Government and Medicine
Refer to: LaDou J: Cumulative injury (Government and Medicine). West J Med 129:250-253, Sep 1978
Cumulative Injury JOSEPH LaDOU, MD, Sunnyvale, California
A few states, notably California, are experiencing large increases in the number and cost of disability settlements under workers' compensation. Claims of cumulative injury for coronary heart disease, hypertension, stroke, cancer and neuropsychiatric problems have all been interpreted as compensable under workers' compensation, even when these conditions are clearly related to the aging process. Legal precedents for such claims are building rapidly throughout the country. The resultant costs may lead to the demise of the workers' compensation system. The situation in California is discussed in detail including the legal aspects, cumulative injury claims by type of disease and age of claimants, legal costs to the individual and the employer, and the economic outlook for the workers' compensation insurance system. THE CONCEPT of cumulative injury is creating a crisis in the California workers' compensation system. The term "cumulative injury" is legal rather than medical and refers to physical and psychological disabilities that result from repetitive injuries in the workplace. Although these injuries may be minor at the time they occur, over time they can result in medical problems.' Cumulative injuries are differentiated from "specific injuries," the latter resulting from one or a series of exposures to toxic substances or traumatic incidents over a short time. Most cumulative injury claims against workers' compensation in the past have been related to disabilities sustained as the result of the physical requirements of work-for example, back problems resulting from years of heavy lifting. Over the past 15 years, however, a new type of cumulative injury claim has appeared. This type of cumulative injury results from occupaFrom a paper delivered at the California Medical Association Annual Session held in San Francisco, March 19, 1978. Reprint requests to: Joseph LaDou, MD, Medical Director, Peninsula Industrial Medical Clinic, 1197 East Arques Avenue, Sunnyvale, CA 94086.
250
SEPTEMBER 1978 * 129 * 3
tional stress rather than from physical work. Such claims are most often for coronary heart disease, hypertension, stroke and other diseases thought to result from emotional stress and tension in the work environment. These types of claims have become a major source of workers' compensation litigation in California and, to a somewhat lesser degree in Michigan, Minnesota and Wisconsin.- In time, it could become a common disability claim in many states since workers' compensation laws in all states recognize cumulative injury to some degree.
The California Experience California's problems with cumulative injury litigation began with the Beveridge decision in 1959, in which the court held that a claimant's back problem resulted from working in a job that aggravated a previously incurred back condition. The decision stated: We think the proposition irrefutable that while a succession of slight injuries in the course of employment may not in themselves be disabling, their cumulative effect in work effort may become a destructive force. The fact that a single but slight work strain may not be disabling
CUMULATIVE INJURY TABLE 1.-State Compensation Insurance FundCumulative Injury Losses, 1969-1976 Cumulativ e
TABLE 2.-Industrial Indemnity-Cumulative Injury Losses, 1969-1976
Year
Injury Losses
Total Incurred Losses
Percent Cumulative
Injury
Year
1969 1970 1971 1972 1973 1974 1975 1976
$ 7,325,984 8,562,800 12,116,119 17,243,135 20,775,125 28,831,840 41,389,290 45,395,631
$100,067,523 103,133,002 114,642,680 142,058,617 161,799,492 185,882,677 202,745,027 209,796,419
7.3 8.3 10.6 12.1 12.8 15.5 20.4 21.6
1969 ..... $ 589,049 1970 857,304 1971 1,541,399 1972 1,421,952 1973 2,625,983 1974 ... 3,959,237 1975 5,977,551 1976 9,885,005
... ... ... ... ... ... ... ...
Cumulative Injury Losses
.....
.....
.....
.....
..
.....
.....
Total Incurred Losses
$41,275,773 41,554,008 39,825,806 49,383,708 64,071,910 72,100,139 67,274,124 63,082,262
Percent Cumulative
injury
1.4
2.1 3.9 2.9 4.1 5.5 8.9 15.7
Source: State Compensation Insurance Fund, California.
Source: Industrial Indemnity Company, California.
does not destroy its causative effect, if in combination with other such strains it produces a subsequent disability. The single strand entwined with others, makes up the rope of causation.2
ingly concerned with protecting the health and welfare of the worker, (2) medical and legal practitioners have become more knowledgeable about the physical and psychological effects of occupational stress and (3) workers have become aware of the occupational stress factors in the work environment. A large number of diseases and physical conditions can be expected to be the subject of workers' compensation claims and litigation. The state of California has already established a precedent for disability awards under workers' compensation for such diseases as myocardial infarction, coronary insufficiency, stroke, diabetes mellitus, cancer, arthritis and allergies, as well as a host of neuropsychiatric problems including alcoholism.
The outcome of the Beveridge case opened the floodgate to subsequent cumulative injury litigation. Equally important, it established the "date of injury" as the date when the worker becomes aware that his injury is work-related and affects his performance. In effect, the Beveridge decision diluted the statute of limitations and thereby allowed compensation for many conditions that stem more from the aging process than they do from occupational stress. Attorneys, as well as the courts, have also contributed substantially to the problem in California. As Chief Justice Warren Burger has stated, "The harsh truth is that unless we devise substitutes for the courtroom processes, we may be on our way to a society overrun by hoards of lawyers hungry as locusts and brigades of judges in numbers never before contemplated."' Few attorneys are unaware of the possibility that at least some of the disability costs of stress-related disease can be apportioned to workers' compensation insurance. Judgments are given more readily and entail awards that grow steadily larger. Case by case, the bulk of precedent established in the courts accumulates. All workers' compensation claims are financed by a system that includes both private insurance carriers and state workers' compensation insurance funds. Some states, such as California, also permit private employers to be self-insured and government agencies to be legally uninsured. But under each type of arrangement, awards for cumulative injury are becoming an increasing burden to employers, whether they be private or public. The problem stems from three forces: (1) society and government have become increas-
The Economic Impact of Cumulative Injury Since 1970 in California, the number of cases and dollar amount of individual awards in cumulative injury litigation have spiraled. In just the past three years the number of cases has increased by 33 percent, rising from 8,974 in 1975 to 10,791 in 1976, and to 13,393 in 1977.4 These figures from the California Workers' Compensation Appeals Board are conservative, but indicate clearly the trend that is occurring. In terms of dollar amounts, total reported losses rose from $18.0 million in 1970 to $137.5 million in 1976, reflecting an increase of 20 percent to 25 percent annually. Although inflation and broader worker coverage and benefits play a part in the increased dollar amounts, the rapid rise in cumulative injury claims as a percentage of all workers' compensation injury claims indicates the seriousness of the problem (see Tables 1 and 2). Recently published data indicate that during the first two months of 1977 individual compenTHE WESTERN JOURNAL OF MEDICINE
251
CUMULATIVE INJURY TABLE 3.-Nature of Principal Injury, 1977 (as Percent of Total Number of Cases)
Condition
All Disabling Injuries (Percent)
Back ........... Heart/Vascular . . Hearing loss ..... Extremities ...... Neuroses ........ Pulmonary ...... All others .......
24.9 7.4 0.2 54.1 n.a. 0.6 12.8
Cumulative Cumulative Injuries Injuries Resolved New (Percent) (Percent)
37.7 21.1 15.7 11.5 7.2 1.0 5.8
35.7 24.8 15.0 13.4 4.9 0.9 5.3
Source: California Workers' Compensation Institute, September 1977.
sation awards for cumulative injury claims amounted to $9,218 per claimant.5 This figure is more than 41/2 times the amount awarded to individual claimants for specific injury claims. Many cumulative injury claimants also received an additional $7,068 in payment for a specific injury, making a total received of $16,286. In view of this elevated settlement cost and the fact that such claims now account for 10 percent of all compensation claims and are increasing by more than 20 percent annually, the outlook is for ever-higher costs to employers, insurance carriers and society as a whole. In fact, an insurance industry representative recently warned that, if the number and severity of these cases continue to increase at present rates, workers' compensation could become virtually uninsurable in California.5 Michigan, Minnesota, and Wisconsin have now begun to entertain cumulative injury disability claims, with early awards that forecast a nationwide cost experience of epidemic proportions. The number and type of claims in cumulative injury cases provides further insight into the scope of the problem. Back conditions, cardiovascular disease and hearing loss are the most frequent causes, accounting for 37.7 percent, 21.1 percent and 15.7 percent, respectively, of all cumulative injury claims (see Table 3). Each of these conditions also accounts for a higher percentage of claims when compared with disabling specific injuries of these types among the general workforce. Although back problems are the most common cause of cumulative injury claims, cardiovascular conditions are the most costly, amounting to 40.8 percent of all cumulative injury compensation payments (see Table 4). Taken together, back and cardiovascular problems account for almost 75 percent of total dollar awards. These 252
SEPTEMBER 1978 * 129 * 3
TABLE 4.-Award by Injury, 1977 Principi InjLr)'
Percent Dollar Loss
Back .............. 32.7 Heart/Vascular ...... 40.8 Hearing loss ........ 6.6 Extremities ......... 7.3 Neuroses ........... 7.0 Pulmonary ......... 1.0 All other ........... 4.6 Source: California Workers' Compensation Institute, September 1977.
TABLE 5.-Age at Injury (as Percent of Total Cases) Cumulativ e Cumulativ e 36 years or less 37-51 years . 52-60 years .. 61-65 years . Over 65 years
All Injuries (Percent)
Injuries Resolv ed (Percent)
Injuries New (Percent)
57.4
27.1 11.7 3.0 0.8
18.0 34.2 30.6 13.5 3.7
35.1 33.5 11.9 3.5
(Years)
(Years)
(Yearsj
51.2
50.7
.
Median Age ...... 33.4
16.0
Source: California Workers' Compensation Institute, September 1977.
costs clearly indicate the future economic impact
of cumulative injury compensation claims. One major problem related to such claims is that many conditions associated with the normal aging process are included. More than half of the claimants are 50 years of age or older, and more than 15 percent are 60 or older (see Table 5). The age factor suggests that cumulative injury is being used as a source of additional retirement income, at least in a significant number of cases. Furthermore, one study has determined that one of 11 claimants is already retired before claiming compensation.' Permanent disability benefits were designed, however, to compensate injured workers for the lack of a competitive advantage in the labor market-not to improve their retirement incomes. Consequently, many argue that benefits to a retired worker would come more suitably from Social Security and other retirement systems. Essentially all cumulative injury claims are resolved through litigation, and attorneys are retained in 99 percent of the cases. Consequently, as the number of claims increases, the incidence and costs of litigation also increase. From 1974 through 1976 alone, cumulative injury litigation increased by 125 percent. The California experience has been that an active bar is racing far
CUMULATIVE INJURY TABLE 6.-Average Litigation Expense per Employee Attorney Fees
Medical-
Legal
Other
Total
Employee .... $ 780 Employer ... 401
$357 272
$ 52 88
$1,189 761
$1,181
$629
$140
$1,950
Totals ......
Source: California Workers' Compensation Institute, September 1977.
ahead of the insurance industry's ability to control costs, ahead of the medical community's ability to discern true work-related illness and injury, and ahead of the legislature's ability to revise the permanent disability benefit structure to ensure that payments are made only for their intended purpose. Legal costs for cumulative injury cases are higher than the cost of medical treatment for the injury (see Table 6). For example, a settlement delivering $8,438 in net benefits to an employee costs $1,950 in legal expenses, reflecting an overhead factor of 23 percent.1 Because court costs and other items funded by taxpayers were not included in these figures, the costs inherent in each litigated cumulative injury settlement may be greatly underestimated. It is evident that the adversary system for settling cumulative injury claims has subverted the constitutional purpose of the California Workers' Compensation Insurance System. The purpose as stated is "To accomplish substantial justice in all cases expeditiously, inexpensively, and without encumbrance of any character." However, this objective cannot be met under the present court system. It is certainly not possible to settle these claims expeditiously. Fewer than 50 percent of the claims filed with the California Appeals Board are resolved within a year after the filing date,
and about 20 percent wait longer than two years. The cost in time and money to employees and employers-not to mention the cost to taxpayers who support the expense of the court-will not decline under the present system of litigation. It is impossible at present to determine precisely the part that occupational stress plays in the development of any given disease condition. No standard disability formula could ever apply to every specific disease or every group of workers, and development of a settlement system that would apportion costs on a diagnostic basis is highly unlikely. Under such limitations, we can expect that all occupational, stress-related disability claims will be dealt with by an adversary system in which medical experts will be required to determine-and frequently to argue-whether or not a cumulative injury claim against workers' compensation insurance is legitimate. The validity of such a system is questionable, and its cost would be staggering. Few if any workable solutions have been offered toward containing the runaway costs threatened by cumulative injury litigation. Cumulative injury with its crippling costs, litigious framework, and destructive impact on the workers' compensation system presents a problem that challenges the medical profession to clarify the role of occupational stress in the development of disease. REFERENCES 1. Cumulative Injury in California: A Report to the Industry. California Workers' Compensation Institute, Sep 1977, p 4 2. Proceedings of the Committee into the Problems of Assuring Payments of Compensation for Cumulative Occupational Injuries, California, Legislature, Assembly Committee on Finance. Insurance, and Commerce. Interim Hearings, Jan 12 and 19, 1977, pp 51-52 3. U.S. News & World Report 69:68-71, Aug 24, 1970 4. Cumulative Injury in California: A Report to the Industry. California Workers' Compensation Institute, Sep 1977, p 3 5. Proceedings of the Committee into the Problems of Assuring Payments of Compensation for Cumulative Occupational Injuries, California, Legislature, Assembly Committee of Finance, Insurance, and Commerce. Interim Hearings, Jan 12 and 19, 1977, p 31
THE WESTERN JOURNAL OF MEDICINE
253
Refer to: LaDou J: Cumulative injury (Government and Medicine). West J Med 129:250-253, Sep 1978
Cumulative Injury JOSEPH LaDOU, MD, Sunnyvale, California
A few states, notably California, are experiencing large increases in the number and cost of disability settlements under workers' compensation. Claims of cumulative injury for coronary heart disease, hypertension, stroke, cancer and neuropsychiatric problems have all been interpreted as compensable under workers' compensation, even when these conditions are clearly related to the aging process. Legal precedents for such claims are building rapidly throughout the country. The resultant costs may lead to the demise of the workers' compensation system. The situation in California is discussed in detail including the legal aspects, cumulative injury claims by type of disease and age of claimants, legal costs to the individual and the employer, and the economic outlook for the workers' compensation insurance system. THE CONCEPT of cumulative injury is creating a crisis in the California workers' compensation system. The term "cumulative injury" is legal rather than medical and refers to physical and psychological disabilities that result from repetitive injuries in the workplace. Although these injuries may be minor at the time they occur, over time they can result in medical problems.' Cumulative injuries are differentiated from "specific injuries," the latter resulting from one or a series of exposures to toxic substances or traumatic incidents over a short time. Most cumulative injury claims against workers' compensation in the past have been related to disabilities sustained as the result of the physical requirements of work-for example, back problems resulting from years of heavy lifting. Over the past 15 years, however, a new type of cumulative injury claim has appeared. This type of cumulative injury results from occupaFrom a paper delivered at the California Medical Association Annual Session held in San Francisco, March 19, 1978. Reprint requests to: Joseph LaDou, MD, Medical Director, Peninsula Industrial Medical Clinic, 1197 East Arques Avenue, Sunnyvale, CA 94086.
250
SEPTEMBER 1978 * 129 * 3
tional stress rather than from physical work. Such claims are most often for coronary heart disease, hypertension, stroke and other diseases thought to result from emotional stress and tension in the work environment. These types of claims have become a major source of workers' compensation litigation in California and, to a somewhat lesser degree in Michigan, Minnesota and Wisconsin.- In time, it could become a common disability claim in many states since workers' compensation laws in all states recognize cumulative injury to some degree.
The California Experience California's problems with cumulative injury litigation began with the Beveridge decision in 1959, in which the court held that a claimant's back problem resulted from working in a job that aggravated a previously incurred back condition. The decision stated: We think the proposition irrefutable that while a succession of slight injuries in the course of employment may not in themselves be disabling, their cumulative effect in work effort may become a destructive force. The fact that a single but slight work strain may not be disabling
CUMULATIVE INJURY TABLE 1.-State Compensation Insurance FundCumulative Injury Losses, 1969-1976 Cumulativ e
TABLE 2.-Industrial Indemnity-Cumulative Injury Losses, 1969-1976
Year
Injury Losses
Total Incurred Losses
Percent Cumulative
Injury
Year
1969 1970 1971 1972 1973 1974 1975 1976
$ 7,325,984 8,562,800 12,116,119 17,243,135 20,775,125 28,831,840 41,389,290 45,395,631
$100,067,523 103,133,002 114,642,680 142,058,617 161,799,492 185,882,677 202,745,027 209,796,419
7.3 8.3 10.6 12.1 12.8 15.5 20.4 21.6
1969 ..... $ 589,049 1970 857,304 1971 1,541,399 1972 1,421,952 1973 2,625,983 1974 ... 3,959,237 1975 5,977,551 1976 9,885,005
... ... ... ... ... ... ... ...
Cumulative Injury Losses
.....
.....
.....
.....
..
.....
.....
Total Incurred Losses
$41,275,773 41,554,008 39,825,806 49,383,708 64,071,910 72,100,139 67,274,124 63,082,262
Percent Cumulative
injury
1.4
2.1 3.9 2.9 4.1 5.5 8.9 15.7
Source: State Compensation Insurance Fund, California.
Source: Industrial Indemnity Company, California.
does not destroy its causative effect, if in combination with other such strains it produces a subsequent disability. The single strand entwined with others, makes up the rope of causation.2
ingly concerned with protecting the health and welfare of the worker, (2) medical and legal practitioners have become more knowledgeable about the physical and psychological effects of occupational stress and (3) workers have become aware of the occupational stress factors in the work environment. A large number of diseases and physical conditions can be expected to be the subject of workers' compensation claims and litigation. The state of California has already established a precedent for disability awards under workers' compensation for such diseases as myocardial infarction, coronary insufficiency, stroke, diabetes mellitus, cancer, arthritis and allergies, as well as a host of neuropsychiatric problems including alcoholism.
The outcome of the Beveridge case opened the floodgate to subsequent cumulative injury litigation. Equally important, it established the "date of injury" as the date when the worker becomes aware that his injury is work-related and affects his performance. In effect, the Beveridge decision diluted the statute of limitations and thereby allowed compensation for many conditions that stem more from the aging process than they do from occupational stress. Attorneys, as well as the courts, have also contributed substantially to the problem in California. As Chief Justice Warren Burger has stated, "The harsh truth is that unless we devise substitutes for the courtroom processes, we may be on our way to a society overrun by hoards of lawyers hungry as locusts and brigades of judges in numbers never before contemplated."' Few attorneys are unaware of the possibility that at least some of the disability costs of stress-related disease can be apportioned to workers' compensation insurance. Judgments are given more readily and entail awards that grow steadily larger. Case by case, the bulk of precedent established in the courts accumulates. All workers' compensation claims are financed by a system that includes both private insurance carriers and state workers' compensation insurance funds. Some states, such as California, also permit private employers to be self-insured and government agencies to be legally uninsured. But under each type of arrangement, awards for cumulative injury are becoming an increasing burden to employers, whether they be private or public. The problem stems from three forces: (1) society and government have become increas-
The Economic Impact of Cumulative Injury Since 1970 in California, the number of cases and dollar amount of individual awards in cumulative injury litigation have spiraled. In just the past three years the number of cases has increased by 33 percent, rising from 8,974 in 1975 to 10,791 in 1976, and to 13,393 in 1977.4 These figures from the California Workers' Compensation Appeals Board are conservative, but indicate clearly the trend that is occurring. In terms of dollar amounts, total reported losses rose from $18.0 million in 1970 to $137.5 million in 1976, reflecting an increase of 20 percent to 25 percent annually. Although inflation and broader worker coverage and benefits play a part in the increased dollar amounts, the rapid rise in cumulative injury claims as a percentage of all workers' compensation injury claims indicates the seriousness of the problem (see Tables 1 and 2). Recently published data indicate that during the first two months of 1977 individual compenTHE WESTERN JOURNAL OF MEDICINE
251
CUMULATIVE INJURY TABLE 3.-Nature of Principal Injury, 1977 (as Percent of Total Number of Cases)
Condition
All Disabling Injuries (Percent)
Back ........... Heart/Vascular . . Hearing loss ..... Extremities ...... Neuroses ........ Pulmonary ...... All others .......
24.9 7.4 0.2 54.1 n.a. 0.6 12.8
Cumulative Cumulative Injuries Injuries Resolved New (Percent) (Percent)
37.7 21.1 15.7 11.5 7.2 1.0 5.8
35.7 24.8 15.0 13.4 4.9 0.9 5.3
Source: California Workers' Compensation Institute, September 1977.
sation awards for cumulative injury claims amounted to $9,218 per claimant.5 This figure is more than 41/2 times the amount awarded to individual claimants for specific injury claims. Many cumulative injury claimants also received an additional $7,068 in payment for a specific injury, making a total received of $16,286. In view of this elevated settlement cost and the fact that such claims now account for 10 percent of all compensation claims and are increasing by more than 20 percent annually, the outlook is for ever-higher costs to employers, insurance carriers and society as a whole. In fact, an insurance industry representative recently warned that, if the number and severity of these cases continue to increase at present rates, workers' compensation could become virtually uninsurable in California.5 Michigan, Minnesota, and Wisconsin have now begun to entertain cumulative injury disability claims, with early awards that forecast a nationwide cost experience of epidemic proportions. The number and type of claims in cumulative injury cases provides further insight into the scope of the problem. Back conditions, cardiovascular disease and hearing loss are the most frequent causes, accounting for 37.7 percent, 21.1 percent and 15.7 percent, respectively, of all cumulative injury claims (see Table 3). Each of these conditions also accounts for a higher percentage of claims when compared with disabling specific injuries of these types among the general workforce. Although back problems are the most common cause of cumulative injury claims, cardiovascular conditions are the most costly, amounting to 40.8 percent of all cumulative injury compensation payments (see Table 4). Taken together, back and cardiovascular problems account for almost 75 percent of total dollar awards. These 252
SEPTEMBER 1978 * 129 * 3
TABLE 4.-Award by Injury, 1977 Principi InjLr)'
Percent Dollar Loss
Back .............. 32.7 Heart/Vascular ...... 40.8 Hearing loss ........ 6.6 Extremities ......... 7.3 Neuroses ........... 7.0 Pulmonary ......... 1.0 All other ........... 4.6 Source: California Workers' Compensation Institute, September 1977.
TABLE 5.-Age at Injury (as Percent of Total Cases) Cumulativ e Cumulativ e 36 years or less 37-51 years . 52-60 years .. 61-65 years . Over 65 years
All Injuries (Percent)
Injuries Resolv ed (Percent)
Injuries New (Percent)
57.4
27.1 11.7 3.0 0.8
18.0 34.2 30.6 13.5 3.7
35.1 33.5 11.9 3.5
(Years)
(Years)
(Yearsj
51.2
50.7
.
Median Age ...... 33.4
16.0
Source: California Workers' Compensation Institute, September 1977.
costs clearly indicate the future economic impact
of cumulative injury compensation claims. One major problem related to such claims is that many conditions associated with the normal aging process are included. More than half of the claimants are 50 years of age or older, and more than 15 percent are 60 or older (see Table 5). The age factor suggests that cumulative injury is being used as a source of additional retirement income, at least in a significant number of cases. Furthermore, one study has determined that one of 11 claimants is already retired before claiming compensation.' Permanent disability benefits were designed, however, to compensate injured workers for the lack of a competitive advantage in the labor market-not to improve their retirement incomes. Consequently, many argue that benefits to a retired worker would come more suitably from Social Security and other retirement systems. Essentially all cumulative injury claims are resolved through litigation, and attorneys are retained in 99 percent of the cases. Consequently, as the number of claims increases, the incidence and costs of litigation also increase. From 1974 through 1976 alone, cumulative injury litigation increased by 125 percent. The California experience has been that an active bar is racing far
CUMULATIVE INJURY TABLE 6.-Average Litigation Expense per Employee Attorney Fees
Medical-
Legal
Other
Total
Employee .... $ 780 Employer ... 401
$357 272
$ 52 88
$1,189 761
$1,181
$629
$140
$1,950
Totals ......
Source: California Workers' Compensation Institute, September 1977.
ahead of the insurance industry's ability to control costs, ahead of the medical community's ability to discern true work-related illness and injury, and ahead of the legislature's ability to revise the permanent disability benefit structure to ensure that payments are made only for their intended purpose. Legal costs for cumulative injury cases are higher than the cost of medical treatment for the injury (see Table 6). For example, a settlement delivering $8,438 in net benefits to an employee costs $1,950 in legal expenses, reflecting an overhead factor of 23 percent.1 Because court costs and other items funded by taxpayers were not included in these figures, the costs inherent in each litigated cumulative injury settlement may be greatly underestimated. It is evident that the adversary system for settling cumulative injury claims has subverted the constitutional purpose of the California Workers' Compensation Insurance System. The purpose as stated is "To accomplish substantial justice in all cases expeditiously, inexpensively, and without encumbrance of any character." However, this objective cannot be met under the present court system. It is certainly not possible to settle these claims expeditiously. Fewer than 50 percent of the claims filed with the California Appeals Board are resolved within a year after the filing date,
and about 20 percent wait longer than two years. The cost in time and money to employees and employers-not to mention the cost to taxpayers who support the expense of the court-will not decline under the present system of litigation. It is impossible at present to determine precisely the part that occupational stress plays in the development of any given disease condition. No standard disability formula could ever apply to every specific disease or every group of workers, and development of a settlement system that would apportion costs on a diagnostic basis is highly unlikely. Under such limitations, we can expect that all occupational, stress-related disability claims will be dealt with by an adversary system in which medical experts will be required to determine-and frequently to argue-whether or not a cumulative injury claim against workers' compensation insurance is legitimate. The validity of such a system is questionable, and its cost would be staggering. Few if any workable solutions have been offered toward containing the runaway costs threatened by cumulative injury litigation. Cumulative injury with its crippling costs, litigious framework, and destructive impact on the workers' compensation system presents a problem that challenges the medical profession to clarify the role of occupational stress in the development of disease. REFERENCES 1. Cumulative Injury in California: A Report to the Industry. California Workers' Compensation Institute, Sep 1977, p 4 2. Proceedings of the Committee into the Problems of Assuring Payments of Compensation for Cumulative Occupational Injuries, California, Legislature, Assembly Committee on Finance. Insurance, and Commerce. Interim Hearings, Jan 12 and 19, 1977, pp 51-52 3. U.S. News & World Report 69:68-71, Aug 24, 1970 4. Cumulative Injury in California: A Report to the Industry. California Workers' Compensation Institute, Sep 1977, p 3 5. Proceedings of the Committee into the Problems of Assuring Payments of Compensation for Cumulative Occupational Injuries, California, Legislature, Assembly Committee of Finance, Insurance, and Commerce. Interim Hearings, Jan 12 and 19, 1977, p 31
THE WESTERN JOURNAL OF MEDICINE
253
