Treating-Physician Opinions Carry “Substantial Weight” But Are Not Controlling; Lack of Medical Consensus Can Defeat Causation; Medical Journal Articles Are “Medical Evidence” Subject to the Five-Business-Day Disclosure Rule

Case: Appeal of Jane Palangas, No. 2024-0395 (N.H. June 24, 2025)

Court: Supreme Court of New Hampshire

Disposition: Affirmed by order under Sup. Ct. R. 20(3)

Introduction

This workers’ compensation appeal arises from a claim by Jane Palangas, a social worker at Mount Carmel Nursing Home during the first year of the COVID-19 pandemic, who developed herpes zoster ophthalmicus (shingles of the eye) and subsequent post-herpetic neuralgia. She alleged that extraordinary work-related stress caused or contributed to the onset and severity of her condition.

Palangas challenged a decision of the New Hampshire Compensation Appeals Board (CAB) in favor of the respondents (New Hampshire Employers Insurance Company and AIM Mutual Insurance Company on behalf of Mount Carmel), contending that the CAB erred by: (1) holding her claim time-barred under RSA 281-A:19; (2) excluding a medical journal article disclosed less than five business days before the hearing; and (3) finding she failed to prove medical causation. The Supreme Court affirmed on the ground that Palangas did not establish medical causation and, separately, upheld the evidentiary exclusion; it assumed without deciding that the claim was timely.

In doing so, the Court underscores three points that will reverberate in New Hampshire workers’ compensation practice: (a) treating-physician opinions, while important, do not bind the factfinder when a more specialized expert and medical literature suggest otherwise; (b) the CAB may weigh the absence of “widespread acceptance” in the relevant medical community when evaluating novel or disputed causation theories; and (c) medical journal articles constitute “medical evidence” under N.H. Admin. R., Lab 205.09(d) and must be furnished to opposing parties at least five business days before the hearing.

Summary of the Opinion

Affirmance on medical causation: The Court held that substantial evidence supported the CAB’s finding that Palangas failed to prove, by a preponderance of the evidence, that work-related stress probably caused or contributed to the onset or severity of her shingles (or activated disabling symptoms). The CAB permissibly credited the respondents’ expert, Dr. Hedges, over treating physician Dr. Calhoun, particularly given Hedges’ superior relevant expertise and medical literature indicating no widespread acceptance of the causation theory.
Treating physician’s opinion: While treating-physician reports warrant “substantial weight” (Appeal of Morin), that principle does not prevent the CAB from accepting contrary, more persuasive expert testimony (Appeal of Rancourt). The CAB’s choice between competing experts will be upheld if supported by competent evidence.
Evidentiary ruling: The Court agreed that a medical journal article disclosed on Sunday, December 3, for a Friday, December 8 hearing was “medical evidence” and was untimely under Lab 205.09(d)’s “five business days” requirement, as computed under RSA 21:35 and Miller v. Town of Tilton.
Timeliness of the claim: The Court assumed without deciding that the claim was timely under RSA 281-A:19 and affirmed solely on the alternative ground of lack of causation.

Analysis

Precedents and Authorities Cited

Appeal of Rancourt, 176 N.H. 139 (2023); RSA 541:13: Establishes the deferential standard of review. CAB factual findings are deemed prima facie lawful and reasonable; the appellant bears the burden to show they are “clearly unreasonable or unlawful.” The Court does not reweigh evidence but asks whether findings are supported by competent evidence. Rancourt also confirms that factfinders may accept or reject expert testimony, in whole or in part.
Appeal of Kehoe, 141 N.H. 412 (1996): Articulates the medical-causation test in workers’ compensation: the claimant must show that work activities probably caused or contributed to the injury as a matter of medical fact; proof that work activated disabling symptoms may suffice even if it did not directly cause the underlying condition. Kehoe was distinguished because, unlike there, the CAB here cited competing evidence to justify rejecting claimant’s proof.
Appeal of Estate of Dodier, 174 N.H. 548 (2021): Reaffirms the preponderance-of-the-evidence standard for medical causation—the more-likely-than-not threshold.
Appeal of Morin, 140 N.H. 515 (1995): Notes that treating-physician reports are “especially important” and must be accorded “substantial weight,” but Morin does not make such opinions dispositive when weighed against better-founded contrary expert evidence.
Bach v. N.H. Dep’t of Safety, 169 N.H. 87 (2016): Administrative rules are interpreted using the same principles as statutes—relevant to construing Lab 205.09(d).
RSA 21:35; Miller v. Town of Tilton, 139 N.H. 429 (1995): Provides the time-computation rule (exclude the starting day, include the day when the act should occur), applying both when reckoning forward or backward—used to determine that Sunday disclosure did not satisfy the five-business-day requirement ahead of a Friday hearing.
Vogel v. Vogel, 137 N.H. 321 (1993): Invoked for the Court’s decision to decline extended discussion of remaining arguments.
N.H. Admin. R., Lab 205.09(d): Requires medical evidence be furnished to opposing parties five business days before the hearing.
RSA 281-A:19: The workers’ compensation notice/timeliness statute; not reached on the merits because the Court affirmed on causation.

Legal Reasoning

1) The deferential lens controls the outcome. Applying RSA 541:13 and Rancourt, the Court framed its task narrowly: not to decide medical causation de novo, but to confirm whether the CAB’s finding—no causation—was supported by competent evidence. It was. That evidence included (a) Dr. Hedges’ expert opinion, which the CAB found more persuasive based on “considerably more background and expertise” than Dr. Calhoun’s; and (b) medical studies in the record indicating “no widespread acceptance” in the relevant medical community of a causal link between stress and the onset or severity of shingles.

2) Treating-physician weight has limits. The claimant relied on Morin to argue that the CAB had to accord “substantial weight” to Dr. Calhoun’s opinion. The Court agreed with the general principle but emphasized Rancourt: the CAB is free to accept or reject conflicting expert opinions. Here, the CAB accepted Dr. Hedges’ contrary opinion after expressly evaluating the experts’ credentials and the broader medical literature. That approach is well within the CAB’s authority.

3) Role of medical consensus in factfinding. The CAB did not announce a legal rule requiring “widespread acceptance” as a predicate to causation. Rather, it used the absence of such acceptance (as reflected in the admitted literature) as a factor in weighing the probative force of the claimant’s theory. The Supreme Court endorsed this use: where causation hinges on disputed or novel scientific propositions, it is reasonable for the factfinder to consider the state of medical consensus in assessing whether a preponderance of the evidence supports causation. This contrasts with Kehoe, where the CAB gave no competing evidence to justify rejecting the claimant’s proof; here, it had both competing expert testimony and literature.

4) The evidentiary ruling under Lab 205.09(d). The CAB excluded a medical journal article the claimant sent on Sunday, December 3, for a hearing on Friday, December 8. The Supreme Court agreed that (a) a medical journal article is “medical evidence” (not merely argument or demonstrative material), and (b) disclosure did not satisfy the five-business-days rule. Applying RSA 21:35 and Miller, five business days before Friday requires service no later than the preceding Friday; a Sunday transmission leaves only four business days (Monday–Thursday) before the hearing. The exclusion was therefore proper.

5) Timeliness left undecided. Although the CAB alternatively found the claim untimely under RSA 281-A:19 for lack of reasonable diligence, the Court expressly “assume[d] without deciding” that the claim was timely and affirmed solely on causation. Practitioners should not read this decision as guidance on RSA 281-A:19’s application to discovery of work-related causation; that terrain remains open.

Impact and Practical Implications

Expert selection and framing: Claimants advancing medically contested causation theories (e.g., stress as a cause of viral reactivation or severity) should anticipate that the CAB may favor experts with specialized, directly relevant expertise, particularly when supported by peer-reviewed literature. Treating physicians remain important but are not determinative.
Use of medical literature: General medical consensus—or its absence—can materially influence outcomes. Parties should curate high-quality, methodologically sound literature that addresses both general causation (can X cause Y?) and specific causation (did X cause Y in this patient?).
Procedural rigor on disclosures: Medical journal articles are “medical evidence.” To avoid exclusion under Lab 205.09(d), furnish them at least five business days before the hearing, computed under RSA 21:35. As a rule of thumb for a Friday hearing, serve by the prior Friday at the latest.
COVID-era stress claims: This case signals that New Hampshire adjudicators will scrutinize attempts to link pandemic-related occupational stress to somatic conditions like shingles. Without persuasive expert testimony and supportive literature, such claims are vulnerable.
Appellate posture matters: Given the highly deferential standard of review, most disputes over expert weight and medical inferences will be resolved at the CAB level. Building a robust evidentiary record there is critical.
Unresolved limitations questions: Because the Court did not reach RSA 281-A:19, practitioners still lack fresh Supreme Court guidance on how “reasonable diligence” applies when a claimant recognizes work-related causation only years after onset, especially in evolving scientific contexts.

Complex Concepts Simplified

Preponderance of the evidence: The claimant must show it is more likely than not (over 50%) that work activities caused, contributed to, or activated the disabling condition.
Medical causation (general vs. specific): General causation asks whether the type of exposure (e.g., stress) can cause the condition (e.g., shingles onset/severity). Specific causation asks whether it did so for this claimant. Both may be informed by expert testimony and the medical literature.
Treating-physician “substantial weight”: New Hampshire recognizes that treating doctors often have a fuller clinical picture, so their views are important. But there is no presumption that their opinions prevail over other qualified experts; the factfinder chooses which is more persuasive.
Standard of review (“prima facie lawful and reasonable”): On appeal, the Supreme Court largely defers to the CAB’s factfinding. The question is not whether the Court would have decided differently, but whether the CAB’s decision is supported by competent evidence.
“Widespread acceptance” consideration: This is not a legal threshold but an evidentiary consideration. If the relevant medical community has not generally accepted a causal link, that can weigh against finding causation on a more-likely-than-not basis—especially where the opposing expert is highly specialized.
Five-business-day rule (Lab 205.09(d)): Medical evidence (including journal articles) must be furnished at least five business days before the hearing. Under RSA 21:35, exclude the day of service and include the hearing day when counting. Practically, for a Friday hearing, serve by the prior Friday at the latest; weekend service does not count as a business day.

Conclusion

The Supreme Court’s order in Appeal of Palangas delivers a clear procedural and evidentiary message in New Hampshire workers’ compensation law. First, while treating-physician opinions matter, they do not bind the CAB when a more specialized expert, supported by medical literature and the state of scientific consensus, gives a contrary view. Second, the CAB may consider the absence of widespread medical acceptance of a causal link—here, between occupational stress and shingles onset/severity—in evaluating whether the claimant met the preponderance standard. Third, medical journal articles are “medical evidence” subject to the strict five-business-day disclosure rule, and weekend service will not satisfy that requirement for a Friday hearing.

Because the Court affirmed on causation and left the timeliness issue unresolved, the decision’s principal legacy is evidentiary: it strengthens the CAB’s discretion to weigh expert qualifications and medical literature in causation disputes and underscores the importance of rigorous, timely disclosure practices. For practitioners, the case is a reminder that the decisive battle is often won or lost at the CAB, where the record must be scientifically sound and procedurally airtight.