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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. ADJ8691809
Regular
Apr 14, 2017

NICOLE BORAGNO vs. STATE OF CALIFORNIA, CDCR - CENTRAL CALIFORNIA WOMEN'S FACILITY CHOWCHILLA, STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES

This case involves Nicole Boragno's workers' compensation claim against the State of California, CDCR. The applicant sought reconsideration of a decision denying the admission of a supplemental medical report. The WCAB denied reconsideration, adopting the WCJ's report which found the supplemental report inadmissible. This was because discovery had closed at the mandatory settlement conference, and the defendant failed to establish good cause for introducing evidence not previously disclosed. The WCJ noted there was no change in circumstances to warrant the late-filed report, distinguishing it from precedent that allows such reports.

WORKERS' COMPENSATION APPEALS BOARDPetition for Reconsiderationmandatory settlement conferencediscovery closureLabor Code section 5502(d)(3)good causesupplemental reportPQMEapportionmenttimeliness
References
2
Case No. 03-17-00666-CV
Regular Panel Decision
Dec 05, 2018

Facility Insurance Corporation v. Patients Medical Center

This appeal arises from a medical fee dispute under the Texas Workers’ Compensation Act between Facility Insurance Corporation (Carrier) and Patients Medical Center (Provider). The Carrier challenged a trial court's judgment that affirmed a SOAH Decision and Order, mandating the Carrier to pay the Provider $20,495.78 for medical services. The primary issue was whether the administrative law judge (ALJ) incorrectly shifted the burden of proof from the Provider to the Carrier during the contested-case hearing. The Court of Appeals found that the Provider, as the party seeking affirmative relief, bore the burden of proof in the de novo hearing. Consequently, the court reversed the trial court's judgment and remanded the case to the Division for new proceedings consistent with its opinion.

Workers' Compensation ActMedical Fee DisputeBurden of ProofAdministrative Law Judge (ALJ)SOAH DecisionJudicial ReviewSubstantial Evidence RuleTexas Department of InsuranceSpinal Cord StimulatorReimbursement Claim
References
25
Case No. 19-0533
Regular Panel Decision
Jan 29, 2021

Patients Medical Center v. Facility Insurance Corporation

This case is an administrative appeal stemming from a medical fee dispute between Patients Medical Center, a healthcare provider, and Facility Insurance Corporation, a worker's compensation insurance carrier. The core issue revolves around the proper allocation of the burden of proof in a contested case hearing before the State Office of Administrative Hearings (SOAH) following an initial decision by the Texas Department of Insurance, Division of Workers’ Compensation. While the Division and the ALJ initially placed the burden on the carrier, the court of appeals reversed. The Texas Supreme Court, however, reversed the court of appeals, holding that the burden of proof lies with the party seeking relief from the Division's initial decision, which in this case was the carrier. The Supreme Court remanded the case for the court of appeals to address other unaddressed issues.

Worker's CompensationMedical Fee DisputeAdministrative LawBurden of ProofTexas Supreme CourtAppellate ReviewInsurance LawHealthcare ReimbursementSOAHALJ Decision
References
10
Case No. ADJ10330860
Regular
Feb 24, 2025

RACHELLE MARTINEZ vs. CALIFORNIA MEDICAL FACILITY, STATE COMPENSATION INSURANCE FUND

Applicant Rachelle Martinez suffered a work-related injury on August 17, 2015, while working for California Medical Facility, exacerbated by a subsequent incident. The parties reached a settlement through Stipulations with Request for Award, but a lien claimant, CCPOA-Benefit Trust Fund, asserted its lien was not properly considered, leading to a Petition for Reconsideration of a December 18, 2024 Award. The Appeals Board found the petition premature as no evidence was admitted into the record regarding the lien claimant's allegations of good cause to set aside the award. Therefore, the Petition for Reconsideration was dismissed, and the matter returned to the trial level for further proceedings to allow the lien claimant to present evidence.

Workers' Compensation Appeals BoardPetition for ReconsiderationLabor Code section 5909Electronic Adjudication Management System (EAMS)transmission datenotice of transmissionReport and RecommendationStipulations with Request for Awardlien claimantCCPOA-Benefit Trust Fund
References
26
Case No. 03-18-00663-CV
Regular Panel Decision
Dec 05, 2019

Facility Insurance Company v. Vista Hospital of Dallas, Vista Medical Center Hospital and Surgery Specialty Hospitals of America

This case involves an appeal from a suit for judicial review of an administrative decision concerning workers’ compensation medical benefits. Multiple insurance carriers (Appellants) disputed the reimbursement amounts sought by Vista Hospital entities (Appellees) for outpatient medical services provided between 2002 and 2008. Vista initially claimed 70%-100% of billed charges but later revised its calculations to 200% of the Medicare allowable reimbursement, following a 2008 regulatory change and a clarifying court opinion. The State Office of Administrative Hearings (SOAH) and the trial court affirmed Vista's revised calculations as 'fair and reasonable.' The Court of Appeals affirmed the trial court's judgment, finding substantial evidence to support SOAH's decision regarding the reimbursement methodology and the accrual of interest.

Medical Reimbursement DisputesAdministrative Agency ReviewAppellate Court DecisionTexas Labor CodeFee Guideline InterpretationHospital Billing PracticesWorkers' Compensation InsuranceState Office of Administrative Hearings (SOAH)Due Process RightsStatutory Interpretation
References
18
Case No. 2-06-016-CV
Regular Panel Decision
Mar 15, 2007

Shioleno Industries, Inc. AND Columbia Medical Center of Arlington Subsidiary, L.P. and Columbia North Texas Subsidiary, GP, LLC D/B/A Medical Center of Arlington v. Columbia Medical Center of Arlington Subsidiary, L.P. and Columbia North Texas Subsidiary, GP, LLC D/B/A Medical Center of Arlington AND Shioleno Industries, Inc.

Shioleno Industries, Inc. appealed a summary judgment granted in favor of Columbia Medical Center of Arlington Subsidiary, L.P. and Columbia North Texas Subsidiary, GP, LLC d/b/a Medical Center of Arlington (the Hospital). The case originated from the Hospital's alleged failure to disclose an employee's positive drug and alcohol test results to Shioleno after an on-the-job injury. Shioleno contended that this omission led to increased workers' compensation premiums and expenses in unemployment benefit disputes. The appellate court affirmed the trial court's judgment, ruling that Shioleno failed to provide a valid authorization for the disclosure of medical information. Consequently, the Hospital had no legal duty to disclose the results and could not be held liable for negligence, breach of contract, or Deceptive Trade Practices Act (DTPA) violations.

Summary JudgmentMedical RecordsDisclosure AuthorizationHealth & Safety CodeNegligenceBreach of ContractDTPADrug TestingAlcohol TestingEmployer Liability
References
13
Case No. 03-17-00357-CV
Regular Panel Decision
Nov 21, 2017

George Allibone, M.D. v. Scott Freshour, in His Official Capacity as the Interim Executive Director of the Texas Medical Board Juanita Garner, Investigator of the Texas Medical Board And the Texas Medical Board

George Allibone, M.D., appealed the denial of his petition for a protective order against an administrative subpoena issued by the Texas Medical Board. The subpoena sought patient medical and billing records for an investigation into complaints against Allibone. He contended the trial court erred by failing to issue findings of fact and conclusions of law and by abusing its discretion in finding the subpoena reasonable and relevant. The appellate court found Allibone waived his complaint regarding missing findings. It also concluded the trial court did not abuse its discretion, citing the Board's need for complete records for investigation and Allibone's failure to prove the unconstitutionality of the statute requiring compliance. The trial court's order was affirmed.

Medical Board InvestigationAdministrative SubpoenaPhysician RecordsConstitutional RightsDue ProcessJudicial Review of Agency ActionAbuse of DiscretionFourth AmendmentTexas LawProfessional Licensing
References
50
Case No. 02-22-00072-CV
Regular Panel Decision
Jul 27, 2023

BioTE Medical, LLC v. John Carrozzella, MD, JCMD Medical Services, Inc., Dan Deneui, and Terri Deneui

This case addresses whether a contractual "residual benefit" clause, requiring a post-termination fee for using a competing treatment method, constitutes a covenant not to compete under Texas law. Appellant BioTE Medical, LLC, licensed a pellet-based bioidentical hormone replacement therapy (BHRT) method. Appellee JCMD Medical Services, Inc., a former customer, terminated its agreement and began using a competitor's BHRT without paying the residual-benefit fee. BioTE Medical sued JCMD for breach of contract. The trial court granted summary judgment to JCMD, finding the clause unenforceable either as a noncompete or a violation of public policy. The appellate court reversed, holding that the residual-benefit clause is not a covenant not to compete as it does not restrict JCMD from competing with BioTE Medical, but rather from using a competitor's product. The court also declined to invalidate the clause on uncodified public policy grounds, deferring to the Legislature's policy determinations.

Contract lawCovenants Not to Compete ActResidual benefit clausePublic policyBioidentical hormone replacement therapy (BHRT)Breach of contractSummary judgmentAppellate reviewTexas lawBusiness and Commerce Code
References
33
Case No. ADJ9433946
Regular
Feb 19, 2015

ELLEN REED vs. STATE OF CALIFORNIA, CDCR CALIFORNIA CORRECTIONAL CENTER, Legally Uninsured; STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES, Adjusting Agency

In *Reed v. State of California, CDCR California Correctional Center*, the applicant, Ellen Reed, petitioned for reconsideration of a prior decision. The Workers' Compensation Appeals Board (WCAB) has granted this petition. The Board believes reconsideration is necessary to allow further study of the factual and legal issues to ensure a just and reasoned decision. Pending the decision after reconsideration, all filings must be submitted in writing directly to the WCAB Commissioners in San Francisco, not to any district office or via e-filing.

Workers' Compensation Appeals BoardPetition for ReconsiderationGranting PetitionStatutory Time ConstraintsFactual and Legal IssuesJust and Reasoned DecisionFurther ProceedingsOffice of the CommissionersElectronic Adjudication Management SystemRedding District Office
References
0
Case No. ADJ8181938; ADJ8702275
Regular
Apr 10, 2023

KAREN MILLER vs. STATE OF CALIFORNIA, VENTURA YOUTH CORRECTIONAL FACILITY, STATE COMPENSATION INSURANCE FUND, STATE CONTRACT SERVICES

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The defendant argued against the statutory 15% increase, the method of evaluating spine impairment, and the inclusion of a sleep disorder. The Board adopted the WCJ's report, finding no error in the application of the 15% increase or the evaluation of the spine impairment using the ROM method as deemed appropriate by the agreed medical examiner. Furthermore, the Board upheld the finding of an industrially caused sleep disorder, noting that formal sleep studies are not always required for diagnosis and that the physician's rating falls within the AMA Guides.

WCABPetition for ReconsiderationDeniedVentura Youth Correctional FacilityAdjudication NumbersOccupational Group 214Cervical SpineLumbar SpineBilateral ShouldersGastrointestinal System
References
1
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