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

Case No. ADJ7692623
Regular
Sep 07, 2012

ANTHONY FAGONE vs. CITY OF FRESNO

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The Board upheld the finding that the applicant sustained industrial injuries and that the defendant lost control of medical treatment due to failing to process the applicant's pre-designated physician form. The defendant's argument that the applicant could not pre-designate a chiropractor was rejected, as the employer's inaction estopped them from benefiting from their processing failure. Therefore, the applicant is entitled to treatment by his chosen chiropractor during the period of the employer's processing error.

Workers' Compensation Appeals BoardIndustrial InjuryNeck InjuryChest Wall InjuryMedical Provider Network (MPN)Pre-designation of Treating PhysicianChiropractorLabor CodeEstoppelFindings and Award
References
1
Case No. ANA 0378959
Regular
May 27, 2000

MAI HO vs. MARRIOTT INTERNATIONAL

The Appeals Board granted reconsideration to reverse a restitution order against chiropractor Vu Phan, D.C., who provided unauthorized treatment. While Phan is not entitled to further payment for treatment not authorized by the employer, the Board found that the employer voluntarily paid $6,500 for past treatment and thus cannot recover it absent fraud, thus denying the employer's restitution claim. The Board otherwise affirmed the original decision denying Phan's lien claim for the unauthorized treatment.

Workers' Compensation Appeals BoardLien claimantRestitutionOverpaymentMedical treatmentUnauthorized treatmentPrimary treating physicianSelf-procured treatmentUnjust enrichmentVoluntary payment
References
6
Case No. ADJ1524412 (RDG 0043469)
Regular
Oct 18, 2011

STEPHEN FLESHMAN vs. MANDINA'S CUSTOM CABINETS, STATE COMPENSATION INSURANCE FUND

This case involves a dispute over ongoing chiropractic treatment for a back injury sustained in 1989. The defendant sought reconsideration of a prior award granting weekly chiropractic visits, arguing the treatment wasn't providing functional restoration after 21 years. The Appeals Board affirmed the award of 90 days of weekly chiropractic treatment, finding it supported by the treating chiropractor's reports and testimony. However, the Board amended the order to require further medical evaluation after the 90 days to determine future treatment needs.

Workers' Compensation Appeals BoardIndustrial InjuryBack and SpineStipulated AwardPermanent DisabilityFurther Medical TreatmentChiropractic TreatmentChronic Pain Medical Treatment GuidelinesFunctional RestorationProgress Report
References
1
Case No. ADJ4129998 (ANA 0358353)
Regular
May 21, 2013

BACILISA MARTINEZ vs. WEIMER FARMS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for LEGION INSURANCE CO. in liquidation, administered by SEDGWICK CMS

This case concerns a lien claimant chiropractor seeking unpaid treatment fees. The Appeals Board denied the lien claimant's petition for reconsideration because they failed to prove the treatment was reasonable and necessary for the admitted industrial injury. Specifically, the claimant did not adequately document which treatments pertained to the industrial injury versus unrelated conditions. The Board also noted procedural issues with the claimant's filing, including a lack of proof of service. The matter was returned to the trial level.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationIndustrial InjuryReasonable and Necessary TreatmentCausationUtilization ReviewEvidentiary BurdenCalifornia Insurance Guarantee AssociationLegion Insurance Co.
References
3
Case No. MISSING
Regular Panel Decision

Tucciarone v. Progressive Insurance

Plaintiffs, chiropractors, initiated a breach of contract action against defendants, a group of insurance companies. They sought additional compensation for specific chiropractic treatments (diathermy, ultrasound, traction) administered during office and home visits, arguing these were not explicitly covered by no-fault insurance fee schedules. Plaintiffs contended they should receive prevailing fees for these nonscheduled discrete treatments, despite being paid the scheduled fees for visits. The Supreme Court granted summary judgment in favor of the defendants, dismissing the complaint. The appellate court affirmed, emphasizing that the chiropractic fee schedule explicitly includes "any and all chiropractic treatment and modalities" within the flat fees for home and office visits, aligning with the legislative intent of Insurance Law § 5108.

No-Fault InsuranceAutomobile Liability InsuranceChiropractic ServicesMedical Fee ScheduleBreach of ContractSummary JudgmentAppellate ReviewStatutory InterpretationRegulatory InterpretationProfessional Fees
References
1
Case No. MISSING
Regular Panel Decision

Matter of Castler v. National Grid

Claimant sustained a low back injury in 2006, receiving workers' compensation benefits. In 2013, chiropractor Douglas Van Vorst treated him for two exacerbations after incidents involving shoveling snow and lifting a kayak. The employer's carrier disputed the medical bills, arguing the treatments did not comply with Workers’ Compensation Board Medical Treatment Guidelines (MTG). A Workers’ Compensation Law Judge initially ruled in favor of the medical provider, but the Workers’ Compensation Board reversed, finding insufficient documentation for the exacerbation. On appeal, the court examined the documentation and found that Van Vorst adequately detailed how the exacerbations occurred, objective changes from baseline, expected treatments, and claimant's response, satisfying the MTG requirements. The court concluded that the Board’s finding lacked substantial evidence and therefore reversed the Board's decision, remitting the matter for further proceedings.

Medical Treatment GuidelinesExacerbation of InjuryLow Back InjuryChiropractic TreatmentObjective Functional ImprovementVariance Request12 NYCRR 324.212 NYCRR 324.3Substantial EvidenceRemittal
References
5
Case No. MISSING
Regular Panel Decision
Jan 22, 2004

Mete v. New York State Office of Mental Retardation

This class action alleged age discrimination in employment against the New York State Office of Mental Retardation and Development Disabilities (OMRDD). Plaintiffs, former Chiefs of Developmental Center Treatment Services, claimed disparate treatment and disparate impact arising from a 1989 reduction in force (RIF) that eliminated their positions. All 46 Chiefs, who were over 40, were either demoted or retired, and statistical evidence showed a disproportionate impact on employees over 40. The Supreme Court granted defendants’ motion for summary judgment, dismissing all causes of action. The appellate court affirmed, finding that while plaintiffs established a prima facie case, OMRDD provided a legitimate, nondiscriminatory reason for the RIF (economic conditions and long-standing concerns about the position's utility), which plaintiffs failed to adequately prove was a pretext for discrimination.

Age DiscriminationClass ActionSummary JudgmentDisparate TreatmentDisparate ImpactReduction in ForceEmployment LawPretextPrima Facie CaseStatistical Evidence
References
11
Case No. MISSING
Regular Panel Decision

Claim of Evevsky v. Liberty Mutual Group

This case involves an appeal from a Workers’ Compensation Board decision regarding a claimant's unauthorized medical treatment. The claimant, who sustained neck and shoulder injuries in 1993, had her case reopened in 2001 after the employer's carrier objected to her request for authorized massage therapy. Both the Workers’ Compensation Law Judge and the Board determined that the treatment was not authorized under Workers’ Compensation Law § 13-b, as the massage therapist was not Board-authorized nor supervised by an authorized physician. The appellate court reviewed the Board's decision, affirming that there was no legal basis to overturn the finding. The court also considered and dismissed the claimant's constitutional arguments as being without merit.

Workers' CompensationMedical TreatmentMassage TherapyAuthorizationBoard DecisionAppellate ReviewStatutory InterpretationPhysician SupervisionConstitutionalityPermanent Partial Disability
References
3
Case No. ADJ11025609
Regular
Apr 30, 2018

DONNA IVES vs. DR MYERS DISTRIBUTING COMPANY, PREFERRED EMPLOYERS INSURANCE COMPANY

In this workers' compensation case, the Appeals Board rescinded the WCJ's decision and returned the matter for further proceedings. The Board found that the defendant improperly modified the applicant's Request for Authorization (RFA) for treatment by a chiropractic neurologist. Instead of referring the request for medical utilization review, the claims administrator authorized treatment with a general chiropractor. The Board emphasized that claims adjusters cannot modify RFAs and that medical necessity decisions must be made by physicians.

WCABPetition for ReconsiderationFindings of FactWCJindustrial injurychiropractic neurologistMedical Provider Network (MPN)Request for Authorization (RFA)Utilization Review (UR)Medical Treatment Utilization Schedule (MTUS)
References
3
Case No. ADJ9066751
Regular
Aug 10, 2015

CONSTANZA MEDINA VARGAS vs. BARRETT BUSINESS SERVICES, INC.

The Workers' Compensation Appeals Board dismissed the defendant's Petition for Removal, treating it as a Petition for Reconsideration, and denied that petition. The Board affirmed the administrative law judge's finding that the defendant failed to comply with Medical Provider Network (MPN) access standards. Specifically, the defendant did not have the required number of available chiropractors within the specified distance at the relevant time. Therefore, the applicant is not required to seek treatment within the defendant's MPN and may seek treatment elsewhere at the defendant's expense.

Workers Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationMedical Provider NetworkMPN access standardsLabor Code section 4616Administrative Director Rule 9767.5primary treating physicianchiropractorsMinutes of Hearing
References
3
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