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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. ADJ519728
Regular
Aug 08, 2011

LOWELL BAPTISTE vs. METROPOLITAN TRANSIT AUTHORITY

The Workers' Compensation Appeals Board granted reconsideration of a prior award finding industrial injury and temporary total disability dating back to 2000. The Board found that the medical opinion relied upon by the workers' compensation judge was not substantial evidence due to staleness, lack of complete records, and insufficient specialization. To ensure a fair resolution, the Board ordered new evaluations by independent orthopedic and psychiatric physicians, who will report on all outstanding medical issues.

Workers' Compensation Appeals BoardReconsiderationCompelling Medical EvaluationsTemporary Total DisabilityIndustrial InjuryOrthopedicsPsychiatrySubstantial EvidenceMedical OpinionWCJ
References
2
Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
Case No. MISSING
Regular Panel Decision

Claim of Clark v. Siara Management, Inc.

Claimant, a custodian, sustained two work-related injuries in 2000, and his workers' compensation benefits were approved. In 2003, the employer's workers' compensation carrier requested an independent medical examination (IME) by Charles Totero. Claimant moved to preclude Totero's report, arguing it was improperly mailed by UMC Medical Consultants, EC., an IME services company, instead of Totero himself, in violation of Workers' Compensation Law § 137. Both a Workers' Compensation Law Judge and the Board denied the motion, finding UMC, as Totero's direct employer and a registered IME company, was authorized to perform administrative services like mailing reports under 12 NYCRR 300.2 (e) (1). The appellate court affirmed the decision, concluding that the submission substantially complied with statutory requirements.

IME Report AdmissibilityWorkers' Compensation Law § 137Procedural ComplianceMedical Report MailingIME Services CompanyAppellate AffirmationStatutory InterpretationIndependent Medical Examiner12 NYCRR 300.2
References
1
Case No. MISSING
Regular Panel Decision
Jun 19, 2001

Carman v. Abter

A nurse employed by a medical center providing dialysis services alleged she contracted HIV after a needle stick injury sustained while drawing blood from a patient. She filed a medical malpractice action against the medical center, a salaried physician (Dr. Ma) employed by a nephrology group associated with the center, and an independent infectious disease consultant (Dr. Abter) used by the group. The Supreme Court initially dismissed the complaint against all defendants, applying the Workers' Compensation Law's "fellow employee rule." On appeal, the judgment was modified. The appellate court affirmed the dismissal for the medical center and Dr. Ma, concluding their services to the plaintiff were employment-related and not available to the general public. However, the complaint against Dr. Abter was reinstated, as the fellow-employee rule was found not to apply to him given his status as an independent consultant.

Medical malpracticeHIV exposureNeedle stick injuryWorkers' CompensationFellow employee ruleIndependent contractorPhysician negligenceEmployer liabilityAppellate reviewNew York law
References
1
Case No. MISSING
Regular Panel Decision
Dec 27, 2001

MacRo v. Independent Health Ass'n, Inc.

Plaintiffs Cheryl Macro and Kim Zastrow, insured under a group health contract with Independent Health through the Tonawanda City School District, initiated a class action in state court to challenge Independent Health's modification of infertility treatment coverage. Defendant Independent Health removed the case to federal court, asserting ERISA preemption. Plaintiffs moved to remand, arguing that their claims fell under New York Insurance Law, which is exempt from ERISA preemption by the saving clause, and that their health plan qualified as a 'governmental plan' also exempt from ERISA. The District Court granted the plaintiffs' motion, concluding that the claims were indeed saved from ERISA preemption and that the plan was exempt, thus rendering federal subject matter jurisdiction absent. The court accordingly remanded the case back to New York State Supreme Court.

Infertility CoverageHealth Insurance DisputesERISA PreemptionSaving ClauseGovernmental PlansRemoval to Federal CourtSubject Matter JurisdictionNew York Insurance LawClass Action LitigationEmployee Benefits Plan
References
31
Case No. ADJ947475 (AHM 0148580)
Regular
Dec 27, 2016

VIVIAN RODRIGUEZ vs. SIMI VALLEY UNIFED SCHOOL DISTRICT

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior decision that found Utilization Review (UR) inapplicable to a home health care evaluation. The WCAB determined that a request for an evaluation for home health care assistance constitutes medical treatment under Labor Code Section 4600 and is therefore subject to the UR process. Consequently, the prior decision compelling the employer to provide the evaluation was rescinded. The case is returned to the trial level for further proceedings, as disputes regarding the medical necessity of UR-denied treatment must be resolved through Independent Medical Review (IMR).

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationHome Health Care EvaluationMedical TreatmentIndependent Medical ReviewLabor Code section 4610Labor Code section 4600Primary Treating PhysicianFindings and Order
References
5
Case No. MISSING
Regular Panel Decision

Schlesinger v. New York City Employees' Retirement System

Petitioner Michael Schlesinger, a former correction officer, challenged the denial of his accident disability retirement pension by the New York City Employees’ Retirement System Board of Trustees through a CPLR article 78 proceeding. Schlesinger sustained a neck injury in 2002, leading to a two-level cervical fusion. Although the Medical Board found him disabled, it repeatedly denied causation between the injury and the 2002 incident. The Board of Trustees adopted the Medical Board's recommendation without an independent evaluation of causation, which the court found to be an arbitrary and capricious abdication of its responsibility. Consequently, the court annulled the Board of Trustees' determination and remanded the matter for an independent evaluation of causation.

accident disability retirementpension denialcorrection officer injurycausationadministrative reviewCPLR Article 78 proceedingBoard of TrusteesMedical Boardarbitrary and capriciousremand
References
5
Case No. ADJ3374876 (SJO 0268303)
Regular
Feb 25, 2010

SUSAN MOYERS vs. COUNCIL ON AGING, STATE COMPENSATION INSURANCE FUND, SUBSEQUENT INJURIES BENEFITS TRUST FUND

In this case, the Subsequent Injuries Benefits Trust Fund (SIBTF) sought to compel the applicant to use the same Agreed Medical Examiner (AME) from her original workers' compensation claim for her SIBTF claim. The Workers' Compensation Appeals Board affirmed the WCJ's order allowing the applicant to obtain new medical-legal evaluations for her SIBTF claim with a different physician, independent of the original AME. The Board determined that the discovery procedures for workers' compensation claims, as outlined in Labor Code section 4062.2, do not apply to SIBTF claims due to their distinct legal issues. Therefore, SIBTF is responsible for reasonable costs of these independent evaluations, ensuring due process for developing evidence specific to the SIBTF claim.

Subsequent Injuries Benefits Trust FundSIBTFMedical-Legal DiscoveryAgreed Medical ExaminerAMEQualified Medical ExaminerQMELabor Code Section 4062.2Workers' Compensation ClaimMedical Evaluations
References
0
Case No. ADJ9826556
Regular
Aug 05, 2016

Spencer Bachus vs. John F. Kennedy Memorial Hospital, Hi-Desert Medical Center

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a prior decision finding applicant sustained a work-related viral meningitis injury. Defendants argued insufficient medical evidence linked the injury to employment and that the identified virus was not definitively work-acquired. The WCAB determined the existing medical evidence, particularly the Qualified Medical Evaluator's opinions, did not sufficiently establish a special risk of exposure due to the applicant's specific job duties. The case was returned for further development of the record, including a more detailed analysis of the applicant's job tasks and potential exposure risks, and potentially a new medical evaluation by an infectious disease specialist.

Workers' Compensation Appeals BoardViral meningitisIndustrial injuryDual employmentPanel Qualified Medical Evaluator (PQME)Substantial medical evidenceCausationSpecial riskFurther proceedingsRescinded
References
0
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