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Docket No. 98748-Agenda 15-January 2005.
TWICE OVER CLEAN, INC., Appellee, v. THE INDUSTRIAL
COMMISSION et al. (Howard Haulk, Appellant).

Opinion filed March 24, 2005.

JUSTICE KILBRIDE delivered the opinion of the court:

This case is before us again following our supervisory order (188Ill. 2d R. 383) directing the appellate court to reconsider its opinionsetting aside an award of compensation to Howard Haulk (Twice OverClean, Inc. v. Industrial Comm'n, 337 Ill. App. 3d 805 (2003)) in thelight of our decision in Sisbro, Inc. v. Industrial Comm'n, 207 Ill. 2d193 (2003). The appellate court vacated its original opinion (348 Ill.App. 3d 638, 639) and again set aside the Industrial Commission'saward of compensation to Haulk, holding that "in light of hissusceptibility to a heart attack outside of work, he failed in the firstinstance to prove a 'sufficient causal connection' between his workand his injury." 348 Ill. App. 3d at 652. We granted Haulk's petitionfor leave to appeal (177 Ill. 2d R. 315). We allowed Rush UniversityMedical Center, United Wisconsin Insurance Company, and IPCInternational Corporation to file an amicus curiae brief in support ofTwice Over Clean. 155 Ill. 2d R. 345. We now reverse the judgmentof the appellate court and affirm the judgment of the circuit court.

BACKGROUND

The record reveals that Haulk was employed as a laborer forTwice Over Clean in Peoria, Illinois. He was assigned to an asbestosremoval job in Minneapolis, Minnesota, in December 1996. OnJanuary 2, 1997,while performing heavy labor, he suffered chest pains.After he finished work, he went to his hotel and did not feel likeeating. He again experienced chest pains and broke out in a coldsweat. He was taken by ambulance to Hennepin County MedicalCenter (the hospital), where he was admitted and diagnosed with anacute inferior myocardial infarction. Upon his release, he returned toPeoria, where he received additional care from his internist and acardiologist.

Haulk filed an application for adjustment of claim pursuant to theWorkers' Compensation Act (820 ILCS 305/1 et seq. (West 1996))with the Industrial Commission (Commission),⁽¹⁾ seeking compensationfor his heart attack. The claim was heard before an arbitrator. Theprincipal disputed issue was whether the injury arose out of and in thecourse of Haulk's employment (820 ILCS 305/1(b) (West 1996)).

At the hearing, Haulk testified that his work assignment onJanuary 2, 1997, was to assist in the removal of 500 to 700 bags ofasbestos, each weighing 45 to 50 pounds, located on the top floor ofan unheated four- to five-story building in downtown Minneapolis.The temperature in the building was approximately five degreesFahrenheit. Haulk carried the bags down the stairs and outside to aDumpster located approximately 100 feet from the building, where hehad to pile the asbestos bags high in the dumpster. While performingthis task, Haulk was required to wear a large, air-pack-driven facialrespirator and protective clothing. At about 2:30 p.m., whileperforming this work, he noticed pains in his chest, neck, and leftshoulder. The pains subsided when he sat down and rested for 10 to15 minutes, but returned when he resumed working. He left workaround 4:30 p.m. The pains never stopped entirely, although theywere more severe at times. Ultimately, he began having cold sweatsand nausea, an ambulance was called, and he was taken to thehospital. Haulk denied experiencing chest pain prior to January 2,1997.

The hospital records for Haulk's treatment were admitted inevidence. An unsigned resident's history and physical form, datedJanuary 3, 1997, noted that Haulk was evaluated for chest painbeginning while he was "lifting items" around 8 p.m. that evening andreturning while he was in bed around 10 p.m. An admission dataprofile, also dated January 3, 1997, signed by the person preparing it,recited that Haulk described getting "chest pain yesterday afternoonwhile loading a truck," but that it went away. A signed inpatientconsultation stated that Haulk presented with an onset of acute chestpain while lifting weight. Narrative notes dated January 3, 1997,signed by a treating physician, referred to Haulk as a patient with"angina x 4 wks." who experienced "severe pain starting at about10:00 p.m. today." A critical care flow sheet dated January 3, 1997,signed by a nurse, recorded that Haulk had chest pain with exertion inthe morning that subsided on its own. Haulk was diagnosed with andtreated for acute inferior myocardial infarction. Coronary angiographyrevealed a 90% obstruction in a portion of the right coronary artery.These records were sent to Haulk's internist in Peoria, Dr. BrianCohen.

Upon his return to Peoria, Haulk consulted Dr. Cohen, who inturn referred him to a cardiologist, Dr. Frank Gold. Those doctorsprovided care for Haulk beginning January 16, 1997, and continuinguntil he was released to return to work on June 30, 1997.

Haulk had recurring chest pain in February 1997, and wasadmitted by Dr. Cohen to Methodist Medical Center in Peoria, wherehe was seen in consultation by Dr. Mark Shima. The consultationrecord was admitted in evidence. Dr. Shima's impression was:"Atypical resting chest discomfort which radiates to the back and theback of neck. Despite this, this is the same discomfort the patient feelsthat he had in the pre-infarction period of the day or so prior to aninferior infarct occurring in January of 1997 for which he underwentangioplasty at Hennepin County Hospital in Minnesota." Dr. Shimafound no evidence of a myocardial infarction on the occasion of thisFebruary 1997 consultation.

Two written reports from Dr. Gold were admitted at the hearing.The first, dated January 16, 1997, was a letter to Dr. Cohen,confirming that Haulk clearly sustained a myocardial infarction andwas not capable of returning to his duties as a laborer. Dr. Gold statedthat, apart from smoking, Haulk had limited risk factors for coronaryartery disease. He reported Haulk advised him that he underwentacute salvage angioplasty in Minneapolis, and that the doctors toldhim "there was a 50% residual stenosis." In the second report, datedApril 10, 1997, Dr. Gold opined that Haulk was then totally disabledas a result of a myocardial infarction sustained while working inMinneapolis, Minnesota.

The report of Dr. Cohen, dated December 4, 1998, was admittedat the hearing. In the report, Dr. Cohen wrote: "The myocardialinfarction that Howard Haulk, Jr. suffered at 9:00 P.M. on January 2,1997, in my medical opinion, was precipitated by the heavy lifting thathe did all day long at work. He was actually experiencing the chestpain while doing the lifting, and probably was developing his heartattack at that time."

The evidence deposition of Dr. Cohen, taken on March 10,1999,was admitted at the hearing. Dr. Cohen testified that he wasboard certified in internal medicine. Prior to January 13, 1997, he hadseen Haulk on only two occasions in 1990, when he performed aphysical examination and some follow-up studies. The examinationrevealed no problems. He and Dr. Gold both followed Haulk'sprogress after January 13, 1997. Dr. Cohen was primarily concernedwith risk factors for coronary disease. He prescribed medication forelevated cholesterol and provided care through February 1999.

Dr. Cohen was asked to assume hypothetically that Haulkperformed the work duties Haulk described in his testimony underthose same conditions. He then was asked whether he had an opinion"based upon a reasonable degree of medical certainty as to whetherthe myocardial infarction that Mr. Haulk suffered as indicated in therecords from the hospital in Minneapolis might or could have beencaused by the physical activity engaged in on January 2nd, 1997." Dr.Cohen responded affirmatively and stated "that activity very likelycould have led him to have a heart attack." He further opined, basedon a review of enzyme studies taken on January 2 and 3, 1997, thatHaulk's heart attack could have occurred around 2 p.m.

On cross-examination, Dr. Cohen conceded the arteriogram takenat the time of his initial work up in Minneapolis, showing a 90%occlusion of the right coronary artery, was "very significant" and thatany activity or no activity by a person having that degree of occlusioncould put sufficient stress on the heart to result in a myocardialinfarction. He testified that "anybody can experience a myocardialinfarction at rest, really." He also agreed with the cross-examiner'sstatement that "a person with that degree of occlusion is basically aheart attack waiting to happen." On redirect, Dr. Cohen stated thatphysical activity contributes to the risk of myocardial infarction inpersons having Haulk's degree of occlusion, and the kind of liftingHaulk was doing in the afternoon is "tremendous stress and causes avery high work load on the heart and the heart muscle."

Twice Over Clean presented the evidence deposition of Dr. GaryN. Wilner of Evanston, Illinois, taken November 15, 1999. Dr. Wilner,who is board certified in both internal medicine and cardiovasculardiseases, was engaged by Twice Over Clean to evaluate Haulk'smedical records. He did not physically evaluate Haulk. In his opinion,Haulk's work activity was not a factor in his myocardial infarction,based on the enzyme levels he had at the time of his admission. Thoselevels were within normal limits, indicating the infarction had notoccurred prior to the preceding five or six hours. He admitted oncross-examination that other studies might be found that wouldsupport a different conclusion.

The arbitrator found the heart attack arose out of and in thecourse of Haulk's employment and entered an award in his favor. TheCommission affirmed and adopted the arbitrator's decision, with onecommissioner dissenting. The circuit court of Peoria Countyconfirmed the Commission's decision. The appellate court reversed,holding the evidence established that Haulk's physician agreed Haulkwas a "heart attack waiting to happen" and could have suffered aheart attack even while at rest. Therefore, the normal daily activityexception applied to defeat Haulk's claim. Twice Over Clean, Inc.,337 Ill. App. 3d at 810-11.

Haulk petitioned for leave to appeal to this court. We initiallydenied leave to appeal, but entered a supervisory order directing theappellate court to reconsider its opinion in the light of our recentpronouncement in Sisbro. Twice Over Clean, Inc. v. IndustrialComm'n, 205 Ill. 2d 650 (2003) (supervisory order). The appellatecourt vacated its opinion and issued a new opinion, again reversing thecircuit court's judgment and setting aside the award of the IndustrialCommission. 348 Ill. App. 3d at 652. This appeal followed.

ANALYSIS

In Sisbro, we rejected the argument that the "normal dailyactivity" exception bars recovery when the claimant's physicalcondition has so deteriorated that the condition of ill-being could havebeen produced by normal daily activity, despite a causal connectionbetween the work and the condition. Sisbro, 207 Ill. 2d at 208-09.Instead, we held "whether 'any normal daily activity is anoverexertion' or whether 'the activity engaged in presented risks nogreater than those to which the general public is exposed' are mattersto be considered when deciding whether a sufficient causal connectionbetween the injury and the employment has been established in thefirst instance." Sisbro, 207 Ill. 2d at 211-12. We observed this courthas never initially found a causal connection to exist between workand injury and then, as a further analytical step, denied recovery basedon a " 'normal daily activity exception.' " Sisbro, 207 Ill. 2d at 212.We then analyzed the evidence of record and concluded the manifestweight of the evidence supported the Commission's decision awardingcompensation, despite testimony by respondent's expert witness thatclaimant's condition was the result of the normal degenerative processof his preexisting diabetic condition. Sisbro, 207 Ill. 2d at 215. Weheld:

"When an employee with a preexisting condition is injuredin the course of his employment, serious questions are raisedabout the genesis of the injury and the resulting disability.The Commission must decide whether there was anaccidental injury which arose out of the employment, whetherthe accidental injury aggravated or accelerated the preexistingcondition or whether the preexisting condition alone was thecause of the injury. *** However, the Commission's decisionmust be supported by the record and not based on merespeculation or conjecture. If there is an adequate basis forfinding that an occupational activity aggravated oraccelerated a preexisting condition, and, thereby, caused thedisability, the Commission's award of compensation must beconfirmed." Sisbro, 207 Ill. 2d at 215.

From our review of the record, we then determined that alegitimate inference arose from the evidence before the Commissionthat the claimant's occupational activity was a causative factor inhastening the onset of his disabling condition. Accordingly, weconfirmed the Commission's award of compensation. Sisbro, 207 Ill.2d at 215.

Sisbro established the standard for reviewing the Commission'sfindings where a preexisting condition may be a cause of the disability.Thus, we will apply that standard in determining whether the recordsupports a legitimate inference that Haulk's occupational activity wasa causative factor in hastening the onset of his disabling myocardialinfarction, considering as a factor the preexisting 90% occlusion of hisright coronary artery and the likelihood his heart attack could haveoccurred even without activity. The Commission is entitled to drawreasonable inferences from the evidence, and we will not disregardthose inferences unless the Commission's decision is against themanifest weight of the evidence. City of Des Plaines v. IndustrialComm'n, 95 Ill. 2d 83, 90 (1983).

Here, the appellate court majority held the normal daily activitylimitation bars compensation, based entirely on the admission ofHaulk's treating expert, Dr. Cohen, that " 'any activity or no activitycould put sufficient stress on the heart to result in a myocardialinfarction' " and his agreement with the cross-examiner's statementthat the claimant was a " 'heart attack waiting to happen.' " 348 Ill.App. 3d at 651-52. As the dissent in the appellate court points out,however, the majority made no reference to the extensive testimonyestablishing that Haulk's symptoms began during his performance ofheavy labor under extreme temperature conditions. 348 Ill. App. 3dat 654 (Goldenhersh, J., dissenting). The majority further ignored Dr.Cohen's testimony that physical activity contributes to the risk ofheart attack in persons having Haulk's degree of coronary arteryocclusion, and that the heavy labor he was performing when hissymptoms began "is tremendous stress and causes a very high workload on the heart and heart muscle."

The appellate court majority held that "in light of hissusceptibility to a heart attack outside of work, he failed in the firstinstance to prove a 'sufficient causal connection' between his workand his injury." 348 Ill. App. 3d at 652. This conclusion completelyignores competent testimony in the record establishing that Haulk'swork activity contributed to his risk of heart attack and that hissymptoms began while he was performing tremendously stressfulheavy labor. From this testimony a reasonable inference arises that thework activity was a contributing cause of the heart attack, evenconsidering the 90% occlusion of a portion of Haulk's right coronaryartery. Thus, the Commission's determination that a sufficient causalconnection was demonstrated is not against the manifest weight of theevidence. If a causal connection between the work activity and theinjury is shown by competent testimony, no "limitation" or"exception" to compensation can be imposed to defeat a right torecovery.

In Rock Road Construction Co. v. Industrial Comm'n, 37 Ill. 2d123 (1967), we affirmed an award of compensation for a fatal heartattack. The decedent, an asphalt truck driver, was found dead in histruck after the truck went out of control, lightly struck a guard rail,and came to rest. He had previously suffered two myocardialinfarctions, carried nitroglycerin pills, and cold weather bothered him.Rock Road, 37 Ill. 2d at 125-26. The record established that the fatalheart attack occurred shortly after the decedent finished rolling up anddown his tarpaulin and dumping a load of asphalt. Rock Road, 37 Ill.2d at 127-28. Conflicting expert medical testimony was offered, oneexpert supporting the existence of a causal relationship between thework activity and the heart attack, and three others denying any causalconnection. One of the experts believed decedent's death wasinevitable, regardless of his work activity. Rock Road, 37 Ill. 2d at126. We observed it was likely that the ultimate result of decedent'sheart condition would have been death at some indeterminate futuredate, and possibly occurring in a situation wholly unrelated to workor exertion. Nevertheless, we found the Commission's finding ofcompensable injury was not against the manifest weight of theevidence, noting conflicting evidence of the extent of deterioration ofthe decedent's condition. Rock Road, 37 Ill. 2d at 128.

Similarly, in County of Cook v. Industrial Comm'n, 69 Ill. 2d 10(1977), we confirmed an award of compensation for a fatal heartattack when the victim had a prior history of myocardial infarction anddied following a period of an unusually busy workload in his office.We held the employee need only prove that some act or phase of theemployment was a causative factor of the resulting injury, explainingthat "[t]he mere fact that an employee might have suffered a fatalheart attack, even if not working, is immaterial." County of Cook, 69Ill. 2d at 17-18. We acknowledged the limitation that compensationwill be denied when it is shown that the employee's health has sodeteriorated that any normal daily activity is an overexertion, butstated the application of this limitation presented a question of fact forthe Commission. County of Cook, 69 Ill. 2d at 18.

As in Rock Road, the record in this case raised a reasonablelikelihood that Haulk's heart attack was inevitable and could haveoccurred in circumstances unrelated to work activities. The testimonyof Dr. Cohen, however, also provided a reasonable basis for theinference that Haulk's heavy labor put extreme stress on his heart, andthis stress was in fact a cause of his myocardial infarction. Under thestandard we announced in Sisbro, it was the Commission's functionto decide whether, considering the extent of Haulk's right coronaryartery occlusion and its predicted effect, his preexisting condition wasaggravated or accelerated by the work activity, thus sufficientlyestablishing a causal relationship between the work activity and theinjury.

Twice Over Clean concedes in its brief that if Haulk's history ofthe onset of symptoms is accurate, then Dr. Cohen's opinion on causalconnection based on that history had adequate foundation and isentitled to be given weight by the trier of fact. Twice Over Clean alsoconcedes in its brief that if Haulk's testimony is accurate, thearbitrator's reliance on that history is supported by the manifestweight of the evidence.

Twice Over Clean claims the history testified to by Haulk isinaccurate because it conflicts with his description of the onset ofsymptoms given to hospital personnel at the time of his admission.Twice Over Clean contends those descriptions were contemporaneouswith Haulk's January 2, 1997, cardiac event and, thus, were made ata time when the desire for proper diagnosis and treatment outweighedany motive to testify falsely for gain. Accordingly, Twice Over Cleanargues Haulk's testimony contradicting the hospital records should bedisregarded.

In Horath v. Industrial Comm'n, 96 Ill. 2d 349 (1983), this courtheld the Commission's decision denying compensation was not againstthe manifest weight of the evidence, despite the undisputed expertmedical testimony establishing a causal connection between the injuryand the claimant's disability. The Commission's opinion noted theclaimant gave a different account of his symptoms to treatingphysicians immediately after the injury than he gave to the doctor whotestified at the hearing. Horath, 96 Ill. 2d at 356. We held the findingregarding causation involved the credibility of the claimant. Theassessment of credibility is a function of the Commission, not thereviewing court. Thus, the Commission did not err in rejecting medicalopinions based on testimony found not credible. Horath, 96 Ill. 2d at356-57.

It is true, as Twice Over Clean argues, that some of thedescriptions in the medical records reflect a different account of theonset of symptoms than Haulk's testimony before the arbitrator,particularly as to timing. However, the nature and progression of thesymptoms as described in both the records and Haulk's testimony aresimilar. Only the record indicating the attack was preceded byintermittent chest pain for four weeks sharply contradicts Haulk'sdenial of prior chest pain in his testimony. The hypothetical questionposed to Dr. Cohen did not, however, include an assumption thatHaulk had no prior chest pain. In addition, Dr. Cohen was asked oncross-examination the significance of intermittent chest pain for aperiod of about a month. He stated it was consistent with stableangina, a symptom of coronary artery disease, but added that othersources of chest pain, including heartburn and muscle strain can mimicangina. Regardless of whether Haulk had prior intermittent pain owingto heart disease or some other cause, it is undisputed that Haulk'sright coronary artery occlusion preceded his heart attack.

We cannot say, based on this record, that the arbitrator'sacceptance of Haulk's testimony is without foundation or based onspeculation and conjecture. There was, accordingly, a reasonable basisfor acceptance of Dr. Cohen's opinion based on that testimony. Wehold, therefore, that he decision of the Commission is not against themanifest weight of the evidence.

CONCLUSION

There is an adequate basis in the record to conclude that thework activity described by Haulk aggravated or accelerated hispreexisting coronary artery disease and was, accordingly, a cause ofthe myocardial infarction resulting in his disability. The "normal dailyactivity limitation," while relevant to the question of causation, cannotbe applied as a matter of law to defeat Haulk's claim. It was,therefore, error for the appellate court to reverse the judgment of thecircuit court and set aside the decision of the Commission on theground that Haulk failed to prove a sufficient causal connectionbetween his work and the injury because of his susceptibility to a heartattack outside of work. Accordingly, we reverse the appellate court'sjudgment and affirm the judgment of the circuit court.

Appellate court judgment reversed;

circuit court judgment affirmed.

1. Now known as the Illinois Workers