Court Opinion

ID: 4545251
Source: CourtListenerOpinion
Date Created: 2020-06-30 19:03:06.629213+00
Date Added: 2024-06-11T09:24:58.600667
License: Public Domain

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                                                         Electronically Filed
                                                         Supreme Court
                                                         SCWC-XX-XXXXXXX
                                                         30-JUN-2020
                                                         08:12 AM

           IN THE SUPREME COURT OF THE STATE OF HAWAIʻI

                            ---o0o---
________________________________________________________________

                            JAY D. CADIZ,
                   Petitioner/Claimant-Appellant,

                                  vs.

                             QSI, INC.,
                   Respondent/Employer-Appellee,

                                  and

            FIRST INSURANCE COMPANY OF HAWAI‘I, LTD.,
             Respondent/Insurance Carrier-Appellee.
________________________________________________________________

                           SCWC-XX-XXXXXXX

         CERTIORARI TO THE INTERMEDIATE COURT OF APPEALS
   (SCWC-XX-XXXXXXX; CAAP-XX-XXXXXXX; AB 2012-099 (2-10-46361)
 AND SCWC-XX-XXXXXXX; CAAP-XX-XXXXXXX; AB 2013-250 (2-11-46922))

                            JUNE 30, 2020

  RECKTENWALD, C.J., NAKAYAMA, McKENNA, POLLACK, AND WILSON, JJ.

                 OPINION OF THE COURT BY WILSON, J.

                          I.   INTRODUCTION

          This case concerns a workers’ compensation claim by an

employee for an injury-by-disease stemming from his exposure to
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pervasive mold in his work environment over a four-year period

and the subsequent breakdown of his health.           The employee,

Jay D. Cadiz (“Cadiz”), worked different jobs at various Times

Supermarket stores in different locations on Oʻahu for several

years.   Cadiz then transferred to Times Supermarket in Kāne‘ohe,

owned by QSI, Inc. (“employer”),1 where he worked for four years

in the meat department as a “meatcutter.”          Prior to working at

the Kāne‘ohe store, Cadiz was healthy and exercising daily,

including engaging in martial arts.         Shortly after moving to the

Kāne‘ohe store in 2004, he “began to feel sick all the time.”

           Cadiz filed a workers’ compensation claim for injury-

by-disease, and the Labor and Industrial Relations Appeals Board

(“LIRAB”) rejected Cadiz’s claim,2 concluding that the employer’s

reports based on three Independent Medical Examinations (“IME”)

provided sufficient substantial evidence to overcome the

statutory presumption in favor of compensability.            See Hawaiʻi

Revised Statutes (“HRS”) § 386–85(1)(1984) (“In any proceeding

for the enforcement of a claim for compensation . . . it shall

be presumed, in the absence of substantial evidence to the

contrary: (1) That the claim is for a covered work injury[.]”)

     1
            For ease of reference, QSI, Inc.’s insurance carrier, First
Insurance Company of Hawaii, Ltd., also a party, is included in our use of
the term “employer.”
     2
            This brief summary simplifies and condenses a more complicated
and extended process. See section II below for a more detailed and accurate
account.

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           “When determining whether a worker’s compensation

claim is work-related, it is well established in Hawaiʻi that ‘it

shall be presumed, in the absence of substantial evidence to the

contrary . . . [t]hat the claim is for a covered work injury[.]’

HRS § 386-85 (1993).”    Panoke v. Reef Dev. of Hawaii, Inc., 136

Hawaiʻi 448, 461, 363 P.3d 296, 309 (2015).     The presumption that

a worker’s claimed injury is “work-connected” and therefore

compensable is one of “the ‘keystone principles’ of our workers’

compensation plan.”    Flor v. Holguin, 94 Hawaiʻi 70, 79, 9 P.3d

382, 391 (2000).   That presumption is paramount, in part,

because the workers’ compensation statute “provides an injured

employee’s exclusive remedy for an injury arising out of and in

the course of employment.”    Ihara v. State Dep’t of Land & Nat.

Res., 141 Hawaiʻi 36, 42, 404 P.3d 302, 308 (2017) (internal

quotation marks and citation omitted).     To rebut the

presumption, the employer has the burden of going forward with

the evidence, which is the burden of production, as well as the

burden of persuasion; the burden of production means that the

employer must initially introduce substantial evidence that, if

true, could rebut the presumption that the injury is work-

related.   Panoke, 136 Hawaiʻi at 461, 363 P.3d at 309.      The

burden of production means that the employer must initially

introduce substantial evidence that, if true, could rebut the

presumption that the injury is work-related.      Id.; see also,

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Korsak v. Hawaii Permanente Med. Grp., 94 Hawaiʻi 297, 307, 12

P.3d 1238, 1248 (2000) (“Hawaii’s workers’ compensation

presumption places a heavy burden on the employer to disprove

that an injury is work-related. . . .       HRS § 386–85(1) creates a

presumption in favor of the claimant that the subject injury is

causally related to the employment activity.”       (citation

omitted, first emphasis added)).       Substantial evidence is

relevant and credible evidence of a quality and quantity

sufficient to justify a conclusion by a reasonable person that

an injury or death is not work-connected.       Panoke 136 Hawai‘i at

469, 363 P.3d at 317.

          If the employer meets the burden of production, the

burden of persuasion requires that the trier of fact weigh the

evidence elicited by the employer against the evidence elicited

by the claimant.   Id.   In evaluating whether the burden of

persuasion has been met in the workers’ compensation context,

“the broad humanitarian purpose of the workers’ compensation

statute read as a whole requires that all reasonable doubts be

resolved in favor of the claimant.”       Van Ness v. State Dep’t of

Educ., 131 Hawaiʻi 545, 558, 319 P.3d 464, 477 (2014)(citations,

internal quotation marks, and brackets omitted).

          For the reasons detailed more fully below, we hold the

employer’s IME reports failed to provide substantial evidence to

meet its burden to produce evidence that, if true, would

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overcome the statutory presumption that the injury is work-

related.   As the employer failed to meet its burden of

production, we do not reach the issue of whether the employer

met its burden of persuasion.        Panoke at 462, 363 P.3d at 310.

           Cadiz presented laboratory evidence of elevated levels

of dangerous mycotoxins in his body.         That evidence was never

rebutted by the employer’s IME reports.          Indeed, the employer’s

IME reports never addressed the scientific evidence of elevated

levels of mycotoxins in Cadiz’s body in relation to the

presumption in favor of compensability.          In addition, although

the LIRAB’s decision and order included the boilerplate language

that “all reasonable doubts have been resolved in favor of

Claimant,” in fact, the LIRAB failed to do so.

           Based on the laboratory evidence confirming elevated

levels of harmful mycotoxins in Cadiz’s body, and based on the

employer’s failure to meet its burden of production, we conclude

that the employer failed to overcome the presumption in favor of

compensability.     Accordingly, we vacate the ICA’s judgment on

appeal and its Summary Disposition Order (“SDO”), and we vacate

the LIRAB’s decision and order in case number AB 2012-099 (2-10-

46361) (Cadiz I).3     We remand to the LIRAB with the instruction

      3
            As our background section below narrates, this case was the
subject of two different full de novo hearings before the LIRAB, which we
designate Cadiz I and Cadiz II. In the first, for procedural reasons, Cadiz
was not allowed to present the live testimony of his expert, Dr. Janette
                                                             (. . . continued)

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that Cadiz’s injury-by-disease is compensable under Hawaiʻi’s

workers’ compensation law and for proceedings consistent with

this opinion.

                             II.    BACKGROUND

            After working different jobs at various Times

Supermarket stores in different locations for several years, Jay

Cadiz transferred to the Times Supermarket in Kāne‘ohe.            He

worked for four years in the Kāne‘ohe meat department as a

meatcutter, working eight hours a day, five days a week, with

approximately five hours of overtime per week.           According to

Cadiz, prior to working at the Kāne‘ohe store, he was healthy and

exercising daily.     He engaged in martial arts.        Shortly after

moving to the Kāne‘ohe store in approximately June 2004, he

“began to feel sick all the time.”         The Kāne‘ohe store, he said,

“was the first dirty store I worked in:          molds all over the

walls, ceilings, lots of drain[s] with molds, caved in ceilings,

crack[s] in ceilings.”
_____________________
(continued. . . )

Hope, on the various adverse health-related effects of mycotoxin exposure and
inhalation. In the second, Dr. Hope gave extensive live testimony, but the
LIRAB disregarded that testimony for procedural reasons.

            As noted, we base our holding on the laboratory evidence
confirming elevated levels of harmful mycotoxins in Cadiz’s body presented in
Cadiz I (albeit in abbreviated form), and we base it, as well, on the
requirement in Hawai‘i’s workers’ compensation law that all reasonable doubts
must be resolved in favor of the claimant. Because our holding rests on
those bases, it is unnecessary to address the merits of the LIRAB’s
procedural determinations in Cadiz II.

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          According to Cadiz, the mold covered “all the fans,

the AC fans, the left side wall was just covered in black mold

and the right side of the wall, near the cutting table, it was

just black; like pitch black mold just eating up the walls and

ceiling,” as well as the storage room.        The ceiling of the meat

department was always wet.    Twice, the ceiling fell into the

meat department when it rained.        The first time the ceiling fell

was in early August 2004, a few months after he began working at

the Kāne‘ohe store.

          After a few months of working in this environment,

Cadiz began experiencing “breathing problems, asthma attacks,

sinus infections, and debilitating headaches,” as well as

dizziness and vertigo.    Four of the other workers in the meat

department at the time also complained of breathing difficulties

and other ailments.    Beginning in 2007, Cadiz took extensive

leaves for illness, and he finally resigned from his job as a

meatcutter towards the end of 2008.

          For the five years prior to working at the Kāne‘ohe

Times store, Cadiz averaged eight visits to a doctor or

emergency room per year, including visits relating to a

concussion he received while performing martial arts.        While

working in the meat department, he saw a physician or received

emergency treatment on average of twenty-six times per year.

From August 31, 2007, when he experienced heart palpitations,

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through the end of 2007, Cadiz sought treatment from medical

personnel or social workers forty-three times.

            Cadiz brought an initial claim for workers’

compensation in September 2010.     In the space on the claim form

reserved for a response to “describe how accident occurred,” he

indicated that the accident occurred when he was working at the

Kāne‘ohe Times Supermarket and was “exposed to black mold” over

four years in his work at the meat department.      In the space on

the claim form reserved for a response to “describe

injury/illness,” he responded:     “Headaches, dizziness,

respiratory problems, memory problems, vision, skin problems,

anxiety.”    Cadiz brought an “amended claim” for workers’

compensation benefits in November 2011, based largely on the

same set of facts but this time claiming “exposure to mold”

generally, and alleging “additional injuries.”      The description

of the illness in the amended claim expanded to “headaches,

respiratory illnesses, cognitive impairment, psychological

injury, chronic rhinitis/sinusitis, vertigo, tinnitus,

palpitations, sleep disturbance, myalgia, GERD, gastritis,

urinary frequency, dysuria, malaise, fatigue.”

            In October 2011, Dr. Myles Suehiro ordered a urine

test from RealTime Laboratories on behalf of Cadiz in order to

detect the presence of any mycotoxins in Cadiz’s body.       Cadiz

tested positive for elevated levels of two mycotoxins;

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ochratoxin and trichothecene.        Mycotoxins are toxins generated

by molds or fungi.      According to a RealTime Laboratories article

cited by both parties:

           The negative health effects of mycotoxins are a function of
           the concentration, the duration of exposure and the
           individual’s sensitivities. The concentrations experienced
           in a normal home, office, or school are often too low to
           trigger a health response in occupants. However,
           concentrations experienced in a home or building which has
           experienced water leaks are often high enough to trigger
           health responses in the occupants.

Trichothecenes are mycotoxins generated by different fungi,

including Stachybotrys chartarum (“Stachybotrys”).            According to

the same source, “[t]heir mechanism of action is the inhibition

of protein synthesis, therefore they are known to kill cells and

are extremely dangerous.”       In addition, “when Stachybotrys grows

in a mold infested building, the organism produces trichothecene

mycotoxins.    It is also known that these toxins can get into the

air where they can be inhaled.”        Different variations of

trichothecene mycotoxins “are strongly toxic compounds.”

           Pursuant to HRS § 386-79 (1996), the employer

designated and paid two physicians and one psychologist to

examine Cadiz and produce independent medical examinations.4

     4
            In the workers’ compensation context, the word “independent,” in
the phrase “independent medical examination,” can be something of a misnomer.
A physician who performs an “independent medical examination” has been
selected by the employer and paid for by the employer. HRS § 386-79(a)
(“After an injury and during the period of disability, the employee, whenever
ordered by the director of labor and industrial relations, shall submit to
examination, at reasonable times and places, by a duly qualified physician or
surgeon designated and paid by the employer.”) The examining physician is

                                                             (. . . continued)

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Cadiz was examined by Dr. Leonard Cupo on January 11, 2011.               Dr.

Cupo produced an IME on November 12, 2011.          Cadiz was examined

by psychologist Dr. Roger Likewise on January 10, 2011.             Dr.

Likewise produced an independent psychological examination

(referred to below for convenience as an IME) on November 18,

2011.

            Finally, Cadiz was examined by Dr. Ajit Arora for one

and a half hours on October 29, 2012.          Only three days later,

Dr. Arora produced a 407-page, single-spaced IME report,

including appendices and synopses of articles in the medical and

toxicological literature.       Appendix B, for example, ran from

page 360 to 385 of Dr. Arora’s report.          It included a list of

the titles of 51 articles dealing with mold and related health

issues in humans.     The most recent of those articles was from

2002, 10 years prior to the IME.          Appendix B also included

abstracts of various articles relating to mold, mycotoxins, and

toxicology, none more recent than 2002.          Appendix B also

included various excerpts from the American College of

Occupational Environmental Medicine (“ACOEM”) relating to toxic

_____________________
(continued. . . )

“independent” in the sense that she cannot be the claimant’s personal
physician, and the examination is “independent” in the sense that no
physician-patient relationship is created between the physician-examiner and
the employee as a result of the examination. See 61 Am. Jur. 2d Physicians,
Surgeons, Etc. § 273 (“When an employer retains a physician to examine its
employees, generally, no physician-patient relationship exists between the
employee and the doctor[.]”)

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mold, including excerpts concerning a particularly dangerous

toxic mold whose scientific name is Stachybotrys.      The excerpts

from the ACOEM are also from 2002.

          Dr. Cupo’s IME report itemized 16 of Cadiz’s symptoms

under the heading “Diagnoses.”     For each symptom, Dr. Cupo wrote

the same refrain, repeated 16 times: X symptom was “not caused,

aggravated, or accelerated by job activities as a meat cutter

for Times Supermarket.”    According to Dr. Cupo, Cadiz had not

tested positive for an allergy to mold but had tested positive

for an allergy to dust mites.     Thus, Cadiz’s rhinosinusitis,

chronic headaches, recurrent shortness of breath, etc., all were

“medically plausibly explainable by other medical conditions”

without needing to resort to toxic mold exposure.

          According to Dr. Likewise, Cadiz suffered from

“hypochondriacal preoccupations,” chronic somatization,

generalized anxiety disorder, or chronic panic attacks, and

dependent personality disorder.     Dr. Likewise does not appear to

have offered any suggestion as to which of Cadiz’s multiple

symptoms were psychosomatic and which were not.      Rather, his

report gives the impression that, apart from allergies, they all

might be psychosomatic.

          According to Dr. Arora, Cadiz’s headaches, dizziness,

nausea, chronic rhinitis, sinusitis, and asthma could be

“explained by chronic anxiety and panic disorder” through the

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mechanism of “hyperventilation.”         On the subject of mold, Dr.

Arora opined that the

     black mold of concern has been Stachybotrys chartarum, which does
     not grow on walls and ceilings. It is a fastidious mold that
     only grows above the ceilings in dark and on wooden beams in
     attics. The black mold that grows in the lighted areas on walls
     or ceilings is Cladosporium, which is a relatively benign mold,
     causing only allergies.

Dr. Arora opined that spore counts are the proper measure of

mold toxicity.    According to him, if the meat department at

Times “was the worst building ever described in the United

States, then one would not anticipate more than 1700 spores of

Stachybotrys per cubic meter.       That will not be sufficient to

cause toxicity from inhalation.”

            Materials included in Dr. Arora’s IME report included

an abstract of an article stating that in one study, “evidence

was found of a relationship between high levels of inhalation

exposure or direct contact to mycotoxin-containing molds or

mycotoxins and demonstrable . . . health effects in humans[.]”

Nonetheless, according to the abstract, the then-current

literature (2002) did not provide “compelling evidence that

exposure at levels expected in most mold-contaminated indoor

environments is likely to result in measurable health effects.”

Still, the abstract from the article cautioned that “the point

at which mold contamination becomes a threat to health is

unknown.”   (Emphasis added.)

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           In Appendix B to his IME report, Dr. Arora himself

testified to the adverse health consequences of mycotoxins.             He

wrote, for example, of the “[t]oxic effects from mycotoxins

produced by certain fungal species.         This may include disruption

of cellular function, alteration of immune competence, and

cytotoxic effects with DNA damage and mutations resulting in

cancer such as with aflatoxins.”          In addition, Dr. Arora wrote

that “exposure to mycotoxins at toxic levels can cause illness

. . . in humans and animals.”       Finally, Dr. Arora characterized

trichothecenes, one of the mycotoxins verified by laboratory

results to be present at elevated levels in Cadiz’s body:

“Trichothecenes are the most widely studied mycotoxins. . . .

Trichothecenes are potent inhibitors of protein synthesis in

eukaryotic cells, particularly in rapidly proliferating tissues.

This property has led to their use as biological weapons.”

Other than these relatively generic mentions of trichothecenes

in Appendix B of his IME report, Dr. Arora never specifically

discusses trichothecenes in relation to Cadiz.          That is, in his

IME report, Dr. Arora never discusses the laboratory results

proving that Cadiz had elevated levels of trichothecenes in his

body.5

      5
            Appendix B to Dr. Arora’s IME report appears to be from a
presentation Arora made to a different audience at some point prior to the
IME. One indication of this is that there is no mention of Cadiz in Appendix
B (other than in the “Re:” line at the top of each page).

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   A. Proceedings before the Director and the LIRAB in Cadiz I
      (LIRAB Case No. AB 2012-099)

          Cadiz’s September 3, 2010 claim for injury-by-disease

was the subject of a hearing before the director on December 1,

2011.   The director ruled that the claim was not time-barred but

nevertheless denied the claim for compensation on the basis that

the record revealed “an absence of empirical evidence confirming

that claimant’s worksite contained black mold.”      The director

concluded that “claimant’s claimed injury was not the result of

exposure to purported black mold at work,” and therefore

concluded that Cadiz “did not suffer an injury on 8/31/2007

arising out of and in the course of his employment.”       Cadiz

appealed the director’s decision to the LIRAB for a full de novo

hearing on his claim.    See HRS § 386-87(b) (“The appellate board

shall hold a full hearing de novo on the appeal.”).

          Prior to the de novo hearing, the Board refused to

allow Dr. Janette Hope to give live testimony because Cadiz’s

attorney had not named her as a live witness by the relevant

deadlines in the Board’s pre-trial order.      The Board excluded

Dr. Hope’s detailed declaration apparently for the same reason.

The only evidence from Dr. Hope allowed by the Board appears to

have been her two-page opinion letter dated November 16, 2011.

In that letter, after having reviewed medical records and

symptom summaries concerning Cadiz, Dr. Hope observed that “Mr.

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Cadiz experienced a marked decline in his health starting in

2007 resulting in numerous physician, specialist and urgent care

visits for a multitude of symptoms which are most likely

attributable to his exposure to a severely water damaged/moldy

workplace.”   She connected this assessment of the “likely” cause

of his varied symptoms with the laboratory results of his

mycotoxin exposure.    “Mr. Cadiz shows elevations in ochratoxin

and trichothecene mycotoxins on urine mycotoxin testing which

likely resulted from his exposure to a severely water

damaged/moldy workplace and contributed to his numerous health

complaints including respiratory, gastro-intestinal, urologic

and immune system complaints.”     She stated that, “In addition,

he shows evidence of immune system dysfunction as well as

abnormalities on pulmonary function testing consistent with his

exposure.”

           The hearing was held on June 14, 2013 and June 17,

2013, and the Board issued its decision and order on March 10,

2014.   In its decision and order, the Board made extensive

findings of fact.   The Board found, inter alia, that Cadiz had

presented evidence “that mold was present in the area of

Claimant’s work environment during the period in question” and

that Cadiz was exposed to the mold.     The Board found that Cadiz

does not have an allergy to Stachybotrys, the black mold that

according to Dr. Arora is “of concern,” but Cadiz was allergic

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to dust mites.   In addition, the Board found that the Mycotoxin

Panel Report documented the presence of ochratoxin and

trichothecene in Cadiz’s body.

          The Board made various findings of fact concerning

Cadiz’s multiple symptoms, including recitations of the

conclusions of Drs. Cupo, Arora, and Likewise.      The Board’s

recitations of the employer’s IME reports centered on the fact

that they had provided possible alternative explanations for

Cadiz’s symptoms that were not mold-related and therefore were

evidence that his injury-by-disease was not work-connected.       In

Dr. Cupo’s words, Cadiz’s “symptoms were easily and medically

plausibly explainable by other medical conditions” without the

need to resort to explanations based on exposure to mold.

          On the issue of the compensability of Cadiz’s

illnesses, the Board stated that it would apply the unitary test

as then-recently articulated by Van Ness, 131 Hawaiʻi at 560, 319

P.3d at 476.   The Board started with the presumption in favor of

compensability, but it determined that the employer had

presented substantial evidence to rebut that presumption.       Once

over the hurdle of the presumption, the Board “weighed the

evidence by Employer against that presented by Claimant” on the

evidence relating to causation.

          The Board found the “medical opinions” presented by

Dr. Hope and another doctor on behalf of Cadiz “severely lacking

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in quality to justify their conclusions,” stating that Dr. Hope

and the other doctor “appeared to accept Claimant’s hypothesis

with only cursory medical data.”          In contrast, the Board found

Drs. Cupo, Likewise, and Arora to have “provided a sufficient

degree of specificity to rebut the presumption of

compensability.”     The Board credited their opinions, and

accordingly concluded that Cadiz did not sustain a personal

injury arising out of and in the course of employment.

           The Board made no findings or conclusions on what

exactly it found persuasive in the evidence provided by Drs.

Cupo, Likewise, and Arora, other than to suggest that they had

examined and treated Cadiz, whereas there was no indication of

“what medical data” Dr. Hope had relied on “to form an opinion

regarding causation” of Cadiz’s condition.          The Board made no

findings or conclusions concerning what, if any, doubts it

resolved in favor of the claimant.          The Board made no findings

or conclusions on the elevated levels of mycotoxins verified to

have been absorbed by Cadiz’s body, other than to note the bare

results of the laboratory test.        The Board made no findings or

conclusions on whether or how the employer’s IME reports

disproved the work-connection between Cadiz’s illnesses and the

pervasive mold in the meat department.6         The Board appears to

     6
            The Board found as fact that the employer failed to present “any
evidence that contradicts the presence of the alleged black mold at the
                                                             (. . . continued)

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have simply accepted the IME reports’ suggestion that other

medical causes could “medically plausibly” explain Cadiz’s

illnesses and then concluded that the work-connection issue

therefore tipped towards the employer.

   B. Proceedings before the Director and the LIRAB in Cadiz II
      (LIRAB Case No. AB 2013-250) in which Dr. Hope provided
      live testimony previously excluded by the Board

            Cadiz’s November 15, 2011 claim for injury-by-disease

was the subject of a hearing before the director on April 30,

2013 (Cadiz II).     The director ruled on June 27, 2013, that the

claim was an attempt to circumvent the director’s prior decision

for the same injury.      On July 11, 2013, Cadiz appealed the

director’s decision in Cadiz II to the LIRAB for a full de novo

hearing on his claim.      The LIRAB issued a pre-trial order on

January 31, 2014, stating that the “sole issue to be determined

is whether Claimant sustained a personal injury on November 14,

2011, arising out of and in the course of employment.”            The full

de novo evidentiary hearing before the Board was held on August

26, August 27, and September 26, 2014.         In Cadiz II, Dr. Hope’s

detailed declaration concerning mycotoxin exposure through mold

inhalation and resulting ill-health, along with its multiple

_____________________
(continued. . . )

workplace” and that “mold was present in the area of Claimant’s work
environment during the period in question.” In addition, the Board further
found “that Claimant was exposed to such mold.”

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exhibits, was admitted.     In addition, Dr. Hope provided

extensive live testimony.

          Having heard and admitted this testimony by Dr. Hope

into the record, the Board’s resulting order and decision in

Cadiz II made no findings or conclusions with respect to Dr.

Hope’s extensive testimony.    The decision and order in Cadiz II

simply vacated the underlying decision of the director in Cadiz

II, effectively terminating the proceedings, without remanding

to the director for any further findings or conclusions

concerning the newly admitted testimony of Dr. Hope.       In other

words, in spite of its pretrial order governing the scope of the

Cadiz II hearing—the order stating that “the sole issue to be

determined on this appeal is whether Claimant sustained a

personal injury on November 14, 2011, arising out of and in the

course of employment”—the Board made no findings or conclusions

on the testimony admitted into evidence concerning the sole

issue on appeal to the Board in Cadiz II.      Instead of rendering

a decision as to whether Cadiz sustained an injury-by-disease

that was work-connected, or interpreting the newly-admitted

testimony of Dr. Hope in light of that question, the Board

concluded that in Cadiz I, it had rejected Cadiz’s initial claim

for work-related injury of September 3, 2010 as time-barred and

had instead based its order and decision in Cadiz I on the

November 21, 2011 claim.

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          Thus, the Board in Cadiz II decided that it had

already addressed the same claim in Cadiz I, concluding that

“the November 21, 2011 claim was not a new or subsequent claim

for compensation, but an amended claim for an industrial injury

by disease that was before the Director and decided by the Board

in Cadiz I[.]”   However, rather than take into account the

significant newly-admitted testimony of Dr. Hope bearing

directly on the work-connectedness of Cadiz’s injury-by-disease

claim, the Board ignored Dr. Hope’s extensive testimony.       That

is to say, the Board’s decision and order in Cadiz II never

mentions Dr. Hope’s extensive testimony, admitted into the

record in Cadiz II, concerning (a) the nature and harmfulness of

exposure to mycotoxins, (b) the sometimes complex array of

symptoms that can be generated by exposure to mycotoxins, or (c)

the fact that Cadiz’s multiple symptoms match what she has

repeatedly seen in her treatment of patients exposed to

mycotoxins.

  C. Proceedings before the Intermediate Court of Appeals (ICA)

          Cadiz filed a notice of appeal of the Board’s decision

in Cadiz I with the ICA on March 21, 2014.      Cadiz filed a notice

of appeal of the Board’s decision in Cadiz II with the ICA on

January 20, 2016.   The ICA consolidated the appeals of Cadiz I

and Cadiz II on December 15, 2016.     On March 31, 2017, the ICA

issued its SDO in the combined appeals.      Cadiz v. QSI, Inc.,

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Nos. CAAP-XX-XXXXXXX and CAAP-XX-XXXXXXX, 2017 WL 1194168 (App.

March 31, 2017) (SDO).

          The ICA’s SDO affirmed the LIRAB’s decision and order

dated March 10, 2014 in Cadiz I, which ruled that Cadiz had not

sustained an injury arising out of and in the course of

employment.     The ICA also affirmed the LIRAB’s December 22, 2015

decision and order in Cadiz II vacating the director’s decision.

Cadiz, Id. at *8.

          The ICA began by addressing Cadiz’s claim that the

Board had failed to properly apply the presumption in favor of

compensability.     The ICA reviewed the relevant law providing

that the presumption can only be overcome by the employer

producing substantial evidence that the injury-by-disease “is

unrelated to employment.”     Id. at *2 (quoting Akamine v.

Hawaiian Packing & Crating Co., 53 Haw. 406, 408, 495 P.2d 1164,

1165 (1972)).    The ICA also drew attention to this court’s

conclusion in Van Ness that the employer had “failed to present

substantial evidence to overcome the presumption that the

aggravation of [claimant’s] asthma was an injury ‘by disease

proximately caused by’ his employment.”      Id. at *3 (quoting Van

Ness, 133 Hawaiʻi at 565, 319 P.3d at 484).

          The ICA next highlighted the conclusions of the IME

reports of Dr. Cupo and Dr. Arora.     Specifically, the ICA quoted

with approval Dr. Cupo’s assertion that Cadiz’s multiple

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symptoms were “easily and medically plausibly explainable” by

medical conditions other than exposure to toxic mold.         Id.    It

also quoted Dr. Arora’s assertion that Stachybotrys does not

grow on walls and ceilings, implying that it could not have been

the kind of mold conspicuous on the ceiling in the Kāne‘ohe meat

department.   In addition, the ICA found helpful Dr. Arora’s

assertions regarding the low probability of any toxic effect

from inhalation of mycotoxins, given the high spore count that

would be required.   Id. at *3-4.      According to the ICA, “Drs.

Cupo and Arora also provided alternative explanations for

Claimant’s allergic rhinitis, GERD, and anxiety.”        Id. at *4.

The ICA explained that Drs. Cupo and Arora in their reports

“explained why mold exposure could not have caused or aggravated

Claimant’s injuries, and did not provide mere generalized

medical opinions.”   Id.   The ICA also dwelled at length on Dr.

Likewise’s psychological report.       Id. at *4-5.

          The ICA concluded that the IME reports provided the

requisite “substantial evidence” to rebut the presumption of

compensability through providing alternative explanations of

Cadiz’s symptoms and illnesses.     In particular, the ICA seemed

impressed by the “substantial evidence of a high degree of

specificity, quantity, and quality that Claimant did not have a

mold allergy and that Claimant’s conditions were not otherwise

caused by exposure to mold in the workplace.”         Id. at *5.    The

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ICA specifically rejected Cadiz’s suggestion that the LIRAB

erred in crediting Dr. Likewise’s opinion.             Id. at *6.

           Cadiz argued to the ICA that the LIRAB in Cadiz I

erred in excluding Dr. Hope’s declaration, her credentials, and

various other materials relating to past professional complaints

and administrative actions against Dr. Arora.            Dr. Hope’s

declaration and other materials excluded from Cadiz I seem to

have been excluded by the LIRAB based on Cadiz’s failure to meet

discovery deadlines.      Cadiz, Id. at *6-7; (noting that the ICA

was “not able to properly review what was presented before the

LIRAB [in Cadiz I] as there are no transcripts of the June 14,

2013 and June 17, 2013 hearing in the record.            Nevertheless,

upon review of the LIRAB’s March 10, 2014 Decision and Order, it

appears that the LIRAB excluded Exhibits A-l, B, and FF, because
                                                   7
the exhibits were not timely submitted.”).              The ICA found that

admission or exclusion of evidence is generally in the

discretion of the officials conducting an administrative

hearing, and the LIRAB properly excluded exhibits and other

evidence as untimely.      Id. at *7.     In addition, the ICA noted

that it was “not able to properly review what was presented

before the LIRAB” in Cadiz II because the transcripts from that

      7
            Exhibit A-1 consisted of Dr. Hope’s 5-page declaration; exhibit B
was her 6-page curriculum vitae; and exhibit FF consisted of a series of
articles critical of Dr. Arora as well as references to various complaints
and/or administrative actions against him.

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hearing were not in the record.        Id. at *8.     Finally, the ICA

affirmed the LIRAB’s decision and order in both Cadiz I and

Cadiz II.    Id. at *9.      Cadiz applied for a writ of certiorari,

and we accepted his application.

                      III.     STANDARDS OF REVIEW

  A. Appeals from Agency Determinations Relating to Workers’
     Compensation

            Appellate review of a LIRAB decision is governed by

the provisions of Hawai‘i Administrative Procedures Act (“HAPA”)

relating to judicial review of agency action.           HRS § 91-

14(g)(1993); Bocalbos v. Kapiolani Med. Ctr. for Women &

Children, 93 Hawaiʻi 116, 123, 997 P.2d 42, 49 (App. 2000).

Under HAPA’s judicial review provisions,

            the reviewing court “may affirm the decision of the agency
            or remand the case with instructions for further
            proceedings.” Id. The reviewing court also “may reverse
            or modify the decision and order if the substantial rights
            of the petitioners may have been prejudiced because the
            administrative findings, conclusions, decisions, or orders”
            (1) violate provisions of the constitution or a statute,
            (2) are beyond the agency’s statutory authority or
            jurisdiction, (3) used “unlawful procedure,” (4) were
            “[a]ffected by other error of law,” (5) were clearly
            erroneous, or (6) were arbitrary or capricious “or
            characterized by abuse of discretion or clearly unwarranted
            exercise of discretion.” HRS § 91-14(g)(1)-(6).

Ihara, 141 Hawaiʻi at 41, 404 P.3d at 307.

            “The LIRAB’s conclusions of law are reviewed de

novo, under the right/wrong standard.         Its findings of fact

‘are reviewable under the clearly erroneous standard to

determine if the agency decision was clearly erroneous in

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view of reliable, probative, and substantial evidence on

the whole record.’”    Van Ness, 131 Hawaiʻi at 558, 319 P.3d

at 477 (citation omitted).    Like any agency findings, the

LIRAB’s “findings should be ‘sufficient to allow the

reviewing court to track the steps by which the agency

reached its decision.’”    Kauai Springs, Inc. v. Planning

Comm’n of Cty. of Kauai, 133 Hawaiʻi 141, 164, 324 P.3d 951,

974 (2014) (citation omitted).

   B. Statutory Interpretation

          “Statutory interpretation is a question of law

reviewable de novo.”    Ryan v. Herzog, 142 Hawaiʻi 278, 284, 418

P.3d 619, 625 (2018) (citation omitted).      The Hawaiʻi workers’

compensation statute must be “construed . . . liberally” in

order to effect its “beneficent purposes.”      Puchert v. Agsalud,

67 Haw. 25, 36, 677 P.2d 449, 457 (1984).

                           IV. DISCUSSION

          We begin with a brief overview of the law governing

workers’ compensation in Hawaiʻi and then apply those principles

to the decisions below.

   A. Principles Governing Hawaiʻi Workers’ Compensation Law

          The Hawaiʻi workers’ compensation statute “is social

legislation that is to be interpreted broadly.”      Davenport v.

City & Cty. of Honolulu, Honolulu Fire Dep’t, 100 Hawaiʻi 481,

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491, 60 P.3d 882, 892 (2002).     The provisions of the Hawaiʻi

workers’ compensation law “are highly remedial in character.

Their paramount purpose is to provide compensation for an

employee for all work-connected injuries, regardless of

questions of negligence and proximate cause.”       Flor, 94 Hawaiʻi

at 79, 9 P.3d at 391 (emphasis added).       The overarching policy

of workers’ compensation in this state is that “an employee

should be indemnified for all infirmities resulting from [their]

employment.”    Van Ness, 131 Hawaiʻi at 559, 319 P.3d at 478

(citation omitted); Iddings v. Mee-Lee, 82 Hawaiʻi 1, 5, 919

P.2d 263, 267 (1996) (stating that the workers’ compensation

statute provides “an injured employee’s exclusive remedy for an

injury arising out of and in the course of employment.”).

“Under our workers’ compensation statute, the slightest

aggravation or acceleration of an injury by the employment

activity mandates compensation.”       Korsak, 94 Hawaiʻi at 305, 12

P.3d at 1246.

            The workers’ compensation statute rests on the

presumption that a claimed injury is work-connected and

therefore compensable.    HRS § 386–85 (1993) (“In any proceeding

for the enforcement of a claim for compensation . . . it shall

be presumed, in the absence of substantial evidence to the

contrary:   (1) That the claim is for a covered work injury[.]”);

Panoke, 136 Hawai‘i at 461, 363 P.3d at 309 (“When determining

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whether a workers’ compensation claim is work-related, it is

well established in Hawai‘i that ‘it shall be presumed, in the

absence of substantial evidence to the contrary . . . [t]hat the

claim is for a covered work injury[.]”).           “The presumption has

been described as one of the ‘keystone principles’ of our

workers’ compensation plan.”        Flor, 94 Hawaiʻi at 79, 9 P.3d at

391 (citation omitted).        It is the burden of the employer to

produce substantial evidence that, if true, could rebut the

presumption that the injury is work-related.           Panoke, 136 Hawaiʻi

at 461, 363 P.3d 296 at 309.        Once the burden of production is

met, the burden of persuasion requires that “the trier of fact .

. . weigh the evidence elicited by the employer against the

evidence elicited by the claimant.”          Id.   In evaluating whether

the burden of persuasion has been met, the “broad humanitarian

purpose of the workers’ compensation statute read as a whole

requires that all reasonable doubts be resolved in favor of the

claimant.”        Ihara, 141 Hawaiʻi at 41, 404 P.3d at 307 (citation

omitted).

             Disputes concerning the validity of claims for

compensation under Hawaiʻi’s workers’ compensation law are

initially decided by the director of Labor and Industrial

Relations.        HRS § 386-86(a)-(b).    The director conducts a

hearing on the claim and issues findings of fact and conclusions

of law.     Id.     The decision of the director may be

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administratively appealed to the LIRAB, which conducts a trial-

like hearing on the appeal de novo.     HRS § 386-87(a)-(c).    A

LIRAB decision may be appealed directly to the ICA.       HRS § 386-

73.5; HRS § 386-88.    Because any appeal from a determination of

the director receives a full hearing de novo from the LIRAB,

this court reviews only the decisions of the LIRAB and not the

decisions of the director.

   B. The Board and the ICA Erred by Misapplying the Presumption
      in Favor of Compensability.

            As noted, Hawaiʻi’s workers’ compensation law begins

with the explicit statutory presumption that a claimed injury is

work-related and therefore compensable.      HRS § 386–85(1).   To

rebut that presumption in favor of compensability, the employer

bears the heavy burden of producing substantial evidence

disproving that the injury is work connected.      Korsak, 94 Hawaiʻi

at 307, 12 P.3d at 1248 (“Hawaii’s workers’ compensation

presumption places a heavy burden on the employer to disprove

that an injury is work-related. . . .     HRS § 386–85(1) creates a

presumption in favor of the claimant that the subject injury is

causally related to the employment activity.” (citation omitted,

first emphasis added)).

          Thus, the “substantial evidence” sufficient to

overcome the presumption in favor of compensability must

disprove the causal relation of the injury-by-disease to the

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conditions and incidents of claimant’s employment, and not

merely suggest plausible alternative explanations.            “In

evaluating whether the burden of producing substantial evidence

has been met, ‘the slightest aggravation or acceleration of an

injury by the employment activity mandates compensation.’”

Panoke, 136 Hawaiʻi at 461, 363 P.3d at 309; see also Van Ness,

131 Hawaiʻi at 561, 319 P.3d at 480 (“The relevant issue under

the unitary or ‘work-connection approach’ is simply whether

there is a causal connection between the injury and any

incidents or conditions of employment[.]”).

     1. The LIRAB and the ICA failed to produce substantial
        evidence that, if true, could disprove the presumption
        of compensability in Cadiz I.

           The presumption in favor of compensability “signals

and reflects a strong legislative policy favoring awards in

arguable cases.”     Lawhead v. United Air Lines, 59 Haw. 551, 560,

584 P.2d 119, 125 (1978) (citation omitted).

Here, the three IME reports offered by the employer in Cadiz I

regarding the claimant’s exposure to mycotoxins did not meet the

burden of production of showing that Cadiz’s injury-by-disease

was not work-related.      The IME reports (a) arrived at mutually

inconsistent results,8 and (b) failed to mention, much less

     8
            To mention only a few examples, Dr. Likewise in his IME report
asserts “there is no clear medical explanation for [Cadiz’s] symptoms,” and
therefore concludes that many or perhaps all of Cadiz’s symptoms were
                                                             (. . . continued)

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directly address, the laboratory tests that objectively proved

the elevated presence of harmful mycotoxins in Cadiz’s body.

            Cadiz’s illnesses and symptoms reasonably appear to be

work-connected.     See id., (stating that “an injury is

compensable if it reasonably appears to have resulted from the

working conditions.”).      The verified presence of harmful

mycotoxins in Cadiz’s body, correlated with the dramatically

increased frequency of his visits to the doctor and the

emergency room during the relevant period, together with the

pervasive moldy conditions of the meat department, make Cadiz’s

claimed injury-by-disease reasonably appear to be work-connected

and therefore compensable.       Id.    The employer did not meet its

burden of producing substantial evidence that, if true, could

rebut the presumption that Cadiz’s injury was work-related.

Moreover, the LIRAB in Cadiz I, and the ICA in reviewing the
_____________________
(continued. . . )

psychosomatic, hypochondriacal, or due to a personality disorder. Dr. Cupo,
on the other hand, concludes that “chronic allergic rhinosinusitis with
sensitivity to dust mites and chronic gastroesophageal reflux disease have
been definitively established.” However, Dr. Cupo concludes that Cadiz’s
“symptoms can in no way be explained by exposure to mold” at Times
Supermarket because allergy skin testing of Cadiz “revealed positivity only
to dust mites and negativity to molds.” Dr. Cupo’s assumption that allergy
to mold is the only possible mechanism by which ill-health is related to
environmental mold is contradicted by parts of Dr. Arora’s IME report. Dr.
Arora’s report describes a scientific article which focuses not on allergies
to mold as the mechanism for adverse health effects but on “epidemiological
studies from the primary literature concerning inhalation of mycotoxins or
potentially toxin-producing molds.” The article’s review of those studies
indicated that “evidence was found of a relationship between high levels of
inhalation exposure or direct contact to mycotoxin-containing molds or
mycotoxins and demonstrable . . . health effects in humans,” although the
article does not find the evidence “compelling.”

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Board’s decision and order, exclusively relied on three IME

reports that themselves fail to consider or in any way account

for the evidence of harmful mycotoxins present in Cadiz’s body

(admitted into evidence in Cadiz I).9         Finally, even if the cause

     9
            The Board did find as fact, “A Mycotoxin Panel Report Form dated
October 27, 2011 documented the presence of ochratoxin of 4.2 [parts per
billion (“ppb”)] and trichothecene at 0.39 ppb” in Cadiz’s urine. But the
Board did not note that according to the Panel Report, each of those results
is twice the level of detection. In addition, the Board provided no further
context in its decision and order for those quantitative levels of
mycotoxins.

            It is true that the Board in Cadiz I had excluded Dr. Hope’s
declaration, which provided the relevant medical and toxicological context
for the particular levels of those specific mycotoxins in Cadiz’s body. The
levels revealed by laboratory testing are “elevated levels.” Any level above
the “detection level” represents “the mycotoxin presence in the persons
exposed to indoor mold compared to those unexposed”; and “the elevated levels
of these mycotoxins” detected in Cadiz “can cause the type of symptoms
experienced by Mr. Cadiz such as a burning sensation of the mouth, esophagus
and stomach and may also impair brain function . . . . Both of these toxins
can also cause depression of the immune system which could lead to flu-like
symptoms such as rhinitis, headache, and dizziness.” However, similar
information was provided in Dr. Hope’s opinion letter dated November 16,
2011, which was admitted in Cadiz I. In that letter, after a review of
portions of Cadiz’s medical history, Dr. Hope opined that Cadiz’s

           multiple symptoms. . . are most likely attributable to his
           exposure to a severely water damaged/moldy workplace. Mr.
           Cadiz shows elevations in ochratoxin and trichothecene
           mycotoxins . . . which likely resulted from this exposure
           to a severely water damaged/moldy workplace and contributed
           to his numerous health complaints including respiratory,
           gastrointestinal, urologic and immune system complaints.
           In addition, he shows evidence of immune system dysfunction
           as well as abnormalities on pulmonary function testing
           consistent with his exposure.

Yet, the Board chose to credit the IME reports of the employer over Dr.
Hope’s opinion letter on this crucial issue, even though the employer’s IME
reports never addressed the presence of those mycotoxins at those levels in
Cadiz’s body. The Board stated it resolved reasonable doubts in favor of the
claimant, but it failed to address that the employer had failed to meet its
burden of producing substantial evidence to overcome the presumption that
Cadiz's injury was work-related.

                                                             (. . . continued)

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of the injury-by-disease is unknown, that in itself is a salient

indication that the employer did not produce substantial

evidence to meet its burden of production.          As we noted in Van

Ness,

            [A doctor’s opinion] that it was impossible to determine
            the cause of the aggravation does not constitute
            substantial evidence rebutting the presumption. On the
            contrary, pursuant to Akamine, doubt as to the cause of the
            injury represents a salient index of the absence of
            substantial evidence required to overcome the presumption
            that the claim is compensable.”

Van Ness, 131 Hawaiʻi at 564, 319 P.3d at 483. (citation and

quotation marks omitted).       An excerpt contained in Dr. Arora’s

own IME report in the present case, credited by the Board,

acknowledges that “the point at which mold contamination becomes

a threat to health is unknown. (Emphasis added.)

      2. The LIRAB and the ICA in Cadiz I mistakenly
         characterized the employer’s IME reports as substantial
         evidence rebutting the presumption in favor of
         compensability.

            In the workers’ compensation context, “substantial

evidence” means “a high quantum of evidence which, at the

minimum, must be relevant and credible evidence of a quality and
_____________________
(continued. . . )

            In any event, it is not Cadiz’s burden to establish that the
mycotoxins caused his adverse health conditions or that he was exposed to
them at work and not somewhere else. Rather, it is the employer’s burden to
prove through substantial evidence that the mycotoxins did not cause his
illnesses, even at the level of “slight aggravation” of existing conditions
such as asthma. Korsak, 94 Hawaiʻi at 305, 12 P.3d at 1246 (“Under our
workers’ compensation statute, the slightest aggravation or acceleration of
an injury by the employment activity mandates compensation.”). Yet the
employer’s IME reports never addressed the scientifically verified levels of
harmful mycotoxins in Cadiz’s body following his four years of employment in
what the Board itself found to be a moldy work environment.

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quantity sufficient to justify a conclusion by a reasonable

[person] that an injury or death is not work connected.”

Panoke, 136 Hawaiʻi at 462, 363 P.3d at 310; Van Ness, 131

Hawaiʻi at 558, 319 P.3d at 477.

          In Cadiz I, the Board credited the IME reports by Drs.

Cupo and Arora as providing substantial evidence to rebut the

presumption in favor of compensability.       However, Dr. Cupo’s

litany of conclusory assertions that none of Cadiz’s illnesses

or symptoms were “caused, aggravated, or accelerated by job

activities as a meat cutter for Times Supermarket,” tracks the

language of the test proposed for occupational disease by this

court in Flor, 94 Hawaiʻi at 82, 9 P.3d at 394 (requiring, inter

alia, that the injury-by-disease be “caused by conditions that

are characteristic of or peculiar to the particular trade,

occupation, or employment” (emphasis added)).       The conclusion

repeated in each of Dr. Cupo’s “diagnoses” is inconsistent with

this court’s decision in Van Ness, published little more than a

month prior to the LIRAB’s decision in Cadiz I.       Van Ness held

that Flor’s test is relevant for injury-by-disease claims going

to the nature of the occupation or employment.       Van Ness, 131

Hawaiʻi at 559, 319 P.3d at 478.       However, Flor’s test is not

relevant for those injury-by-disease claims that go to the

conditions or incidents of employment rather than to the very

nature of the job.   For such situations, the traditional unitary

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or nexus test is used.     That test requires only “a causal

connection between the injury and any incidents or conditions of

employment.”   Van Ness, 131 Hawaiʻi at 560, 319 P.3d at 479.      It

does not require any assessment of the relation of an injury to

the nature of the claimant’s “job activities.”      Stated

otherwise, Dr. Cupo’s conclusions in his IME report are based on

an inapplicable legal conclusion.

          In addition, Dr. Cupo’s conclusions cannot constitute

“substantial evidence” sufficient to rebut the statutory

presumption in favor of compensability.      His sixteen formulaic

conclusions, which he labels “diagnoses,” cannot “justify a

conclusion by a reasonable person that an injury . . . is not

work-connected.”   Id. at 558, 319 P.3d at 477.     Strictly

speaking, Dr. Cupo’s conclusions about the relation of Cadiz’s

symptoms to the nature of his job as a meatcutter are, under Van

Ness, beside the point.    Such conclusions are, in other words,

not legally relevant in the present case and therefore cannot

constitute substantial evidence rebutting the presumption in

favor of compensability.     Id.   Unless Dr. Cupo’s diagnoses

constituted substantial evidence able to reasonably rule out the

mycotoxins discovered in Cadiz’s body as causes of some or all

of his symptoms or injuries, his diagnoses do not add up to

substantial evidence.     Nor does postulating an allergy to dust

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as an alternative explanation for Cadiz’s many symptoms pass

muster under the relevant legal standards.

          In addition, the IME reports of both Dr. Cupo and Dr.

Arora share a similar fatal flaw.      They represent attempts to

assert that Cadiz’s symptoms of illness are, in Dr. Cupo’s

words, “medically plausibly explainable by other medical

conditions” without needing to resort to toxic mold exposure.

This line of analysis by the employer’s IMEs, tacitly approved

by the ICA, misconstrues the relevant legal standard.       “Hawaii’s

workers’ compensation presumption places a heavy burden on the

employer to disprove that an injury is work-related.”       Korsak,

94 Hawaiʻi at 307, 12 P.3d at 1248 (emphasis added).      A plausible

alternative medical explanation, without more, does not disprove

that an injury is work-related.

          A heart-attack may be “medically plausibly

explainable” by an excess of cholesterol from eating too many

french fries, but that does not mean that a claimant’s heart

attack was not to some extent either caused or aggravated by

work-related stress.    See Akamine, 53 Haw. at 412, 495 P.2d at

1168 (noting that the employer offered plausible alternative

non-work-related explanations for a heart attack but rejecting

that standard and holding instead that the employee’s death at

work from a heart attack was compensable under Hawai‘i workers’

compensation law: “The primary focus of the medical testimony

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should have been a discussion on whether the employment effort,

whether great or little, in any way aggravated Mr. Akamine’s

heart condition which resulted in his death.”)          See also Chung

v. Animal Clinic, Inc., 63 Haw. 642, 651-52, 636 P.2d 721, 727

(1981) (finding that despite employer having offered a plausible

alternative medical explanation for claimant’s heart attack,

including arteriosclerosis and jogging, the “heart attack was

work-connected” and therefore compensable).

           A recurring cough could be explained by a lingering

version of the common cold, but it could also be explained by

asbestosis.   Asserting that the cough is “medically plausibly

explainable” by the common cold does not disprove asbestosis.

Similarly, a round hole through a person’s skull might be

“medically plausibly explainable” by the passage of a bullet,

but that is not substantial evidence that Phineas Gage’s on-the-

job injury was not caused by a tamping iron accidentally

transiting through his skull.10

      10
           Gage’s famous workplace injury predated the widespread enactment
of workers’ compensation statutes, but it illustrates the difficulties with
the “medically plausibly explainable by other conditions” standard deployed
by Dr. Cupo.

                 In 1848, Gage, 25, was the foreman of a crew cutting
           a railroad bed in Cavendish, Vermont. On September 13, as
           he was using a tamping iron to pack explosive powder into a
           hole, the powder detonated. The tamping iron — 43 inches
           long, 1.25 inches in diameter and weighing 13.25 pounds —
           shot skyward, penetrated Gage’s left cheek, ripped into his
           brain and exited through his skull, landing several dozen
           feet away. . . . In time, Gage became the most famous

                                                            (. . . continued)

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            “Medically plausibly explainable by other medical

conditions” is neither the relevant medical nor legal standard

in the context of workers’ compensation, and the ICA erred by

considering testimony resting on that standard to constitute

substantial evidence rebutting the statutory presumption that an

injury-by-disease “is causally related to the employment

activity” or conditions.       Chung, 63 Haw. at 650, 636 P.2d at

726.   The fact that there may exist alternative medical

explanations for the symptoms experienced by a claimant claiming

injury-by-disease does not on its own amount to evidence

substantial enough to rebut the presumption under the unitary or

nexus approach of “a causal connection between the injury and

any incidents or conditions of employment.”           Id. at 648, 636

P.2d at 725.

            In order to overcome the presumption in favor of

compensability, the employer must prove through substantial

evidence that the injury or disease was not work-connected.

Panoke, 136 Hawaiʻi at 461, 363 P.3d at 309; Korsak, 94 Hawaiʻi

at 307, 12 P.3d at 1248.       In evaluating whether the burden of
_____________________
(continued. . . )

            patient in the annals of neuroscience, because his case was
            the first to suggest a link between brain trauma and
            personality change.

Steve Twomey, Finding Phineas: An Accident with a Tamping Iron Made Phineas
Gage One of the Most Famous Names in Neuroscience, Smithsonian, Jan. 2010, at
9-10.

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producing substantial evidence has been met, “the slightest

aggravation or acceleration of an injury by the employment

activity mandates compensation.”       Panoke, 136 Hawaiʻi at 461, 363

P.3d at 309; Van Ness, 131 Hawai‘i at 562, 319 P.3d at 481

(citation omitted).     Suggesting plausible alternative

explanations that do not rule out work-connection or even slight

aggravation of pre-existing conditions fails to rise to the

level of showing required to overcome the presumption in favor

of compensability.     Van Ness, 131 Hawaiʻi at 558, 319 P.3d at

477.

          Dr. Likewise’s evocation of Cadiz’s “preoccupation

with multiple, medically unexplained somatic complaints,” might—

in some other legal context—shift the argument in favor of the

employer, which hired Dr. Likewise.       HRS § 386-79 (requiring the

injured employee “to submit to examination . . . by a duly

qualified physician . . . designated and paid by the

employer.”).

          But in the context of workers’ compensation law, a

lack of explanation for experienced symptoms or illnesses

strengthens the presumption in favor of compensability instead

of overcoming it.     Van Ness, 131 Hawaiʻi at 564, 319 P.3d at 483

(stating that “doubt as to the cause of the injury represents a

salient index of the absence of substantial evidence required to

overcome the presumption that the claim is compensable.”

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(quotation marks omitted)); Lawhead, 59 Haw. at 560, 584 P.2d at

125 (noting, in the workers’ compensation context, “a strong

legislative policy favoring awards in arguable cases.” (citation

omitted)).     Dr. Likewise’s diagnosis simply does not address the

laboratory evidence of elevated levels of harmful mycotoxins in

Cadiz’s body.     It was clearly erroneous for the LIRAB to

conclude that Dr. Likewise’s IME report represented a level of

substantial evidence sufficient to rebut the presumption that

Cadiz’s claimed injury-by-disease was work connected.       Van Ness,

131 Hawaiʻi at 558, 319 P.3d at 477; Korsak, 94 Hawaiʻi at 307,

12 P.3d at 1248 (“Hawaii’s workers’ compensation presumption

places a heavy burden on the employer to disprove that an injury

is work-related.” (emphasis added)).

                           IV.   CONCLUSION

          For the reasons stated above, we vacate the ICA’s

judgment on appeal which affirmed the LIRAB’s decision and order

in Cadiz I.    Given our conclusion that the employer failed to

provide sufficient substantial evidence in Cadiz I to meet its

burden to produce evidence that, if believed, could overcome the

presumption in favor of compensability, it is unnecessary for us

to address the issues raised by the Board’s decision and order

in Cadiz II.    We remand to the LIRAB with the instruction that

Cadiz’s injury-by-disease is compensable under Hawaiʻi’s workers’

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compensation law and for further proceedings consistent with

this opinion.

Stanford H. Masui               /s/ Mark E. Recktenwald
Erin B.J.H. Masui
for Petitioner                  /s/ Paula A. Nakayama

Shawn L.M. Benton               /s/ Sabrina S. McKenna
Scott G. Leong
Christine J. Kim                /s/ Richard W. Pollack
for Respondents
                                /s/ Michael D. Wilson

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