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

Case No. ADJ306310
Regular
Mar 23, 2009

MATTHEW T. MORAN vs. ABHE & SVOBODA, INC., ZURICH NORTH AMERICA, BRANDVOLD & ASSOCIATES

The Appeals Board granted reconsideration and rescinded the WCJ's March 23, 2009 decision, which awarded further medical treatment including arthroscopic surgery. The Board found the medical record, particularly regarding the conflict between the treating physician's and QME's opinions on the need for surgery and the causation of the left shoulder tear, was not adequately developed. The matter was returned for further proceedings, specifically to obtain an Agreed Medical Evaluator or have the WCJ appoint an expert to resolve the conflicting medical opinions.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardAdministrative Law JudgeQualified Medical EvaluatorIndustrial InjuryLeft ShoulderArthroscopic SurgeryMR ArthrogramRotator Cuff Tear
References
Case No. ADJ10958168
Regular
Apr 09, 2019

LYN SAMUEL JEFFERS vs. GLENDALE ADVENTIST MEDICAL CENTER, ADVENTIST HEALTH

This case involves a worker's compensation applicant who claimed her left knee injury occurred when she fainted at work on February 8, 2017. Medical reports from her treating physicians documented acute left knee pain, a torn lateral meniscus, degenerative changes, and temporary total disability following the incident. The Workers' Compensation Appeals Board found the applicant's testimony credible, supported by medical evidence, and determined the injury arose out of and occurred in the course of employment. Therefore, the employer's petition for reconsideration was denied.

AOE/COEPrimary Treating PhysicianTemporary Total DisabilityPreponderance of the EvidenceSubstantial EvidenceWCJ CredibilityPetition for ReconsiderationLateral Meniscus TearDegenerative ChangesChondromalacia
References
Case No. ADJ7264915
Regular
Jul 15, 2013

ANA GONZALES vs. WAL-MART ASSOCIATES, INC., ACE AMERICAN INSURANCE

This case involves an applicant who sustained industrial psychiatric injury but whose orthopedic claims were denied due to insufficient medical evidence. The Appeals Board denied the applicant's petition for reconsideration, finding the applicant failed to present substantial medical evidence of industrial causation for her orthopedic complaints. A dissenting commissioner argued that the primary medical evaluator's report was deficient and lacked substantial evidence, warranting further development of the record on orthopedic injuries and other claims. The dissent emphasizes the Board's duty to ensure substantial justice, suggesting it should have ordered further investigation on the denied orthopedic issues.

WCABPetition for ReconsiderationFindings and Orderindustrial injurypsychelow backneckright shoulderright wristright elbow
References
Case No. ADJ3843514
Regular
Sep 15, 2008

Ramona J. Ornelas vs. COUNTY OF SACRAMENTO

Reconsideration granted to address errors in permanent disability rating and apportionment. Matter returned for new rating considering walker use and clarifying apportionment.

RAMONA J. ORNELASCOUNTY OF SACRAMENTOADJ3843514SAC 0274104OPINION AND ORDER GRANTING RECONSIDERATIONDECISION AFTER RECONSIDERATIONLEFT MINOR SHOULDERLEFT MINOR WRISTBILATERAL KNEESPSYCHE
References
Case No. SJO 0262198
Regular
Aug 17, 2007

ANTHONY LAYTON vs. CITY OF SANTA CLARA

The Workers' Compensation Appeals Board granted reconsideration and reversed its prior decision, holding that the 1997 permanent disability rating schedule, not the 2005 schedule, applies to this case. This decision was based on two exceptions to the 2005 schedule's applicability: the treating physician indicated permanent disability before January 1, 2005, and the employer provided proper notice of rights before the 2005 schedule became effective. Consequently, the applicant's permanent disability is rated at 37% under the 1997 schedule, totaling $38,950.00.

Workers' Compensation Appeals BoardReconsideration2005 Schedule1997 ScheduleLabor Code Section 4660(d)ExceptionsTreating Physician ReportSection 4061 NoticePermanent Disability RatingPolice Officer
References
Case No. ADJ383777
Regular
Apr 04, 2011

Roxanna Ortiz vs. ONE SOURCE, ESIS

The Workers' Compensation Appeals Board denied Roxanna Ortiz's petition for reconsideration of a prior findings and order. The initial ruling determined she sustained industrial injury only to her cervical spine as a janitor, not to other body parts or any resulting temporary/permanent disability or need for further medical treatment. Ortiz argued the judge erred by favoring defense medical reports and discrediting her testimony due to minor inconsistencies in her injury description. The Board adopted the WCJ's report, emphasizing deference to credibility determinations and that admissibility of medical reports should have been challenged at trial, not on reconsideration. A dissenting opinion argued the judge overemphasized minor variations in Ortiz's account and that medical evidence did not sufficiently support denial of other injuries or further treatment.

OrtizOne SourceESISWCABFindings and OrderPetition for ReconsiderationWorkers' Compensation Administrative Law Judgeindustrial injurycervical spineright arm
References
Case No. ADJ9887809
Regular
Jan 29, 2019

JOSEPH CAGLIA vs. CALIFORNIA DEPARTMENT OF REHABILITATION, legally uninsured, adjusted by STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration of a finding of five percent permanent partial disability. The Board adopted the Administrative Law Judge's (WCJ) report, which found the opinion of Dr. Pelton more persuasive than that of Dr. Purcell. The WCJ explained that Dr. Pelton's use of a Station and Gait Disorder rating was appropriate given the applicant's objective ligament tear and resulting subjective limitations, even if a conventional application of the AMA Guides yielded zero impairment. The WCJ's detailed report cured any potential defect under Labor Code § 5313, and the reliance on Dr. Pelton's report constituted substantial evidence.

WCABPetition for Reconsiderationsubstantial evidencemedical opinionsWCJ reportpermanent disabilityprimary treating physicianAMA GuidesAlmaraz-GuzmanStation & Gait Disorder
References
Case No. ADJ285099 (SFO 0496940) ADJ224856 (SFO 0496941)
Regular
Nov 13, 2008

PATRA NESSETH-STEFFES vs. HAYWARD UNIFIED SCHOOL DISTRICT, SCHOOLS INSURANCE GROUP

The Appeals Board affirmed the WCJ's decision, finding that the applicant's right knee injury did not have an indicated permanent disability in 2004 based on treating physician reports, thus requiring the use of the 2005 Permanent Disability Rating Schedule. The majority concluded that Dr. Lim's MRI report, while showing tears, did not explicitly state the existence of permanent disability from the industrial injury, and the treating physician's report at the time showed no physical evidence of permanent impairment. A dissenting opinion argued that Dr. Lim's MRI report, supported by subsequent medical findings and the applicant's ongoing restrictions, indicated permanent disability in 2004, warranting application of the older 1997 rating schedule.

Workers' Compensation Appeals BoardReconsiderationPermanent Disability Rating ScheduleMedical-Legal EvaluationTreating Physician ReportPermanent and StationaryLabor Code Section 4660(d)American Medical Association GuidesZenith Insurance Co. v. Workers' Comp. Appeals Bd. (Cugini)Genlyte Group v. Workers' Comp. Appeals Bd. (Zavala)
References
Case No. ADJ6801375
Regular
Jul 13, 2010

MICHAEL DAVID HERNANDEZ vs. VINCE'S ITALIAN TO GO, PREFERRED EMPLOYERS

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a prior award. The WCAB found that the applicant was not entitled to medical treatment outside the employer's Medical Provider Network (MPN) for a meniscus transplant or graft. The applicant failed to follow the required procedures for obtaining a second and third opinion within the MPN before seeking treatment from an out-of-network physician. Therefore, the WCAB concluded there was no showing that treatment outside the MPN was justified under the relevant rules.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNFurther Medical TreatmentSports Medicine DoctorMedical Meniscus TransplantGraft ProcedureDr. Patrick O'MearaDr. John DeSantisSubspecialist
References
Case No. ADJ2516860 (VNO 0402560) ADJ7420955
Regular
Nov 20, 2012

BRIAN SHARP vs. QUINN COMPANY, NBC UNIVERSAL, ELECTRIC INSURANCE COMPANY

This case concerns a petition for reconsideration of a finding that applicant sustained industrial injury to his right knee on October 2, 2009. The defendant argued that the Agreed Medical Evaluator's (AME) opinion did not support industrial injury and that the applicant's attorney engaged in ex parte communication. The Board denied the petition, finding the AME's opinion regarding the right knee injury insufficient. The Board adopted the WCJ's reasoning that the mechanism of injury, as reported by the applicant and corroborated by other physicians, along with the presence of a new tear on MRI, supported the industrial causation finding.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Findings and AwardAgreed Medical Evaluator (AME)Industrial InjuryCausationMedical ProbabilityApportionmentOsteoarthritisIndustrial Exacerbation
References
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