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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

Claim of Rivera v. North Central Bronx Hospital

The employer appealed a decision by the Workers’ Compensation Board, arguing that the Board incorrectly interpreted Workers’ Compensation Law § 13-a (7) by mandating reimbursement to the claimant’s doctor for an EMG test. The employer contended that since the claimant failed to use a specified provider as per statutory notice, it should not be obligated to pay. However, the court found no statutory or historical support for nonpayment as a remedy, noting that the law aims to provide swift benefits to injured employees and prevent providers from collecting directly from workers. The court emphasized that allowing the employer to avoid payment would harm medical providers and deter their participation in the workers’ compensation system. Consequently, the court affirmed the Board’s decision, requiring the employer to pay its in-network rate to the claimant's doctor.

Workers' Compensation LawEMG test reimbursementEmployer appealStatutory interpretationMedical provider paymentClaimant medical expensesSelf-insured employersDiagnostic testsLegislative intentBoard decision affirmed
References
7
Case No. ADJ8118127
Regular
Apr 24, 2015

JUANA PONCE DE MAULEON vs. HARRIS WOOLF CALIFORNIA ALMONDS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a prior finding. The WCAB determined that EMG/NCS diagnostic testing requested by the applicant's primary treating physician constitutes medical treatment. Therefore, this testing is subject to Utilization Review (UR) and subsequent Independent Medical Review (IMR), rather than being classified as a medical-legal expense adjudicated by the WCAB. The employer's petition for reconsideration was granted on this basis.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewElectromyographyNerve Conduction StudyPrimary Treating PhysicianMedical TreatmentMedical-Legal ExpensesFindings & OrderPetition for Reconsideration
References
6
Case No. ADJ4322447 (LAO 0855360)
Regular
Aug 15, 2013

LEOPOLDO BENAVIDEZ vs. ANTONIO SANCHEZ, ALLSTATE, administered by SPECIALTY RISK SERVICES

The Workers' Compensation Appeals Board rescinded a prior award finding new and further disability for the applicant. The Board determined that the applicant's worsened spinal condition, as evidenced by an EMG study, predated the initial stipulated award. Therefore, it was not "new and further" disability as required to reopen the case under Labor Code section 5410. The Board also found no other "good cause" to reopen, as the applicant could have discovered and presented the EMG evidence before the original award.

Workers' Compensation Appeals BoardReconsiderationStipulated AwardNew and Further DisabilityPermanent Disability IndemnityLife PensionAgreed Medical Evaluator (AME)Lumbar Compression FracturePermanent DisabilityElectrodiagnostic Report (EMG)
References
9
Case No. ADJ4337031 (SAC 0363533)
Regular
Aug 19, 2011

CHARLOTTE HUDSON vs. EMG CHILDREN & FAMILY SERVICES, EVEREST NATIONAL INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration of a prior decision, rescinding the judge's award of 11% permanent disability. The case is returned to the trial level to further develop the medical record regarding the applicant's gait derangement impairment and its valuation under *Almaraz/Guzman* principles. The judge must also address the vocational expert's entitlement to fees and consider the recent *Ogilvie* decision's impact on permanent disability determination.

Workers' Compensation Appeals BoardFindings and AwardPermanent DisabilityVocational ExpertAgreed Medical ExaminerAlmaraz/GuzmanOgilvieGait DerangementAntalgic GaitAMA Guides 5th Edition
References
9
Case No. ADJ3408326
Regular
Jan 07, 2013

MOISES MENDOZA vs. WORLD SUPER SERVICES, INC., TRAVELERS INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award. The Board found that the lien claimant, Precision Occupational Medical Group, failed to meet its burden of proof. Specifically, the claimant did not demonstrate that the EMG/NCV study of the applicant's lower extremities was reasonable and necessary to treat the admitted left ankle injury. The matter was returned to the trial level with the lien claim disallowed.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardLien ClaimantReasonable and Necessary TreatmentBurden of ProofStipulations with Request for AwardMaximum Medical ImprovementEMG/NCV StudyLower Extremities
References
2
Case No. ADJ795505 (LAO 0794863)
Regular
Feb 13, 2014

VICTORIA SHANLEY vs. HENRY MAYO NEWHALL MEMORIAL HOSPITAL, TRAVELERS INSURANCE CO.

The Appeals Board reconsidered a WCJ's decision upholding utilization review (UR) denials for an MRI and EMG. While other contentions regarding the UR physician's qualifications and licensing were dismissed based on precedent, the Board found the UR decisions invalid due to untimely communication. Specifically, the defendant failed to prove by substantial evidence that the UR decisions were communicated by phone, fax, or email within 24 hours of being made. The matter is returned to the trial level to determine medical necessity, as the UR denials are void.

Utilization ReviewLabor Code Section 4610Administrative Director Rule 9792.9Physician QualificationLicensing RequirementsCommunication TimeframesTimely CommunicationMedical NecessityIndependent Medical ReviewInvalid UR Decision
References
2
Case No. ADJ7962227
Regular
May 09, 2014

ANDREA REYNOSO vs. SANSUM CLINIC, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration, upholding the initial finding that she did not sustain a cumulative injury during her employment. The applicant claimed new evidence, including EMG testing for wrist issues and diagnoses of pulmonary embolism and blood clots affecting her psyche, should have been considered. However, the Board found this evidence was not "newly discovered" and could have been discovered through due diligence prior to the settlement conference or trial. Even if admitted, the new evidence would not alter the conclusion that any industrial injury occurred in 1999, not during her employment with Sansum Clinic.

Workers' Compensation Appeals BoardCumulative InjuryAgreed Medical EvaluatorPetition for ReconsiderationFindings of Fact and OrderAOE/COECarpal Tunnel SyndromePulmonary EmbolismPsyche InjuryNew Evidence
References
1
Case No. ADJ7917390 ADJ8109606
Regular
Apr 08, 2015

ARLENE ZENDEL vs. COUNTY OF LOS ANGELES, Permissibly Self-Insured, Adjusted By INTERCARE INSURANCE SERVICES

The Appeals Board granted the defendant's petition for reconsideration and affirmed the WCJ's original Findings and Awards, with modifications. The Board corrected clerical errors regarding the date of injury for cumulative trauma in ADJ8109606 and amended the temporary disability finding in ADJ7917390 to include credit for days worked. The Board found that the Agreed Medical Evaluator's use of the range of motion method for rating spinal impairments, based on MRI and EMG results, constituted substantial evidence and rejected the defendant's arguments otherwise. Finally, the Board dismissed applicant's untimely raised issue regarding the "additive method."

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardsApplicantDefendantIndustrial InjuryPsycheBilateral WristsBackNeck
References
10
Case No. MISSING
Regular Panel Decision

Brown v. Achy

This personal injury lawsuit arose from an automobile accident, addressing the 'serious injury' threshold under Insurance Law § 5102 (d). Defendants moved for summary judgment, presenting reports from independent medical examinations that found no objective confirmation of disc herniation, despite an initial MRI. Plaintiff countered with objective evidence, including MRI and EMG/NCV results showing abnormal findings, and a doctor's affirmation detailing significant range of motion limitations and a permanent partial disability. The court ruled that this evidence, alongside an adequate explanation for a treatment gap, created a triable issue of fact as to serious injury. Consequently, the Supreme Court's order granting summary judgment was reversed, and the complaint was reinstated, with a purported appeal from an earlier decision dismissed.

Personal InjuryAutomobile AccidentSerious Injury ThresholdSummary JudgmentInsurance Law § 5102(d)Disc HerniationMRI FindingsEMG/NCV StudyRange of Motion LimitationsStraight-Leg Raising Test
References
21
Case No. MISSING
Regular Panel Decision

Jacobs v. Mostow

The appellate court dismissed the appeal from an intermediate order and affirmed the dismissal of the complaint against various defendants. The Supreme Court properly dismissed claims against Arthur Riegel based on arbitrator immunity, against Steven Payer due to res judicata, and against several other defendants including New York State United Teachers and Jaspan Schlesinger Hoffman, LLP, based on the statute of limitations. Claims against NCS Pearson, Inc. and Randall Solomon were dismissed for failure to state a cause of action, with an additional statute of limitations bar for medical malpractice against Solomon. Claims against the New York State Teachers’ Retirement System, the State of New York Education Department, and the State of New York were dismissed for failure to comply with procedural requirements and failure to state a claim.

Appeal DismissedComplaint DismissedArbitrator ImmunityRes JudicataStatute of LimitationsFailure to State a Cause of ActionProcedural RequirementsDisciplinary HearingAppellate ReviewJudgment
References
12
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