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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. 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. MISSING
Regular Panel Decision

Yklik Medical Supply, Inc. v. Allstate Insurance

Plaintiff Yklik Medical Supply, Inc., a medical supply provider, sued Allstate Insurance Company to recover $317 in unpaid medical bills for equipment supplied to its assignor, Tammy Agosto. Yklik moved for summary judgment, asserting proper bill submission and Allstate's failure to timely pay or deny the claim. Allstate argued that the charges exceeded the Workers' Compensation fee schedule and that a partial payment had been made. The court found that Yklik established a prima facie case. The central issue was whether Allstate's fee schedule defense was precluded due to its failure to issue a timely denial within 30 days as mandated by Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The court ruled that since Allstate waited 56 days to send its denial, it was precluded from raising the fee schedule defense, and therefore, summary judgment was granted to the plaintiff.

No-fault insurancesummary judgmenttimely denialfee schedulepreclusion ruleinsurance lawmedical supplybilling practicespersonal injury protectionassignor
References
19
Case No. MISSING
Regular Panel Decision

Fraser v. Brunswick Hospital Medical Center, Inc.

In this medical malpractice action, the defendant The Brunswick Hospital Medical Center, Inc. appealed an order that granted the plaintiff’s motion to strike its workers’ compensation coverage defense. Concurrently, the plaintiff cross-appealed the dismissal of the complaint against defendant S. Fong. The appellate court affirmed the decision to strike the workers’ compensation defense for The Brunswick Hospital Medical Center, Inc., citing its participation and lack of appeal in the prior Workers’ Compensation Board hearing. However, the dismissal of the complaint against S. Fong was reversed, as S. Fong was not present at the Board hearing, thus preclusion did not apply, and a triable issue of fact existed regarding whether the injury was employment-related. The court also rejected S. Fong's argument regarding the absence of a doctor-patient relationship.

Medical MalpracticeWorkers' CompensationAffirmative DefenseSpecial EmployeeCoemployeePreclusive EffectTriable Issue of FactDoctor-Patient RelationshipAppellate ReviewHospital Liability
References
7
Case No. MISSING
Regular Panel Decision
Sep 16, 1992

Pica v. Montefiore Medical Group

The Supreme Court, Bronx County, dismissed a personal injury action brought by an employee of Montefiore Hospital and Medical Center against Montefiore Medical Group. The dismissal was based on the affirmative defense of Workers' Compensation. The plaintiff failed to demonstrate that Montefiore Medical Group was a separate legal entity from Montefiore Hospital and Medical Center, whose employee controlled her work. Consequently, the court found recovery barred under Workers' Compensation Law § 11. The appellate court unanimously affirmed the dismissal.

Workers' CompensationPersonal InjuryEmployer LiabilityCorporate VeilExclusive RemedyAffirmative DefenseAppellate DecisionMotion to DismissSummary JudgmentBronx County
References
3
Case No. ADJ4406096 (LAO 0784412)
Regular

JOSE MORFIN vs. WHITE MEMORIAL MEDICAL CENTER

Defendant sought removal from a WCJ's order stipulating to two Agreed Medical Evaluators (AMEs), alleging the WCJ "forced" the agreement. Applicant's attorney and the WCJ countered that defense counsel had agreed to and proposed the AMEs, with the WCJ merely documenting the stipulation. The Appeals Board denied removal as defendant showed no prejudice, but initiated its own removal to address the attorney's alleged false statements and vexatious tactics. Consequently, the Board intends to impose sanctions of up to $2,500 on the defendant and its attorneys for filing a frivolous petition containing misrepresentations.

Workers' Compensation Appeals BoardPetition for RemovalAgreed Medical EvaluatorsWCJSanctionsBad Faith TacticsFrivolousUnnecessary DelayStipulationMisrepresentation of Facts
References
1
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. 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
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