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Case Law Database

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

Case No. MISSING
Regular Panel Decision

Main Evaluations, Inc. v. State

The claimant, Main Medical Evaluations, entered into contracts with the New York State Office of Temporary and Disability Assistance (OTDA) to perform consultative medical evaluations. OTDA terminated these contracts, alleging the claimant failed to disclose professional disciplinary proceedings against its chief medical officer, Arvinder Sachdev, and submitted false information during the bidding process. Following the dismissal of its claim in the Court of Claims, the claimant appealed. The appellate court affirmed the lower court's judgment, concluding that OTDA had legitimate grounds for termination due to the claimant's misrepresentations and failure to report substantial contract-related issues concerning Sachdev's integral role. Additionally, the court rejected the claimant's equal protection argument, finding no evidence of selective enforcement based on impermissible considerations.

Contract TerminationProfessional MisconductFalse RepresentationEqual ProtectionGovernment ContractsAppellate ReviewBreach of ContractMedical LicensingAdministrative ProceedingsDue Diligence
References
5
Case No. 2017-2088 K C
Regular Panel Decision
Oct 25, 2019

Quality Comprehensive Med. Care, P.C. v. New York Cent. Mut. Fire Ins. Co.

The Appellate Term, Second Department, reviewed an appeal concerning assigned first-party no-fault benefits. The plaintiff, Quality Comprehensive Medical Care, P.C., appealed a Civil Court order that granted summary judgment to the defendant, New York Central Mutual Fire Insurance Company, dismissing the complaint. The defendant had denied claims asserting a lack of medical necessity and excessive fees. The appellate court determined that the defendant did not establish a lack of medical necessity. However, it agreed that fees exceeding $425.88 per claim surpassed the allowed amount under the workers' compensation fee schedule. Therefore, the Civil Court's order was modified to dismiss only the portion of the complaint seeking recovery in excess of $425.88 per claim, and the order was affirmed as modified.

No-fault benefitsMedical necessityWorkers' compensation fee scheduleSummary judgmentAppellate reviewInsurance claimsFee disputeAssigned benefitsCivil CourtKings County
References
4
Case No. ADJ9725603
Regular
Nov 23, 2020

LUZ LOZA vs. GOLDBLATT GOLDBLATT/BAY AREA RESTAURANT MANAGEMENT, ARCH INSURANCE COMPANY, administered by YORK RISK SERVICES GROUP, INC.

The Workers' Compensation Appeals Board granted reconsideration of an administrative law judge's order finding the applicant entitled to pre-authorization for their treating physician to issue a PR-4 report at the medical-legal billing rate. While affirming the applicant's right to obtain the report, the Board clarified that the defendant retains the right to object to or raise defenses regarding the physician's billing. The Board reasoned that treating physicians are permitted to provide comprehensive medical-legal evaluations, and such reports are governed by specific medical-legal fee schedules, not the Official Medical Fee Schedule.

PR-4 reportmedical-legal billing ratepre-authorizationprimary treating physician (PTP)Qualified Medical Evaluator (QME)comprehensive medical evaluationOfficial Medical Fee SchedulePetition for ReconsiderationFindings of Fact and Order (F&O)Labor Code
References
3
Case No. ADJ1700793 (SAC 0307437) ADJ3714832 (SAC 0307399)
Regular
Jun 13, 2011

JUANITA BRADLEY (Deceased) vs. COUNTY OF PLACER

This case involves a dispute over liability for a medical-legal report cost. The defendant seeks reconsideration of a prior award holding them responsible for Dr. Adelberg's $4,237.50 report. The defendant argues the judge ignored a prior order for an Agreed Medical Evaluation (AME) and that the applicant's attorney improperly proceeded with Dr. Adelberg's exam. The Board granted reconsideration, preliminarily finding it may be inequitable to place the full cost on the defendant, and intends to split the expense between the defendant and applicant's attorney. A dissenting opinion argues the defendant's own correspondence shows an ongoing dispute regarding the AME, supporting the original award of liability.

Workers' Compensation Appeals BoardReconsiderationMedical-Legal ReportAgreed Medical EvaluationQualified Medical EvaluatorJoint Findings and AwardLabor Code Section 4062(a)Stipulation and OrderEquitable PowersLien Claimant
References
1
Case No. ADJ10986659
Regular
Sep 30, 2025

ALFREDO SERRANO vs. BIG IDEA HOLDINGS, LLC; OLD REPUBLIC INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration to further study the legal and factual issues raised by the Petition for Reconsideration. Applicant sought reconsideration of the January 27, 2022 Findings and Award, challenging the findings regarding a specific industrial injury to his right shoulder and a claimed cumulative injury. The Board concluded that the medical-legal opinions of the Qualified Medical Evaluator (QME), Dr. Bruce Huffer, were legally insufficient and analytically incomplete because he applied an incorrect legal standard for causation and apportionment, repeatedly requiring 'certainty' instead of 'reasonable medical probability'. Consequently, the Board rescinded the F&A and returned the matter to the trial level for further development of the medical-legal record, suggesting the selection of an Agreed Medical Evaluator.

QMEcumulative injuryapportionmentarthroplastysubstantial evidencemedical-legal opinionsrecord developmentLabor Code section 5701reasonable medical probabilitysuperimposed injury
References
24
Case No. ADJ11995067
Regular
Jul 25, 2025

ADELINA PEREZ vs. KYONG AE YUN, CHONG MYON YUN, ZENITH INSURANCE COMPANY

Applicant Adelina Perez sought removal of a May 9, 2022, Findings & Order (F&O) by a workers’ compensation administrative law judge (WCJ), which found Dr. Marcel Ponton's medical-legal report inadmissible and ordered his replacement, arguing Dr. Ponton was a treating physician to whom Labor Code section 4062.3 did not apply. The Workers' Compensation Appeals Board (WCAB) treated the petition as one for reconsideration and found that Dr. Ponton was indeed a treating physician, not a panel-selected medical-legal evaluator, rendering section 4062.3 inapplicable. Consequently, the WCAB rescinded the WCJ's F&O, substituted new findings affirming Dr. Ponton's role as a treating physician, and ordered his continuation as the medical-legal neuropsychological evaluator.

RemovalReconsiderationLabor Code section 4062.3Ex parte communicationMedical-legal evaluatorTreating physicianMPNNeuropsychological assessmentTraumatic brain injuryAdmissibility of evidence
References
17
Case No. ADJ9066751, ADJ9886621, ADJ10024303
Regular
Oct 05, 2016

CONSTANZA MEDINA VARGAS vs. BARRETT BUSINESS SERVICES, INC.

Here's a concise summary for a lawyer: The Workers' Compensation Appeals Board denied the applicant's petition for removal of an order taking the case off calendar. The Board found no irreparable harm or extraordinary circumstances justifying removal, as the applicant can refile a declaration of readiness. The Board also suggested the parties attempt to resolve disputes regarding additional medical evaluations before seeking Board intervention. They clarified that medical-legal expenses incurred during comprehensive evaluations are not subject to utilization review.

Petition for RemovalOrder Taking Case Off CalendarIrreparable HarmQualified Medical EvaluationsPrimary Treating PhysicianUtilization ReviewMedical-Legal ExpensesDiagnostic TestsDisputed Medical FactAdjudication of Claim
References
2
Case No. ADJ7212946
Regular
Dec 13, 2012

JOSE QUINTERO vs. CORPORATE PERSONNEL NETWORK, NEW HAMPSHIRE INSURANCE CO., administered by CHARTIS

The Appeals Board granted reconsideration to address the admissibility of Dr. Konstat's psychiatric evaluation. The Board found Dr. Konstat's report inadmissible because it was a medical-legal evaluation obtained in violation of statutory procedures for represented employees, bypassing the requirement for an Agreed Medical Evaluator or Qualified Medical Evaluator. Consequently, the Board amended the prior award to exclude industrial injury to the psyche due to lack of substantial medical evidence. The applicant's award for orthopedic injuries and medical treatment was affirmed.

Workers' Compensation Appeals BoardJose QuinteroCorporate Personnel NetworkNew Hampshire Insurance Co.ChartisAmended Findings and Awardindustrial injuryleft shoulderneckback
References
1
Case No. MISSING
Regular Panel Decision

Legal Aid Society v. Association of Legal Aid Attorneys

The Legal Aid Society sought a preliminary injunction against the Association of Legal Aid Attorneys and its officers to prevent the disciplining of striking union members who crossed picket lines. The plaintiff also claimed tortious interference and a civil rights conspiracy under 42 U.S.C. § 1985(3) on behalf of itself, non-striking attorneys, and indigent clients. The District Court denied the injunction, finding several impediments to success on the merits. These included the NLRB's primary jurisdiction, the Norris-LaGuardia Act's prohibitions, and the plaintiff's lack of standing for third-party claims. Furthermore, the court determined that the conspiracy allegations under Section 1985(3) were conclusory and lacked substantial merit.

Labor DisputePreliminary InjunctionUnion DisciplinePicket LinesNational Labor Relations Act (NLRA)Norris-LaGuardia ActStanding (Law)Conspiracy (Law)Civil Rights (42 U.S.C. § 1985(3))Tortious Interference
References
32
Case No. ADJ9011624
Regular
Dec 13, 2019

ELISHA HARDEN vs. COUNTY OF SACRAMENTO

This case concerns whether specific medical reports obtained for a disability retirement claim are admissible in a workers' compensation proceeding. The Appeals Board rescinded the prior ruling, holding these reports are relevant and may be provided to the orthopedic Agreed Medical Evaluator (AME) and psychiatric Qualified Medical Evaluator (QME). The Board found the reports relevant to the medical issues, even though they were not obtained through the standard workers' compensation medical-legal evaluation process. Consequently, the applicant's objection to providing these reports to the evaluators was overruled.

RemovalReconsiderationAgreed Medical Evaluator (AME)Qualified Medical Evaluator (QME)Medical-legal evaluatorsMedical recordsLabor CodeFindings and Orders (F&O)Disability retirementPermanent impairment
References
9
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