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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

Elmont Open MRI & Diagnostic Radiology, P.C. v. New York Central Mutual Fire Insurance

Plaintiff Elmont Open MRI & Diagnostic Radiology, PC. sued defendant New York Central Mutual Fire Insurance Company (NYCMFIC) for overdue first-party no-fault benefits following a brain MRI performed on Abdelghani Kinane. NYCMFIC moved for summary judgment, asserting the action was premature because Elmont allegedly failed to respond to verification requests, thereby tolling NYCMFIC's time to pay or deny the claim. Elmont countered with an affidavit from its billing supervisor, Brijkumar Yamraj, and a certificate of mailing, proving the requested MRI films and information were sent to NYCMFIC on November 12, 2008. The court found Elmont's proof of mailing sufficient to establish a response, thus denying NYCMFIC's motion and subsequently granting summary judgment to Elmont upon searching the record.

No-fault insuranceVerification requestsSummary judgmentProof of mailingMedical benefitsInsurance claims processTolling of time limitMotor vehicle accidentRadiology fee scheduleBusiness records
References
24
Case No. ADJ2289246 (MON 0362113) ADJ4589003 (MON 0362111) ADJ826510 (MON 0362112)
Regular
Jul 23, 2015

ORLANDO ORTEGA vs. CALIFORNIA CLOSET COMPANY, NATIONAL LIABILITY & FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for removal, upholding the administrative law judge's exclusion of a fax delivery confirmation. This evidence pertained to a utilization review decision that denied a lumbar MRI and was excluded for not being listed on the pretrial conference statement and being served late. The Board found the evidence was not properly admissible as rebuttal under Labor Code section 5704 as the timeliness of the UR decision was a central, expected issue.

Petition for RemovalUtilization ReviewWCJ evidentiary rulingfax delivery confirmationpretrial conference statementmandatory settlement conferenceLabor Code section 5704rebuttal evidencelumbar MRIclaims examiner
References
1
Case No. ADJ9506185
Regular
Jul 13, 2016

JIM NEWELL vs. COUNTY OF KERN

The Workers' Compensation Appeals Board denied the County of Kern's petition for reconsideration of an award to Jim Newell. The award was based on industrial cumulative trauma to the lumbar spine and hypertensive cardiovascular disease, including left ventricular hypertrophy (LVH). The County argued there was insufficient evidence of LVH and sought further medical development, specifically a cardiac MRI. The Board found that the existing medical evidence, including echocardiograms and expert testimony, constituted substantial evidence to support the LVH diagnosis, making further testing unnecessary.

Workers' Compensation Appeals BoardCounty of KernJim NewellSheriff's Sergeantcumulative traumalumbar spinecirculatory systemhypertensionhypertensive cardiovascular diseaseleft ventricular hypertrophy
References
2
Case No. MISSING
Regular Panel Decision

Rosado v. Shalala

The plaintiff filed an application for disability insurance benefits due to a back injury. Despite opinions from treating physicians indicating total disability, an MRI and X-rays of the lumbar spine were negative. The government's physician also found the plaintiff walked normally with minimal physical abnormalities. The Administrative Law Judge deemed the plaintiff's pain testimony incredible and found him capable of light work. The court affirmed the Secretary's decision to deny benefits, concluding it was supported by substantial evidence, as workers' compensation standards differ from those for disability insurance benefits.

Social Security BenefitsDisability ClaimBack InjuryMedical EvidenceCredibility AssessmentAdministrative Law JudgeSubstantial EvidenceTreating Physician RuleLumbar SpineMRI Negative
References
8
Case No. MISSING
Regular Panel Decision

Claim of Porter v. New York State Electric & Gas Corp.

The claimant, who sustained head, neck, and back injuries in 2004, had a workers' compensation case established for occupational disease, with 22.5% liability for neck and back injuries apportioned to the incident. After experiencing continued back problems and being diagnosed with severe biforaminal stenosis, the Chair authorized an MRI in 2010 and lumbar spine surgery in 2011. The workers’ compensation carrier sought to transfer liability to the Special Fund for Reopened Cases under Workers' Compensation Law § 25-a, a request initially denied by a WCLJ but granted by the Board, which found the April 27, 2011 order authorizing surgery constituted a 'true closing' of the case. The Special Fund appealed the Board's decision, arguing against the transfer of liability. The appellate court affirmed the Board's decision, concluding that substantial evidence supported the finding that the case was truly closed, thereby shifting liability to the Special Fund.

Workers' Compensation Law § 25-aSpecial Fund for Reopened CasesLiability ShiftClosed CaseTrue ClosingMedical AuthorizationLumbar Spine SurgeryCervical Spine MRIOccupational DiseaseApportionment
References
8
Case No. ADJ3701295 (AHM 0146448)
Regular
Oct 07, 2013

PAULA GUEVARA vs. NORTHGATE GONZALEZ MARKET, ZENITH ESIS

The Workers' Compensation Appeals Board granted reconsideration for lien claimant Max MRI. While affirming the denial of Max MRI's lien claim for lack of evidence, the Board vacated the sanctions imposed. The Board found that Max MRI was denied due process regarding the sanctions, as the issue was not properly noticed or heard. The case is returned to the trial level for further proceedings and a decision on costs and sanctions.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien claimantMax MRIFrivolous lienSanctionsDue processMedical Provider NetworkCompromise and ReleaseFindings and Order
References
3
Case No. ADJ10679103
Regular
Dec 14, 2017

LARRY SYKES vs. THE ANSCHUTZ CORPORATION, STARR INDEMNITY & LIABILITY COMPANY

The Workers' Compensation Appeals Board granted reconsideration of a prior finding of industrial injury to the applicant's lumbar spine. The Board found that the existing medical reporting from Dr. Hong, Dr. Jamasbi, and the PQME Dr. Schofferman did not constitute substantial evidence to support this lumbar spine injury finding. Therefore, the case is returned to the trial level to develop the record further on the lumbar spine injury issue.

Workers' Compensation Appeals BoardPetition for ReconsiderationIndustrial InjuryCervical SpineThoracic SpineLumbar SpineStagehandSecurity OfficerMedical Treatment RecordsSubstantial Evidence
References
0
Case No. ADJ1083014 (POM 0275607) ADJ4477705 (POM 0275608)
Regular
May 29, 2009

LILIAN SOTO vs. PM GLOVES, INC., STATE COMPENSATION INSURANCE FUND

This case involved a lien claimant seeking payment for an MRI. The Workers' Compensation Judge initially disallowed the lien for failing to meet Labor Code section 5703 requirements. The Appeals Board granted reconsideration, finding the WCJ erred by strictly applying section 5703. They determined that other evidence, including the treating physician's report referenced in a settlement, established the validity of the MRI expense. Therefore, the Board allowed the lien claim for the MRI.

Lien claimantReconsiderationLabor Code Section 5703Labor Code Section 4626Finding and OrderWorkers' Compensation Judge (WCJ)Compromise and Release (C&R)MRILumbar SpineSelf-procured medical treatment
References
0
Case No. ADJ10384099
Regular
Jan 29, 2018

RODOLFO RODRIGUEZ vs. ROBERT BOSCH AFTERMARKET DIVISION, ZURICH NORTH AMERICA

The Appeals Board granted reconsideration to amend the finding of fact, clarifying that the applicant sustained a compensable injury to his lumbar spine arising out of and occurring within the course of employment. While medical evidence supported the lumbar spine injury, the Board deferred the issue of lower extremities as an injured body part for further development. This decision affirmed the original finding regarding the lumbar spine, based on applicant's credible testimony and medical opinions from Drs. Hutchinson and Schaffzin.

AOE/COELumbar spineLower extremitiesPetition for ReconsiderationFinding of FactWCJMedical evidencePreexisting conditionAggravationLighting up
References
14
Case No. AD10769216
Regular
Dec 13, 2019

Richard Hovannisian vs. UCLA, Permissibly Self-Insured, Administered By SEDGWICK CMS

The WCAB granted reconsideration and deferred issues of lumbar spine injury and permanent disability from a prior award. The WCJ's decision relied on a QME report that failed to establish industrial causation for the lumbar spine injury and lacked sufficient explanation for departing from AMA Guides methodology for permanent disability ratings. The Board found these deficiencies meant the decision was not based on substantial medical evidence. Further proceedings are required for the QME to adequately address causation, rating methodology, and lumbar spine classification.

WCABPetition for ReconsiderationFindings of Fact & Awardindustrial injurylumbar spinepermanent disabilitysubstantial medical evidencedue processDisability Evaluation Unitpanel qualified medical evaluator
References
4
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