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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. 2019 NY Slip Op 04254 [172 AD3d 1858]
Regular Panel Decision
May 30, 2019

Matter of Rangasammy v. Philips Healthcare

Claimant Bridje Rangasammy, a medical equipment trainer, sought workers' compensation benefits for head and neck injuries allegedly sustained in a taxicab accident. A Workers' Compensation Law Judge initially awarded benefits, but the Workers' Compensation Board reversed this decision, concluding that the claimant failed to prove that an accident arising out of and in the course of his employment actually occurred. The Appellate Division, Third Department, affirmed the Board's decision, deferring to its assessment of claimant's credibility, especially given inconsistent accounts of the incident, the absence of involved parties at the scene, and a lack of objective medical findings to support the alleged injuries despite CAT scans and MRI studies being normal.

Workers' Compensation BenefitsAccidental Injury ClaimEmployment-Related InjuryClaimant CredibilitySufficiency of EvidenceMedical Report FindingsHead InjuryNeck InjuryTaxicab IncidentAppellate Review
References
7
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. 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. ADJ7611909 ADJ8870925
Regular
Jan 20, 2016

ANTONIA RIVAS vs. EL PRADO RESTAURANT, THE COHEN RESTAURANT GROUP, INC., PACIFIC COMPENSATION INSURANCE COMPANY

The Appeals Board reversed the prior decision, allowing lien claimant Preferred Scan's exhibits into evidence. Applying the en banc decision in *Cornejo*, the Board found that Preferred Scan made an unrebutted prima facie showing of exemption from Business and Professions Code registration requirements. This exemption applies because Preferred Scan acted as an agent or independent contractor for applicant's attorney, a member of the State Bar. The case is returned for a new decision on the lien claim.

Preferred ScanRivas v. El Prado RestaurantADJ7611909ADJ8870925WCABReconsiderationBusiness and Professions Code 22450Business and Professions Code 22451(b)Cornejo v. Younique CaféInc.
References
1
Case No. ADJ7626540, ADJ7626544
Regular
Oct 17, 2013

EFRAIN CERVANTES vs. EXCEL CONSTRUCTION, ZURICH INSURANCE COMPANY

The Appeals Board granted reconsideration, rescinding the WCJ's dismissal of Preferred Scan's lien. Although Preferred Scan paid its lien activation fee on the morning of the lien conference, the WCJ dismissed the lien due to no proof of payment being available at the conference. The Board found the payment timely and the EAMS system's delayed reflection of payment not Preferred Scan's fault. The case is returned to the trial level for further proceedings, including potential dismissal notice or sanctions for the failure to appear.

Workers' Compensation Appeals BoardLien Activation FeePetition for ReconsiderationOrder Dismissing LienDue ProcessLabor Code Section 4903.06Electronic Adjudication Management System (EAMS)Lien ConferenceSanctionsLabor Code Section 5813
References
0
Case No. SAC 0345394
Regular
Feb 22, 2008

DIANA RICHMOND vs. STATE OF CALIFORNIA, DEPARTMENT OF JUSTICE, legally uninsured

The Workers' Compensation Appeals Board denied reconsideration of a decision that applied the 2005 Permanent Disability Rating Schedule. The applicant argued that a pre-2005 MRI and subsequent medical opinions indicated permanent disability, thus triggering the older 1997 Schedule. The Board found that the MRI report alone was insufficient and that the AME's opinion on prior permanent disability was too late to qualify for the exception.

Workers' Compensation Appeals BoardDiana RichmondState of California Department of Justicelegally uninsuredSAC 0345394Opinion and Order Denying ReconsiderationFindings and AwardFebruary 222008industrial injury
References
10
Case No. ADJ6949691
Regular
Sep 05, 2013

GUADALUPE MONTES, GUADALUPE MONTES-GARCIA vs. CITIZEN DEVELOPMENT CORP.; LIBERTY MUTUAL INSURANCE COMPANY, ET AL.

This case involves a petition for reconsideration filed by True Scan Legal Copy Service, a lien claimant. The petition was denied because it was not verified under oath as required by Labor Code section 5902. Furthermore, the Workers' Compensation Appeals Board adopted the WCJ's report, which found that True Scan had sufficient notice of the lien conference and failed to pay its lien activation fee. Therefore, the lien was properly dismissed.

WCABPetition for ReconsiderationLabor Code section 5902Lien ClaimantLien ConferenceActivation FeeEAMS SystemNotice of HearingDismissalAdministrative Law Judge
References
0
Case No. ADJ8067245
Regular
Apr 23, 2015

ISABEL DIMAS vs. CLIFTON'S CAFETERIA, STAR INSURANCE COMPANY, Administered By ILLINOIS MIDWEST INSURANCE AGENCY, LLC, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Preferred Scan, Inc.'s petition for reconsideration. The Board affirmed the administrative law judge's decision to dismiss Preferred Scan's lien for failing to meet its burden of proof. Specific grounds for dismissal included failure to establish reasonableness and necessity of charges, improper service of exhibits, and inadequate evidence preparation. While the lien claimant's services could have been considered legitimate medical-legal costs for a contested claim, the other evidentiary failures were sufficient to uphold the lien's dismissal.

Lien claimantPetition for ReconsiderationWCJFindings and OrdersDismissed lienBurden of proofAOE/COEMedical-legal costsContested claimReasonableness and necessity
References
0
Case No. ADJ1364496 (GRO 0033020)
Regular
Sep 24, 2012

Brenda Garcia-Martinez vs. SMS RESORTS, INC DBA SYCAMORE MINERAL SPRINGS, FIREMANS FUND SACRAMENTO

The Appeals Board granted the defendant's petition for reconsideration, rescinding the previous Findings and Award. The Board found that the evidence presented, particularly from Dr. Ferro, lacked sufficient medical reasoning and history to establish the applicant's left shoulder injury as work-related. While the Agreed Medical Evaluator (AME), Dr. Ovadia, also found no work-related injury, his reports were incomplete as he never received the applicant's left shoulder MRI. The case is remanded for further development of the medical record, including providing Dr. Ovadia with the MRI, to determine causation.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardAgreed Medical EvaluatorTreating PhysicianSubstantial EvidenceCompensable ConsequenceMedical Record DevelopmentAOE/COEOrthopedics
References
11
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