a notice of compensation payable and an original or supplemental agreement or upon petition filed by either party with the department, or in the course of the proceedings under any petition pending before such referee, if it be proved that such notice of compensation payable or agreement was in any material respect incorrect.

77 P.S. § 771.

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Bluebook (online)
737 A.2d 733, 558 Pa. 400, 1999 Pa. LEXIS 2885, Counsel Stack Legal Research, https://law.counselstack.com/opinion/waugh-v-workmens-compensation-appeal-board-pa-1999.