Court Opinion

ID: 5142368
Source: CourtListenerOpinion
Date Created: 2021-12-31 01:15:14.401237+00
Date Added: 2024-06-11T08:24:36.328685
License: Public Domain

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                 THE SUPREME COURT OF NEW HAMPSHIRE

                          ___________________________

Compensation Appeals Board
No. 2020-0185

                   APPEAL OF ESTATE OF PETER DODIER
                (New Hampshire Compensation Appeals Board)

                         Argued: November 19, 2020
                       Opinion Issued: October 14, 2021

      Law Office of Manning & Zimmerman, PLLC, of Manchester (Anna Goulet
Zimmerman and Maureen Raiche Manning on the brief, and Anna Goulet
Zimmerman orally), for the petitioner.

      Trombley & Kfoury, PA, of Bedford (Paul R. Kfoury, Jr. and J. Kirk
Trombley on the brief, and Paul R. Kfoury, Jr. orally), for the respondents.

       BASSETT, J. The petitioner, the Estate of Peter Dodier, appeals an order
of the New Hampshire Compensation Appeals Board (CAB) denying the estate’s
claim for workers’ compensation and death benefits following Peter Dodier’s
death. See RSA 281-A:2, XI, XIII, :26 (2010). The CAB denied the estate’s
claim based on its determination that Dodier’s anxiety and depression were not
a compensable injury. It therefore did not reach the issue of death
benefits. Because we conclude that Dodier’s anxiety and depression are
compensable, we reverse the CAB’s decision and remand for its consideration
of whether the estate is entitled to death benefits.
      The following facts are derived from the CAB’s orders, are supported by
the record, or are otherwise undisputed. Peter Dodier was employed as a
branch manager in the Exeter office of respondent OL International Holdings,
LLC (OL), an international shipping and logistics company. His responsibilities
included overseeing logistics for export and import operations, managing
budgets for the Exeter office, engaging in sales, and managing sales staff. At
the time of his death, Dodier had worked in the transportation industry,
including international transportation, for approximately 30 years.

      In 2016, Dodier began to express feelings of stress related to both work
and his personal life. His stress worsened over a period of months, and on
February 18, 2017, he was admitted to the hospital with symptoms resembling
a panic attack. Dodier told hospital personnel that, over the prior six weeks,
he had experienced increasing stress at work and feelings of personal
inadequacy. He was prescribed anxiety medication, and was discharged the
next day with a diagnosis of unspecified anxiety disorder.

      On February 20, Dodier attended a doctor’s appointment, where he
stated that he had felt increased stress from work for about two months, was
unsure if he could meet the demands of his job, and was concerned about
losing his job. He stated that he had thought about hurting himself, including
thoughts of suicide.

      On February 23, Dodier was admitted to the hospital again, expressing
worsening anxiety and suicidal thoughts. He remained in the hospital for
several days, receiving medication and attending therapy groups. On February
28, he appeared to be in full control of his behavior and denied having “safety
issues.” He requested discharge, and was discharged with a plan for treatment
with a psychiatrist and therapist. Following his discharge, Dodier returned to
work full-time.

       From March 1 to March 9, Dodier attended numerous medical and
therapy appointments with multiple providers, during which he expressed
feeling significant stress related to his employment. At multiple appointments
he described persisting anxiety, largely attributable to feelings of inadequacy at
work. He stated that he was looking for a new job and felt guilty about taking
anxiety medication. He also stated that he was experiencing financial stress.

      On Sunday, March 12, Dodier completed errands in the morning. Later
that day, he died by suicide.

      In May 2018, Dodier’s estate provided a notice of accidental injury or
occupational disease to OL. See RSA 281-A:19, :20 (2010). The notice stated
that Dodier had “developed severe depression and anxiety from the stress of his
job.” Respondent Utica National Insurance Group — OL’s workers’

                                        2
compensation insurer — denied the estate’s claim for benefits. The estate
challenged the denial in the Department of Labor, which upheld Utica’s
decision.

      The estate then appealed to the CAB, arguing that Dodier’s employment
had caused his depression, anxiety, and, ultimately, his death by suicide. The
estate asserted that his depression and anxiety were a compensable injury or
occupational disease under the Workers’ Compensation Law. See RSA 281-
A:2, XI, XIII. The estate also argued that Dodier’s dependents were entitled to
compensation for his death. See RSA 281-A:26.

       In a 2-1 decision, the CAB disagreed, ruling that the estate “failed to
prove by a preponderance of the evidence that . . . Dodier’s anxiety and major
depression illness was causally-related to his employment.” Dr. Albert
Drukteinis and Dr. Lloyd Price opined that Dodier’s employment had
substantially contributed to his depression. In finding for the respondents, the
CAB observed that those opinions were based in part on representations about
Dodier’s work environment made by his wife, who was not familiar with his
day-to-day employment responsibilities. The CAB noted that many of the wife’s
assertions were contradicted by Dodier’s colleagues, who “describe[d] a
generally normal, reasonable, and functional work environment.” Importantly,
the CAB stated that Dr. Drukteinis’s opinion “that work ‘substantially
contributed’ to causing the injury does not permit us to find that the burden of
proving causation has been met. This does not meet the legal requirement that
the injury would not have occurred ‘but for’ the work stress.”

      The CAB concluded that the estate had failed to prove causation in
regard to Dodier’s underlying anxiety and depression, finding that Dodier
experienced several sources of stress, and that “the largest number” were
personal stressors unrelated to his employment. The CAB relied upon the
opinion of the respondents’ expert, Dr. David Bourne. Dr. Bourne had
concluded that “in the final analysis, one cannot attribute . . . Dodier’s
depression to any specific cause. This means that one should not conclude
that work stressors played a substantial contribution to the depression,
because the substantial contributor to the depression was the depression itself,
rather than any external cause.” The CAB did not reach the issue of whether
Dodier’s death by suicide was caused by his employment.

       The estate filed a motion to reconsider, arguing that the CAB had applied
the incorrect causation standard, and that it erred in weighing the evidence,
resulting in an unjust and unreasonable decision. The estate asserted that the
CAB’s use of a “but for” causation standard was error, and that the applicable
standard was whether Dodier’s employment was a “substantial contributing
factor” to his anxiety and depression. The estate also argued that the CAB had

                                       3
erred by failing to adequately consider Dodier’s medical records, which
provided extensive evidence that his employment substantially contributed to
his anxiety and depression.

       The CAB denied the motion, relying on its previous findings that Dodier
had not experienced an increase in work pressure in the months before his
death, and that his work environment was not unusually stressful. The CAB
reiterated that it had credited the opinion of Dr. Bourne, and summarily
maintained that it “did not apply a ‘but for’ legal standard” in regard to
causation. This appeal followed.

       “We will not disturb the CAB’s decision absent an error of law, or unless,
by a clear preponderance of the evidence, we find it to be unjust or
unreasonable.” Appeal of Kelly, 167 N.H. 489, 491 (2015) (quotation omitted);
see RSA 541:13 (2007). We review the CAB’s factual findings deferentially, and
we review its statutory interpretation de novo. Appeal of Northridge Envtl., 168
N.H. 657, 660 (2016). “We construe the Workers’ Compensation Law liberally
to give the broadest reasonable effect to its remedial purpose.” Appeal of
Phillips, 165 N.H. 226, 230 (2013). “Thus, when construing it, we resolve all
reasonable doubts in favor of the injured worker.” Id.

      On appeal, the estate first argues that the CAB erred when it concluded
that the estate did not demonstrate that Dodier’s depression and anxiety were
caused by his employment. The estate contends that the CAB applied too
demanding a standard in determining causation, and that it unreasonably
disregarded evidence from Dodier’s medical records, which establish that his
work “caused or contributed” to his depression and anxiety. The respondents
counter that the CAB’s decision is consistent with New Hampshire law and
supported by the evidence, and is therefore neither unjust nor unreasonable.
We agree with the estate.

      To recover under the Workers’ Compensation Law, an employee must
demonstrate that his injury or occupational disease arose “out of and in the
course of” his employment. RSA 281-A:2, XI, XIII; see Appeal of Margeson, 162
N.H. 273, 277 (2011). In Margeson, we explained that the phrase “in the
course of” employment refers to whether the injury occurred within the
boundaries of time and space created by the terms of employment and
occurred in the performance of an activity related to employment. Margeson,
162 N.H. at 277. We further explained that the phrase “arising out of”
employment refers to the causal connection between the injury and the risks of
employment, and requires proof that the injury resulted from a risk created by
the employment. Id. We set forth a framework for determining when an injury
arises out of employment. See id. at 277-79, 284-85; see also Kelly, 167 N.H.
at 492-94 (recounting our decision in Margeson).

                                       4
       There are four types of injury-causing risks commonly faced by an
employee at work: (1) risks directly associated with employment; (2) risks
personal to the claimant; (3) mixed risks; and (4) neutral risks. Margeson, 162
N.H. at 277. The first category, employment-related risks, includes the risk of
injuries generally recognized as industrial injuries, such as fingers being
caught in gears. Id. “This category of risks always arises out of employment.”
Id.

       The second category is so clearly personal that, even if the risks take
effect while the employee is on the job, they could not possibly be attributed to
the employment. Id. An example would be a fall caused solely by an
employee’s medical condition, such as epilepsy. Id. at 277-78. “Injuries falling
squarely into this category are never compensable.” Id. at 278.

      The third category involves a personal risk and an employment risk
combining to produce injury. Id. A common example of a mixed-risk injury is
when a person with heart disease dies because of employment-related strain on
the person’s heart. Id. “While not all injuries resulting from mixed risks are
compensable, the concurrence of a personal risk does not necessarily defeat
compensability if the claimant’s employment was also a substantial
contributing factor to the injury.” Id.

      Finally, neutral risks are of neither distinctly employment nor distinctly
personal character. Id. These risks include being hit by a stray bullet or
struck by lightning. Id. They can also include cases in which the cause itself,
or the character of the cause, is simply unknown. Id.; see, e.g., Appeal of
Doody, 172 N.H. 802, 808-09 (2020).

       In Margeson, we identified the applicable standards based on the type of
risk that caused the employee’s injury. See Margeson, 162 N.H. at 284-85. If
the injury was caused by a neutral risk, the “increased-risk test” applies, which
provides that an employee may recover if his employment subjected him to a
risk greater than that faced by the general public. See id. at 283-85. If,
however, the injury was caused by a non-neutral risk, the claimant must
demonstrate both legal and medical causation, as set forth in New Hampshire
Supply Co. v. Steinberg, 119 N.H. 223, 230-31 (1979). See Margeson, 162 N.H.
at 285.

       “Legal causation requires a showing that the claimant’s injury is in some
way work-related, while medical causation requires a showing that the injury
was actually caused by the work-related event.” Kelly, 167 N.H. at 493
(quotation omitted); see Steinberg, 119 N.H. at 230-31. “The test to be used for
legal causation depends upon the previous health of the employee.” Kelly, 167
N.H. at 493. If the employee suffers from a preexisting condition, the

                                        5
employment-connected stress or strain must be greater than that encountered
in normal non-employment life. Id. If the claimant does not have a preexisting
condition, any work-related activity connected with the injury as a matter of
medical fact is sufficient to show legal causation. Margeson, 162 N.H. at 279.

      The test for medical causation requires the claimant to establish, by a
preponderance of the evidence, that work-related activities probably caused or
contributed to the injury as a matter of medical fact. Appeal of Kehoe, 141
N.H. 412, 417 (1996). When a claimant demonstrates that he had no
preexisting condition, a showing of medical causation also establishes legal
causation. See Petition of Dunn, 160 N.H. 613, 622 (2010).

       The respondents argue that we should affirm the CAB’s decision because
it properly found that the estate failed to prove either medical or legal
causation. The respondents contend that, by crediting the opinion of Dr.
Bourne, the CAB properly exercised its discretion to weigh competing evidence,
and reasonably concluded that medical causation had not been shown. The
respondents further assert that, by concluding that Dodier’s work environment
was generally normal and reasonable, and by considering evidence of non-
employment stressors that may have affected Dodier, the CAB reasonably
found that legal causation had not been shown. As explained below, we
disagree.

      In conducting its causation analysis, the CAB erred. Here, as the CAB
noted, Dodier experienced work-related stress as well as stress from sources
outside of work. Accordingly, Dodier’s anxiety and depression resulted from a
mixed risk, and therefore the Steinberg causation analysis of legal and medical
causation applies. See Kelly, 167 N.H. at 493. However, rather than apply this
analysis, the CAB utilized a “but for” causation test, rejecting the proposition
that the estate could meet its burden by showing that Dodier’s employment
was a “substantial contributing factor” to his injury. See id. at 494-96;
Margeson, 162 N.H. at 278.

       In regard to Dr. Drukteinis’s opinion “that work ‘substantially
contributed’ to causing the injury,” the CAB stated that “[t]his does not permit
us to find that the burden of proving causation has been met. This does not
meet the legal requirement that the injury would not have occurred ‘but for’ the
work stress.” (Emphasis added.) Similarly, when analyzing Dr. Price’s opinion
that events and stresses associated with work were “the most significant and
predominate contributing cause of . . . Dodier’s symptoms of anxiety and
depression,” the CAB stated, “[a]gain, this can only mean that he believes there
were other causes that contributed to cause these conditions.” The CAB
concluded: “In sum, no medical expert has stated that, but for the work
pressures, . . . Dodier would not have developed his anxiety and depression.”
(Emphasis added.)

                                       6
       Notwithstanding these explicit statements, the respondents argue that
the CAB did not actually apply a “but for” causation test. They note that, in its
order denying the estate’s motion to reconsider, the CAB denied that it had
“appl[ied] a ‘but for’ legal standard” in regard to causation. However, the CAB’s
disavowal is not convincing; not only did the CAB fail to provide an alternative
analysis, but merely insisting that it did not employ a “but for” standard does
not erase the fact that it did just that. When we construe the two orders
together, it is evident that the CAB did not apply the proper causation
standard, and did not make the factual findings necessary to support a proper
causation analysis. See In the Matter of Sheys & Blackburn, 168 N.H. 35, 39
(2015) (“The interpretation of a court order is a question of law, which we
review de novo.”).

       Ordinarily, we would remand to the CAB for it to apply the Steinberg
causation analysis. However, “when a lower tribunal has not addressed a
factual issue, but the record reveals that a reasonable fact finder necessarily
would reach a certain conclusion, we may decide that issue as a matter of law.”
Appeal of Cote, 139 N.H. 575, 580 (1995). Here, none of the doctors who
submitted expert reports testified before the CAB. Therefore, “because we have
before us the same documentary record that was available to the [CAB],” our
determination as to whether a reasonable fact finder could conclude that the
estate failed to demonstrate legal and medical causation is a “purely legal
question.” Id. at 580-82 (observing that, without testimony from the medical
experts, the CAB was not “in a better position to assess the experts’ credibility,”
and ruling that a reasonable fact finder would necessarily conclude that
employee’s medical condition was related to an earlier work-related injury,
when five of six doctors who submitted reports reached that same conclusion).
After reviewing the same medical records and expert reports as reviewed by the
CAB, we conclude that this is a “purely legal question,” and that, for the
reasons set forth below, the evidence leads to only one reasonable conclusion:
that, even assuming that Dodier suffered from a preexisting condition, see
Margeson, 162 N.H. at 279, the estate demonstrated legal and medical
causation as to Dodier’s anxiety and depression. See Cote, 139 N.H. at 580.

      The evidence in the record is extensive, and includes several hundred
pages of medical records, expert reports, and testimony. The most significant
evidence as to legal and medical causation is found in Dodier’s medical records
from February and March of 2017, when he received treatment for his anxiety
and depression. During that time, Dodier also kept a journal to help him
process and cope with his condition. As Dr. Price correctly observed, these
records — generated just weeks before Dodier’s death — are “replete with
references to . . . Dodier’s workplace stresses and stressors.”

      For example, when Dodier first sought treatment at the hospital on
February 18, he stated that “over the last 6 weeks he ha[d] had increasing
stress at work and feelings of personal inadequacy.” During a medical
                                        7
appointment on February 20, he stated that his company was in transition,
that he was not sure whether he could meet the demands, and that he was
concerned about losing his job. When he was re-admitted to the hospital on
February 23, he stated that he was overwhelmed with his job and had been
working many hours. He described his job as very stressful and stated that he
was looking for a new one. During the first week of March, Dodier reported to
a medical provider that he was feeling anxiety “mostly stemming from
inadequacy at work,” and reiterated that he was looking for a new position. He
said that he had experienced increased stress over the previous five months
“since a poor report at a revenue meeting in October, 2016.” In addition, in his
journal entry of Sunday, March 5, Dodier stated that he was “[g]etting pretty
anxious and worried about working tomorrow.” In his entry of March 6, he
stated that he had had a “[t]ough morning [at] work” due to issues with some
deliveries, and that he was doubting his ability at work, which “really
bother[ed]” him. These are but a few of the many references to work stress in
Dodier’s medical records and journal entries.

       To be sure, Dodier’s medical records also contain references to other
sources of stress. Dodier reported that he was experiencing financial stress,
and that he had been struggling with turning 55 and looking at where he was
in his life. Nonetheless, as Dr. Drukteinis correctly observed: “Every one of . . .
Dodier’s mental health treatment providers between 02/18/17 and his death
on 03/12/17 refer[s] to work stress as a primary source of . . . Dodier’s
symptoms.”

      We note that Dr. Bourne found it significant that Dodier did not leave a
suicide note, opining that without such a note

      one cannot know what [Dodier] was thinking in the minutes prior
      to his suicide. I believe that the lack of a suicide note renders the
      connection between any specific stressors – including the work
      stressors – and his death to be speculative.

Given the voluminous evidence of employment-related stress in the final days
and weeks of Dodier’s life — well documented in the medical records — Dr.
Bourne’s reliance on the lack of a suicide note is misplaced.

        In finding that the estate failed to demonstrate causation as to Dodier’s
anxiety and depression, the CAB relied on Dr. Bourne’s opinion. Yet Dr.
Bourne candidly acknowledged that Dodier’s medical records and journal
entries contain numerous references to work-related stress. In Dr. Bourne’s
first report, which was based almost entirely on Dodier’s medical records and
journal entries, he observed that “Dodier’s perception of the work environment
was clearly among the stressors identified to healthcare providers.” Yet, at that
time, he stated that he could not reach a conclusion as to causation without

                                         8
obtaining “a balanced history from multiple perspectives” — particularly those
of the employer. More than a year later, Dr. Bourne submitted a second report,
in which he opined that Dodier’s employment did not substantially contribute
to his depression. That report was based largely on Dr. Bourne’s review of the
testimony of Alan Baer, President of OL, and Kaitlin Painter, an employee
whom Dodier supervised.

       This witness testimony does not support the conclusion that Dodier’s
employment was not a substantial contributing factor to his anxiety and
depression. In fact, in his second report, Dr. Bourne acknowledged that Baer
stated that Dodier “did talk about being stressed and had to be told not to
worry and to relax.” Moreover, although Painter testified that Dodier spoke
about sources of stress outside of work,1 she acknowledged that Dodier also
expressed feelings of stress related to his employment. Painter confirmed that,
in 2016, Dodier made the final decision to hire a salesperson for the Exeter
office. Shortly thereafter, the salesperson was diagnosed with cancer and was
out of work for several months. When he returned, he struggled significantly in
his role, and was put on probation. Painter reported that Dodier expended
significant time and energy trying to motivate the salesperson and help him
improve his performance, but that he “just wasn’t [making sales] so it was a
stressful situation.”

       Further, Painter testified that Dodier believed that the Exeter office was
understaffed. Although Painter did not agree with this assessment, she
acknowledged that Dodier spoke to her about hiring an additional employee for
the office. In fact, as part of his second report, Dr. Bourne reviewed an email
that Dodier wrote to Baer and another supervisor just four days before his
death, in which he urged them to allow the office to hire an additional
employee, emphasizing that he “wouldn’t ask if [he] didn’t think it was
important.” In that same email, Dodier also thanked his supervisors “for giving
[the salesperson] the added time to prove himself,” thereby confirming that the
salesperson’s performance and standing with the company were a source of
concern for Dodier. Taken together, the testimony, emails, medical records,
and journal entries inexorably lead to one conclusion: that Dodier’s
employment was causing him significant stress, which substantially
contributed to his anxiety and depression.

       In addition, even if one accepts Dr. Bourne’s theory of Dodier’s illness as
true, that does not mean that the estate failed to demonstrate legal and
medical causation. Dr. Bourne concluded that “Dodier’s depression was of the
type that would be classified as an endogenous, or biological depression, as

1 Painter testified that Dodier expressed feelings of stress related to caring for his mother and a
lawsuit he had been involved in. It is notable, however, that Dodier’s medical records and
journal entries contain no reference to those issues as sources of his stress.

                                                 9
opposed to reactive, or exogenous depression.” In essence, Dr. Bourne found
that Dodier’s depression was not caused by “any external cause,” such as work
or personal stress, but rather unrelated biological causes. Dr. Bourne
concluded that “[i]t is more likely that, because he was depressed . . . Dodier
started dwelling on issues such as being 55, worrying unreasonably about his
financial future . . . and worrying about work performance and about his ability
to perform his job.” Thus, in Dr. Bourne’s view, Dodier’s depression pre-dated
and was completely unrelated to his work stress, causing him to perceive his
employment as more stressful than it actually was.

      However, at most, Dr. Bourne’s opinion could establish that Dodier
suffered from a preexisting condition; it does not demonstrate that Dodier’s
anxiety and depression are not a compensable injury. The very concept of a
mixed-risk injury reflects the fact that a compensable injury can have both
employment and non-employment causes. See Margeson, 162 N.H. at 278.
That is why an injury is compensable even if the employee suffers from a
preexisting condition, so long as the claimant shows “by a preponderance of
the evidence that his employment contributed something substantial to his
medical condition by demonstrating that the work-related conditions presented
greater risks than those encountered in his non-employment activities.” Id. at
279 (quotation omitted). For example, a heart attack is compensable even if
the employee suffers from “a previously weakened or diseased heart,” so long
as the employment contributed “something substantial to the heart attack.”
Steinberg, 119 N.H. at 231.

      For the same reasons, “[a]n employee with a congenital or degenerative
disease need not prove that his disability would not have arisen but for his
employment. If work activities contribute to the employee’s disability, even if
disability without such contribution would result from his condition at some
future date, the employee may recover.” Appeal of Bellisle, 144 N.H. 201, 204
(1999). An employee must prove that a specific work-related incident or
cumulative work-related stress “contributed to, aggravated, exacerbated, or
accelerated the employee’s congenital or otherwise preexisting condition to
disability.” Id. Consequently, an employee may receive compensation for
depression induced in part by employment-related stress, even if the employee
suffers from preexisting depression and other mental health issues. See
Appeal of N.H. Dep’t of Health and Human Servs., 145 N.H. 211, 212, 214-16
(2000) (decided under prior version of RSA 281-A:2, XI). The mere fact that a
mental illness cannot be attributed solely to a claimant’s employment does not
mean that the injury is not compensable. See Averill v. Dreher-Holloway, 134
N.H. 469, 470-73 (1991) (affirming trial court’s conclusion that claimant’s
employment-related stress caused or contributed to his depressive illness,
when claimant suffered from physical ailments due to multiple pre-employment
accidents, as well as numerous additional medical conditions and personal
problems that developed throughout his thirteen years working for the
employer).
                                      10
       With these principles in mind, and having set out the evidence above, we
now apply the tests for legal and medical causation. In regard to legal
causation, as explained above, when an employee suffers from a preexisting
condition, the employee must show that his work-related conditions presented
greater risks than those he encountered in his non-employment activities. See
Margeson, 162 N.H. at 279; see also Steinberg, 119 N.H. at 231 (explaining
that when an employee suffers from a preexisting condition, an injury is
compensable so long as the employment “contribute[d] something substantial”
to the injury). Here, even accepting Dr. Bourne’s conclusion that Dodier
suffered from biological depression that preexisted his work-induced stress, a
reasonable fact finder would necessarily conclude that the estate met its
burden.

       The CAB found that Dodier did not experience a significant increase in
either work-related or non-work-related pressures in the months before his
death. Given this finding, and that the CAB adopted Dr. Bourne’s opinion that
Dodier’s depression was not caused by events either within or outside of his
employment, we interpret the CAB’s order as concluding that neither Dodier’s
work nor non-work environment was unusually stressful. See Sheys, 168 N.H.
at 39 (stating that the interpretation of a court order presents a question of
law). Notwithstanding that neither source of risk was unusual, the estate
demonstrated legal causation by showing that the risks of stress from Dodier’s
employment were greater than the risks of stress from his non-employment
activities. The medical records and journal entries, “replete with references” to
Dodier’s workplace stressors, demonstrate that Dodier’s employment
contributed more to his stress than did his non-work activities. Indeed, as Dr.
Drukteinis correctly noted, all of Dodier’s mental health treatment providers
between February 18 and his death on March 12 referred to work stress as a
primary source of his anxiety and depression.

       As to medical causation, the employee’s burden is to show that work-
related activities probably caused or contributed to the injury as a matter of
medical fact. Kehoe, 141 N.H. at 417. We have little trouble concluding that a
reasonable fact finder would determine, as did Drs. Drukteinis and Price, that
Dodier’s employment caused or contributed to his anxiety and depression.
Even if Dodier were suffering from biological depression that left him in a more
vulnerable mental condition, the inescapable conclusion from the medical
records and journal entries is that his employment “contributed to, aggravated,
exacerbated, or accelerated . . . [his] preexisting condition to disability.”
Bellisle, 144 N.H. at 204. Even if Dodier’s depression preexisted his work-
induced stress, and his reaction to his work environment may have been
unexpected, we conclude that Dodier’s injury is compensable because his
employment contributed substantially to the worsening of his symptoms. See
N.H. Dep’t of Health and Human Servs., 145 N.H. at 214-15. The CAB’s
conclusion to the contrary was based on its application of an improper “but for”

                                       11
causation test, and, applying the proper causation analysis, we conclude that a
reasonable fact finder would necessarily determine that the estate met its
burden. See Cote, 139 N.H. at 582.

       Finally, the estate urges us to find that Dodier’s anxiety and depression
caused his death by suicide, or, alternatively, that we remand to the CAB
directing it to determine whether his death by suicide was caused by his
mental injury. The respondents counter that because Dodier’s suicide was
caused by a “willful intention to injure himself,” RSA 281-A:2, XI, death
benefits under RSA 281-A:26 are barred as a matter of law, and it is therefore
irrelevant whether Dodier’s suicide was caused by his anxiety and depression.

       On October 13, 2021, we decided Appeal of Pelmac Industries Inc., 174
N.H. ___, ___ (decided October 13, 2021), in which we held that, in some
circumstances, an employee’s death by suicide does not result from the
employee’s “willful intention to injure himself,” RSA 281-A:2, XI, such that
death benefits are barred under RSA 281-A:26. See Pelmac, 174 N.H. at __
(slip op. at 10-13). We stated that an employee’s death by suicide “is
compensable under RSA 281-A:26 if the claimant proves by a preponderance of
the evidence that the suicide resulted from a disturbance of mind of such
severity as to override normal, rational judgment, and that such disturbance of
mind resulted from the employee’s work-related injury and its consequences.”
Id. at __ (slip op. at 12). We explained that this chain-of-causation test, similar
to that adopted in other states, “essentially places the burden on the claimant
to prove by a preponderance of the evidence that there was an unbroken chain
of causation between the work-related injury, the disturbance of mind, and the
ultimate suicide.” Id. at __ (slip op. at 12) (quotation and brackets omitted).

     We remand for further proceedings consistent with this opinion. On
remand, the CAB must apply the test set forth in Pelmac to determine whether
Dodier’s death by suicide was a direct and natural result of his initial
compensable injury of anxiety and depression, such that the suicide is
compensable under RSA 281-A:26.

                                                   Reversed and remanded.

      HICKS, HANTZ MARCONI, and DONOVAN, JJ., concurred.

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