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

Case No. ADJ8331259
Regular
Dec 21, 2012

MARIELA GOMEZ vs. PROVIDENCE FARMS, LLC, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The Board adopted the WCJ's report, emphasizing that the defendant's failure to properly notify the applicant about changing treating physicians within the Medical Provider Network (MPN) resulted in a denial of necessary medical treatment. This failure to inform the applicant of her rights, particularly regarding physician selection and dispute resolution processes within the MPN, constituted a neglect or refusal to provide reasonable medical treatment, as established by precedent. Consequently, the applicant was permitted to continue receiving treatment outside the MPN until she could begin care with a designated physician within the network.

Workers' Compensation Appeals BoardProvidence FarmsLLCZenith Insurance CompanyMariela GomezADJ8331259Order Denying ReconsiderationPetition for ReconsiderationMedical TreatmentMedical Provider Network
References
2
Case No. MISSING
Regular Panel Decision

Queens Blvd. Medical, P.C. v. Travelers Indemnity Co.

The plaintiff, Queens Blvd. Medical, P.C., sought $950 in first-party no-fault benefits for biofeedback medical services provided to its assignor for lower back and chronic pain syndrome. The central issue at trial was the medical necessity of these services under Insurance Law § 5102 (a) (1). The plaintiff established a prima facie case with expert testimony from a board-certified neurologist affirming the medical appropriateness of biofeedback. The defendant insurance company failed to present admissible evidence to disprove medical necessity, as its expert was deemed incompetent to testify on biofeedback for back pain. Consequently, the court granted the plaintiff's motion for a directed verdict, awarding judgment for $950 along with statutory costs, interest, and attorney's fees.

No-fault benefitsMedical necessityBiofeedback treatmentExpert testimonyDirected verdictInsurance lawChronic pain syndromeBack injuryCPT codesBurden of proof
References
9
Case No. ADJ3158190
Regular
Jan 17, 2012

RICK OSEGUERA vs. MITSUMI NAKAMURA, ZENITH INSURANCE COMPANY

In this workers' compensation case, the defendant insurer sought reconsideration of an award for lien claimants' medical services provided outside their Medical Provider Network (MPN). The Appeals Board granted reconsideration, reversing the original award. The Board found that the defendant provided timely MPN notice to the applicant and consistently offered necessary medical treatment within the network. Therefore, the Board concluded the defendant was not liable for treatment obtained outside the MPN and disallowed the lien claimants' claims.

MPNMedical Provider NetworkLien ClaimantsReconsiderationFindings and AwardWCJPenaltiesInterestCompromise and Release AgreementStipulations
References
5
Case No. LBO 0375714
Regular
Jul 09, 2008

VICENTE CARMEN vs. SKB CORPORATION

This case involves a lien claim by California Pharmacy Management for medication provided to an injured worker, Vicente Carmen. The Workers' Compensation Appeals Board denied reconsideration, upholding the finding that the pharmacy's lien was invalid because the medication was not prescribed by a physician within the defendant employer's Medical Provider Network (MPN). The Board reiterated that once an employer provides a MPN, an employee's self-procured treatment outside that network is not compensable, and the pharmacy's reliance on Labor Code section 4600.2 was misplaced as there was no evidence of a contract with the employer.

MPNLien claimMedical treatmentSelf-procuredPharmacy benefit networkLabor Code section 4600.2Treating physicianWorkers' Compensation Appeals BoardFindings and OrderReconsideration
References
1
Case No. ADJ10064259
Regular
Nov 19, 2015

, Applicant, CHARLES WAGNER, vs. , Defendants. BARRETT BUSINESS SERVICES; ACE AMERICAN INS. CO.; CORVEL ADMINSTRATOR

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior order allowing the applicant to treat outside the defendant's Medical Provider Network (MPN). The Board found that while MPN notice requirements are crucial, an employee can only treat outside the network at the employer's expense if a failure to provide notice resulted in a denial of medical care. In this case, the applicant received timely medical treatment, and the defendant presented evidence of providing MPN notices, thus, the applicant was not entitled to self-procured treatment outside the MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)ReconsiderationFindings and OrderAdministrative Law Judge (WCJ)Labor CodeRule 9767.12Medical TreatmentExpedited HearingForklift Operator
References
1
Case No. MISSING
Regular Panel Decision
Feb 10, 2017

Mitchell v. SUNY Upstate Medical University

Plaintiff Robbie Mitchell sued SUNY Upstate Medical Center for alleged Title VII violations, including race discrimination and retaliation, after experiencing a series of adverse employment actions. These actions included reassignment, disciplinary notices (NODs), a mandatory medical examination, a formal counseling memorandum, a verbal dispute, and eventual termination. The defendant moved for summary judgment, arguing the plaintiff failed to establish a prima facie case for most claims and that their actions were based on legitimate, non-discriminatory reasons. The court granted summary judgment in favor of SUNY Upstate Medical Center, concluding that the plaintiff failed to provide sufficient evidence of discrimination or that retaliation was the but-for cause of the challenged employment actions, and consequently, the case was closed.

Title VIICivil Rights ActEmployment DiscriminationRetaliationSummary JudgmentAdverse Employment ActionMcDonnell Douglas FrameworkWorkplace ConductDisciplinary ActionPaid Administrative Leave
References
49
Case No. ADJ4189084 (AHM 0150210), ADJ2609035 (MON 0237343), ADJ2256301 (MON 0237524), ADJ4536480 (MON 0315454)
Regular
Feb 05, 2015

Dennis Pasquel vs. The Boeing Company, ACE American Insurance Company, Sedgwick Claims Management Services, Inc.

The Workers' Compensation Appeals Board overturned a judge's decision and allowed a lien for medical treatment provided by Dr. Powers at Griffin Medical Group. The Board found that while Dr. Powers was listed in the employer's Medical Provider Network (MPN) at a specific facility, there was no explicit restriction in the MPN listing prohibiting him from treating patients elsewhere. The Board concluded that contract disputes between a physician and an MPN provider should not prevent payment for medically necessary treatment when the MPN itself acknowledged the physician as a provider. This decision allows Griffin Medical Group to be paid for Dr. Powers' services rendered at their facility.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNLien claimantPrimary treating physicianJoint Findings and OrderReconsiderationStipulated awardsCumulative trauma injuryIndependent Contractor Agreement
References
3
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. ADJ284264 (VNO 0550515)
Regular
Mar 02, 2009

CAROLEE PETERSON vs. RALPH'S GROCERY COMPANY

The Workers' Compensation Appeals Board affirmed a prior award, granting the applicant the right to treatment with her chosen physician, who was not part of the employer's medical provider network. This decision was based on the employer's failure to provide adequate notice regarding the medical provider network requirements. The Board also upheld the applicant's entitlement to temporary total disability from April 7, 2007, to the present. The employer's contentions regarding compliance and evidence were rejected.

Workers' Compensation Appeals BoardReconsiderationMedical Provider NetworkPrimary Treating PhysicianTemporary Total DisabilityKnight v. United Parcel ServiceLabor Code Section 4610Physician-Patient RelationshipStatutory Notice RequirementsRegulatory Notice Requirements
References
3
Case No. ADJ9311311
Regular
Jul 18, 2014

JUANA FIGUEROA vs. LOS ANGELES AIRPORT MARRIOTT/MARRIOTT HOTEL SERVICES, INC.

This case involves an applicant seeking reconsideration after the WCJ denied her claim for self-procured medical treatment. The applicant contended the employer breached its duty to provide timely treatment within its Medical Provider Network (MPN), entitling her to seek care outside the network at the employer's expense. The Board affirmed the WCJ's finding that the employer did not breach its duty, as the applicant's communications were unclear and did not effectively request treatment. Therefore, the employer retained control over the applicant's medical care within its MPN.

Workers Compensation Appeals BoardMedical Provider NetworkMPNSelf-procure medical treatmentPrimary treating physicianExpedited hearingPetition for ReconsiderationCumulative trauma injuryDWC-1 Claim FormNotice of injury
References
2
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