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Case Law Database

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

Case No. 04-09-00401-CV
Regular Panel Decision
Jul 21, 2010

Texas Mutual Insurance Company v. Sarah Ochoa

Sarah Ochoa sustained a lumbar sprain injury at work and filed a workers' compensation claim. Texas Mutual Insurance Company, the carrier, initially accepted the lumbar sprain but disputed later claims of extensive lumbar disc pathology as an ordinary disease of life. The hearing officer found a sprain/strain injury superimposed on pre-existing degenerative conditions but also ruled that Texas Mutual waived its right to contest the extent of injury by not timely disputing it within 60 days, making the degenerative conditions compensable. Texas Mutual appealed to the state district court, which granted Ochoa's no-evidence motion for summary judgment. This appellate court reverses and remands the trial court's judgment, holding that the 60-day waiver rule in the Texas Labor Code does not apply to extent-of-injury disputes, citing Texas Supreme Court precedent.

Workers' CompensationSummary JudgmentWaiver RuleExtent of Injury DisputeLumbar SprainDegenerative Disc DiseasePre-existing ConditionAppellate ReviewTexas Labor CodeJudicial Precedent
References
7
Case No. 2015-05-0415
Regular Panel Decision
Feb 11, 2016

Leas, Anthony v. Opus Inspection, Inc.

Anthony Leas filed a Request for Expedited Hearing seeking medical and temporary disability benefits after allegedly spraining his left ankle and foot while stepping out of his car. His authorized treating physician, Dr. Joseph Wieck, diagnosed a foot sprain but opined that the injury was not primarily caused by the employment incident. The Court noted that Dr. Wieck's causation opinion is presumed correct under Tennessee Code Annotated section 50-6-102(14)(E). Mr. Leas failed to present expert medical evidence to rebut this presumption. Consequently, the Court denied Mr. Leas's requests for medical and temporary disability benefits, concluding he was not likely to prevail at a hearing on the merits.

Workers' CompensationExpedited HearingMedical BenefitsTemporary DisabilityCausationAnkle SprainFoot SprainMedical EvidenceExpert OpinionBurden of Proof
References
3
Case No. 2018-02-0051
Regular Panel Decision
Jun 05, 2018

Hoss, Timothy v. ASR Metals

Timothy Hoss, an employee, filed an expedited hearing request seeking medical benefits for a back injury sustained on October 29, 2014, while working for ASR Metals. The central issues were the causal relationship between his need for treatment and the injury, and the medical necessity of proposed spinal surgery and facet injections. After an initial denial of decompression surgery recommended by Dr. Morgan Lorio, Mr. Hoss was evaluated by neurosurgeon Dr. Jim Brasfield. Dr. Brasfield recommended an L2-L3 MIS decompressive hemilaminectomy and L5-S1 percutaneous facet injections, citing stenosis and radiculopathy. ASR Metals' utilization review physician, Dr. Kimberly Terry, denied these procedures, attributing findings to pre-existing degenerative disc disease. The Court, however, found that ASR Metals failed to overcome the presumption of correctness of the authorized panel physician, Dr. Brasfield, regarding both causation and medical necessity. Consequently, the Court granted Mr. Hoss's requested relief, ordering ASR Metals to schedule the recommended surgical procedures.

Workers' CompensationBack InjurySpinal SurgeryFacet InjectionsMedical NecessityCausationUtilization ReviewPresumption of CorrectnessExpedited HearingMedical Benefits
References
1
Case No. ADJ132127 (VNO 0524197) ADJ2705905 (VNO 0524198)
Regular
May 24, 2016

MIRELLA FLORES DE LOPEZ vs. FACEY MEDICAL FOUNDATION, CRUM & FORSTER INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted reconsideration for Mirella Flores de Lopez's case against Facet Medical Foundation and Crum & Forster Insurance. This decision was made to allow the Board more time to thoroughly review the factual and legal issues presented. The WCAB requires all future correspondence related to the petition to be filed directly with their office, not district offices or e-filed. Settlements cannot be processed by a WCJ while a case is under reconsideration by the Board.

WORKERS' COMPENSATION APPEALS BOARDMIRELLA FLORES DE LOPEZFACEY MEDICAL FOUNDATIONCRUM & FORSTER INSURANCEPetition for ReconsiderationOpinion and OrderStatutory Time ConstraintsFactual IssuesLegal IssuesJust and Reasoned Decision
References
0
Case No. ADJ2771432 (LAO 0888626) ADJ7117919
Regular
Apr 22, 2014

JOSE HERNANDEZ vs. GENTLE GIANT MOVING & STORAGE COMPANY, FRYE CLAIMS CONSULTATION AND ADMINISTRATION/TRANSGUARD INSURANCE COMPANY

In this case, the Workers' Compensation Appeals Board reversed a finding of continuing temporary disability. The Board rescinded the order for a psychiatric evaluation as the applicant never claimed a psyche injury and rescinded the order for a facet joint injection due to a prior Utilization Review denial that was not timely challenged. The Board also found that the applicant had reached permanent and stationary status and returned the matter for determination of permanent disability on the existing record, allowing for updated reports if necessary.

WCABReconsiderationJoint Findings and AwardTemporary Total DisabilityPermanent DisabilityAgreed Medical ExaminerUtilization ReviewIndependent Medical ReviewFacet Joint InjectionUrodynamics Study
References
0
Case No. ADJ8115084
Regular
Jun 02, 2014

MARY HAYWORTH vs. KCI HOLDINGS USA, INC., FIDELITY AND GUARANTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, rescinding a prior finding that the applicant failed to establish a plainly erroneous fact in an Independent Medical Review (IMR) determination. The Board found the IMR decision was based on a plainly erroneous mistake of fact because it evaluated a request for dorsal medial branch block injections as though it were a request for facet injections, which are different procedures. Consequently, the medical treatment dispute is remanded to the Administrative Director for review by a different independent review organization or reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewLabor Code Section 4610.5Plainly Erroneous Finding of FactMedical Treatment DisputeUtilization ReviewAdministrative DirectorDorsal Medial Branch BlockFacet InjectionsMTUS Guidelines
References
2
Case No. ADJ7744103, ADJ7580182 (MF)
Regular
May 05, 2014

IGNACIO RAMOS vs. GREENWOOD DAIRY, CALIFORNIA LIVESTOCK PROCDUCERS

The Workers' Compensation Appeals Board granted reconsideration, rescinded the judge's decision, and returned the case for further proceedings. While finding no permanent disability from the applicant's industrial foot injury, the Board determined that the applicant did sustain industrial injury in the form of a fungal foot infection and bilateral foot sprain. The Board disagreed with the trial judge's finding of no industrial injury and clarified that Dr. McCoy's opinion, not Dr. Panting's, constituted substantial evidence regarding the nature of the industrial injury. Issues of temporary disability and further medical treatment were deferred to the trial level for further decision.

AOE/COEPetition for ReconsiderationFindings and OrderAgreed Medical ExaminerPanel Qualified Medical ExaminationSubstantial EvidenceMedical ProbabilityOsteonecrosisFreiberg's infractionFungal foot infection
References
0
Case No. ADJ2211743 (SBR 0330510)
Regular
Jul 19, 2011

LAURA GIBSON vs. FOREST HOME, INCORPORATED, CHURCH MUTUAL INSURANCE

The Workers' Compensation Appeals Board denied reconsideration of a lien claimant's petition regarding reimbursement for medical treatment. Although the petition was not acted upon within the statutory 60-day period, the Board considered it on its merits due to circumstances beyond the claimant's control. The WCJ's report, which was adopted by the Board, found that the lien claimant failed to meet the burden of proof for treatment beyond a single epidural injection. The Board determined that only charges attributable to a single epidural procedure were reasonable and necessary, excluding other procedures like facet blocks and manipulation under anesthesia.

WORKERS' COMPENSATION APPEALS BOARDLAURA GIBSONFOREST HOMEINCORPORATEDCHURCH MUTUAL INSURANCEORDER DENYING RECONSIDERATIONPetition for Reconsiderationlien claimantdue processWCJ report
References
1
Case No. 2018-06-0130
Regular Panel Decision
Nov 20, 2018

Lagel. Imad v. Elwood Staffing Services, LLC

Imad Lagel, a temporary employee, experienced right foot pain in July 2016. After initial treatment, Dr. Harold V. Nevels diagnosed an ankle sprain and discharged him to full duty. However, Mr. Lagel's pain reemerged, and during a follow-up, Dr. Nevels concluded that his current symptoms were unrelated to the work injury, attributing them to osteoarthritic changes. Elwood Staffing's motion for summary judgment, which Mr. Lagel failed to respond to, was granted by the Court. The Court found Mr. Lagel could not establish a causal relationship between his workplace injury and his ongoing need for medical treatment.

Workers' CompensationSummary JudgmentCausationMedical ProofOsteoarthritisAnkle SprainPro Se LitigantTennessee LawPreexisting ConditionExpert Medical Evidence
References
4
Case No. 2018 NY Slip Op 01108 [158 AD3d 965]
Regular Panel Decision
Feb 15, 2018

Matter of Williams v. New York State Off. of Temporary Disability & Assistance

Claimant, Theresa J. Williams, appealed a Workers' Compensation Board decision denying her claim for benefits. She alleged an elevator door struck her, causing sprains and contusions. The Workers' Compensation Law Judge (WCLJ) and the Board disallowed the claim, finding she exaggerated the incident and her injuries did not arise from employment, based significantly on video surveillance that contradicted her account. The Appellate Division, Third Department, affirmed the Board's decision, emphasizing the Board's authority to resolve factual issues and assess witness credibility. The court concluded that the Board's determination was supported by substantial evidence and that there was no medical opinion establishing causation based on the incident as depicted in the video.

Workers' Compensation BenefitsAccidental InjuryCourse of EmploymentCredibility AssessmentVideo Surveillance EvidenceElevator IncidentClaim DisallowanceBoard Decision AffirmationFactual Issue ResolutionSubstantial Evidence Review
References
6
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