module 5

Question 1

Define “Causation” in workers’ compensation.

Answer 1

The medical-legal link between job duties/exposures and an injury, disease, or condition; determines if an injury is compensable.

Question 2

What does AOE stand for and mean?

Answer 2

Arising Out of Employment — injury caused by a risk or hazard of the job (why it happened).

Question 3

What does COE stand for and mean?

Answer 3

Course of Employment — injury occurred while doing work tasks, during work hours, on employer premises (when/where).

Question 4

Mnemonic to remember AOE vs COE?

Answer 4

AOE = “A cause”; COE = “Clock & location.”

Question 5

Key difference: AOE vs COE focus?

Answer 5

AOE = cause/hazard; COE = time/place/job duty.

Question 6

Legal test for causation in CA WC?

Answer 6

Substantial Factor Test — work need only be a significant factor in causing the injury, not sole cause.

Question 7

Define “Causation in Fact.”

Answer 7

Actual medical evidence that work activities directly caused or aggravated the injury (but-for cause).

Question 8

Define “Legal Causation.”

Answer 8

Whether injury is compensable under WC law; lower threshold than civil cases — just needs substantial factor.

Question 9

Why is causation important for QMEs?

Answer 9

Determines compensability, apportionment, and benefit eligibility; key part of QME report.

Question 10

Example: Carpal tunnel from typing?

Answer 10

Demonstrates causation in fact — work activity directly produced condition.

Question 11

Example: Smoking + toxic fumes lung dz?

Answer 11

Work exposure can still be a substantial factor even if smoking also contributed.

Question 12

How does preexisting condition affect causation?

Answer 12

Work injury that aggravates or accelerates a prior condition is compensable if work is substantial factor.

Question 13

What’s the “Going and Coming Rule”?

Answer 13

Commuting usually not COE, but exceptions (traveling sales, special errands).

Question 14

AOE/COE table — core:

Answer 14

AOE = cause; COE = time/place; both must be met for WC claim.

Question 15

Mnemonic for causation elements?

Answer 15

C.A.S.E. — Cause (AOE), At work (COE), Substantial factor, Evidence.

Question 16

Types of causation in WC?

Answer 16

Direct, Aggravation, Cumulative, Consequential, Secondary.

Question 17

Define cumulative trauma causation.

Answer 17

Injury from repeated microtrauma/exposure over time at work; satisfies AOE/COE if job is substantial factor.

Question 18

Define consequential injury.

Answer 18

New injury/condition resulting from original work injury (e.g., altered gait → hip pain).

Question 19

Define secondary injury.

Answer 19

Separate injury stemming from treatment/rehab of primary work injury (e.g., medication side effect).

Question 20

Pitfall: purely personal risk injury?

Answer 20

Usually not compensable unless work substantially contributed (e.g., stress + personal heart disease).

Question 21

QME’s role in causation disputes?

Answer 21

Analyze records, exam, job duties to opine if work substantially caused/aggravated condition.

Question 22

Key documents for causation analysis?

Answer 22

Medical history, job duty description, mechanism of injury, diagnostics, prior records.

Question 23

Substantial factor vs proximate cause?

Answer 23

SF is lower bar; doesn’t have to be only or predominant cause.

Question 24

Why define “legal vs factual” causation?

Answer 24

Clarifies medical vs legal thresholds; helps QME frame opinion for WCAB.

Question 25

Mnemonic for substantial factor test?

Answer 25

BIG — “But-for not needed, Important enough, Greater than trivial.”

Question 26

Importance of clear causation statement in QME?

Answer 26

Drives claim acceptance, apportionment, PD rating, dispute resolution.

Question 27

When does AOE fail?

Answer 27

If injury stemmed solely from personal risk unrelated to job hazards.

Question 28

When does COE fail?

Answer 28

If injury occurred off-duty, outside job scope, not benefiting employer.

Question 29

Multiple cause case documentation tip?

Answer 29

Detail each factor (work vs non-work) and weigh significance.

Question 30

Role of QME in apportionment vs causation?

Answer 30

Causation: did work cause/aggravate? Apportionment: % of PD from work vs other factors.

Question 31

Why is timing critical in causation?

Answer 31

Symptom onset soon after work exposure supports work-relatedness.

Question 32

How does CA law treat mixed causation?

Answer 32

Still compensable if work is a substantial factor, even if other causes exist.

Question 33

Why are causation opinions challenged?

Answer 33

Bias, poor rationale, missing history, or failure to address all AOE/COE elements.

Question 34

QME mnemonic to build causation opinion?

Answer 34

H.A.M.M.E.R. — History, AOE/COE, Mechanism, Medical evidence, Employment factors, Rationale.

Question 35

Effect of weak causation evidence?

Answer 35

Claim denial, benefit delays, or need for second QME.