Wruck: Conflicting Medical Ratings Required Clarification Before a Disability Award

When walking and lifting remain painful after a serious ankle injury, a disability percentage can feel far removed from daily life. You need the medical report to explain those limitations clearly. Conflicting percentages or changing explanations can put an award at risk even when the injury and need for further care are established.

In Wruck v. Table Bluff Brewery, No. ADJ16533639 (WCAB July 22, 2024), a divided Workers’ Compensation Appeals Board panel required further medical clarification before deciding permanent disability. The majority deferred that issue and attorneys’ fees while keeping an award of future medical treatment. The disagreement concerned how the doctor reached the rating, including whether different measures described separate limitations or overlapped.

The medical reports did not give one clear final rating

Steven Wruck sustained a work injury to his right ankle, back and hips while working as a warehouse manager/laborer. The judge awarded 73 percent permanent disability. The employer challenged the impairment analysis of qualified medical evaluator David Cox, D.C., arguing that it lacked sufficient medical support.

Whole person impairment, or WPI, is a medical impairment measure used in the rating process. It is different from the final permanent disability percentage. The reporting history described in Wruck contained several competing approaches to the ankle. In his initial report, Dr. Cox used a 20 percent gait rating, based on routine use of a walking stick, and a separate 19 percent lifting-capacity rating by analogy to a hernia table. He reported a combined result of 32 percent WPI.

His supplemental report changed the explanation. Because Wruck used the walking aid part time, Dr. Cox described a 15 percent gait rating. He then proposed a different 20 percent assessment based on loss of lower-extremity function. That report also gave separate ratings for the hips, whereas the initial approach had treated the gait impairment as already accounting for the hip condition.

The deposition discussion in Wruck added another conflict. Dr. Cox said the lifting-capacity method was intended as an alternative to the ordinary rating, rather than an additional rating. Yet he later agreed with a question referring to 32 percent WPI for the ankle. The majority could not reconcile that answer with the revised gait assessment and his statement that the methods were alternatives.

Those differences affected the judge’s instructions to the disability rater. The instructions used 20 percent for gait and 19 percent for lifting, plus separate hip ratings. The majority questioned whether that assembled a consistent medical opinion from the different reports. A doctor’s later answer needs to be read with the supplemental reports it is supposed to explain.

An alternative rating needs a medical explanation

The medical-evidence discussion in Wruck applies a practical requirement: The physician must explain the facts and reasoning behind the impairment opinion. A conclusion alone does not establish why a particular percentage accurately measures this worker’s condition.

The panel applied the Almaraz/Guzman approach, affirmed in Milpitas Unified School District v. Workers’ Compensation Appeals Board (Guzman), 187 Cal.App.4th 808 (2010). A physician may use another chapter, table or method within the AMA Guides when it more accurately reflects the worker’s impairment. The analysis must remain grounded in the Guides and supported by medical reasoning. Labor Code section 4660.1(h) expressly preserves the Guzman holding for the post-2013 rating system.

Here, the majority wanted the doctor to identify his final opinion: Which gait assessment was correct, whether he still used a lifting-capacity analogy, and whether that method replaced another rating or was meant to be combined with it. The practical value of an alternative method lies in explaining the functional loss that the ordinary method misses.

Combination and rating instructions were separate problems

The combination analysis in Wruck asked whether the gait measure already accounted for the strength or lifting limitation. If it did, using another measure for the same loss could count it twice. If a combination was proposed, the doctor needed to explain why it better described limitations in activities of daily living and was consistent with the Guides.

The majority also identified a rating-instruction problem. The rater had adjusted the gait and lifting components before combining them and used a digestive-system impairment number for the ankle’s hernia analogy. The Board directed attention to the schedule’s instruction about combining multiple impairments of a single part of an extremity before conversion and adjustment. It also stated that an ankle impairment should use an ankle impairment number even when another chapter supplies the analogy.

For the worker, this means there are two things to check: The medical explanation for each component and the way the supported components move through the rating process. A larger medical percentage does not answer whether the instructions use the correct body-part classification or combination method. Those are questions for the medical and rating professionals working from the complete record.

The dissent would have kept the award

Commissioner Craig Snellings disagreed. His dissent in Wruck quoted the judge’s report describing a fall from a beer keg while tagging a pallet overhead, severe lower-leg fractures and a long recovery. The report recounted that Wruck spent about a year in a hospital bed at home and later left a delivery job because it was too physically demanding.

The dissent accepted the judge’s explanation that the selected factors most accurately reflected Wruck’s disability. The quoted report relied on the doctor’s account of impaired walking and lifting and discussed other decisions allowing supported alternative approaches. That was the dissent’s reason to leave the award in place. The majority instead required the doctor to resolve the inconsistencies before a permanent disability determination.

Permanent disability was deferred; future medical care remained awarded

The amended findings and award in Wruck preserved industrial injury to the ankle, back and both hips, maximum medical improvement and the need for future treatment. Permanent disability and attorneys’ fees were deferred, with jurisdiction reserved. The future-medical award remained in the operative decision.

The result was further development of the rating evidence, rather than a final replacement percentage. The distinction matters when reviewing a reconsideration decision: Check which benefits remain awarded and which issues must be decided after clarification. In this case, the majority identified specific questions for Dr. Cox and the rating process.

Compare the full reporting history before relying on a percentage

Ask your attorney to compare the initial report, each supplemental report, the deposition and the rating instructions in date order. For each proposed impairment, identify the body part, the medical findings, the activities affected, the Guides method and whether the doctor means an alternative or an additional component. Check whether the latest explanation accounts for changes such as part-time rather than routine use of a walking aid.

If the reports conflict, identify the exact unanswered question for a supplemental explanation or further questioning. In Wruck, clarification was needed about both the medical assessment and how it would be rated. Preserve the examination findings and descriptions of actual daily limitations; they provide the basis for a reasoned opinion.

Our Radilla analysis discusses a different record supporting alternative ratings and addition of impairments. Wruck focuses on an earlier problem: Establishing a coherent final medical opinion and accurate rating instructions before relying on the resulting percentage.