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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

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
Case No. ADJ3135829 (AHM 0099139)
Regular
Jul 28, 2014

CAROLYN BERTRAND vs. COUNTY OF ORANGE, YORK

This case concerns a dispute over medical treatment disputes between an applicant and the County of Orange. The parties had previously stipulated to have the Agreed Medical Examiner (AME), Dr. Wilson, resolve future treatment disputes, potentially bypassing the statutory Utilization Review (UR) and Independent Medical Review (IMR) processes. The Workers' Compensation Appeals Board (WCAB) dismissed the employer's petition for reconsideration as the prior order was procedural, but granted removal. As a decision after removal, the WCAB clarified that while the stipulation to use the AME is valid and can supersede IMR, treatment requests must first go through UR, and only subsequent disputes are referred to the AME.

StipulationAgreed Medical ExaminerAMEUtilization ReviewURIndependent Medical ReviewIMRRemovalPetition for ReconsiderationLabor Code section 4610
References
3
Case No. ADJ339088 (SDO 0304788)
Regular
Aug 30, 2016

Gregory Parrent vs. SBC-PACIFIC BELL TELEPHONE COMPANY

This case clarifies the utilization review (UR) and independent medical review (IMR) process for medical treatment recommendations within a Medical Provider Network (MPN). The Appeals Board affirmed that even when a physician is part of the defendant's MPN, their treatment recommendations are subject to UR by the employer if disputed. If UR denies or modifies the recommendation, the dispute must then proceed to IMR, not the Appeals Board. The applicant's contention that MPN physicians' recommendations are exempt from UR was rejected, emphasizing a uniform standard of care and review for all medical treatment.

Workers' Compensation Appeals BoardSBC-Pacific Bell Telephone CompanySedgwick Claims Management ServicesPetition for ReconsiderationMedical Provider Network (MPN)Independent Medical Review (IMR)Utilization Review (UR)Labor Code section 4600primary treating physicianRequest for Authorization (RFA)
References
5
Case No. ADJ3781289 (MON 0347653)
Regular
Jan 06, 2012

Margaret Batten vs. Long Beach Memorial Medical Center, TRISTAR RISK MANAGEMENT

The Workers' Compensation Appeals Board granted reconsideration to amend a prior award. The Board affirmed the finding that the defendant unreasonably delayed medical treatment for the applicant's neck, noting the defendant failed to follow proper utilization review procedures. However, the Board deferred the award of medical treatment for the applicant's ankle, as a determination of industrial causation for that body part was still pending. The decision specifically mentions the defendant's adjuster's testimony disputing an AME's finding of industrial injury to the cervical spine.

WCABLong Beach Memorial Medical CenterTristar Risk Managementunreasonable delaymedical treatmentorthoticsnecklumbar sacral spinepsycheankle
References
5
Case No. ADJ927657
Regular
Mar 24, 2009

SHERRI J. RODNEY-TROULLIER vs. TALBERT MEDICAL GROUP, ST. PAUL/TRAVELERS

In this workers' compensation case, the applicant sustained admitted injuries and was treating with Dr. Sobol within the defendant's Medical Provider Network (MPN). When Dr. Sobol was terminated from the MPN, the defendant failed to properly follow continuity of care procedures as required by law. Specifically, the defendant did not resolve the dispute regarding the applicant's need for continued treatment with Dr. Sobol through the required dispute resolution process under Labor Code section 4062. Therefore, the Appeals Board rescinded the prior order and found that the applicant is entitled to continue treatment, including surgery, with Dr. Sobol.

MPNcontinuity of careterminated providerserious chronic conditionLabor Code section 4616.2AD Rule 9767.10dispute resolutionDr. Sobolsurgery authorizationLabor Code section 4062
References
1
Case No. ADJ11595561 ADJ11602485
Regular
Jun 27, 2019

CINTIA LEMUS vs. MOTEL 6/G6 HOSPITALITY, LIBERTY MUTUAL

In this case, the applicant sustained work-related injuries to her mid and low back. The defendant disputed the applicant's request for a chiropractic Qualified Medical Evaluator (QME) panel, arguing an orthopedic-spine specialist was more appropriate. The Medical Director initially agreed, citing the use of prescription medication outside a chiropractor's scope. However, the Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, finding that the Medical Director's rationale was insufficient. The Board affirmed the Workers' Compensation Judge's decision to overrule the Medical Director and allow a chiropractic QME, citing precedent that QMEs cannot provide treatment or opine on disputed treatment issues.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalFindings and OrderAdministrative Law Judge (WCJ)Qualified Medical Evaluator (QME)Medical DirectorQME Panel SpecialtyChiropracticOrthopedic-Spine
References
9
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. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. ADJ21 45168 (GOL 0096589)
Regular
Sep 20, 2016

THOMAS HOGENSON vs. VOLKSWAGEN OF AMERICA, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

This case concerns whether medical treatment proposed by an injured worker's physician, chosen from the employer's Medical Provider Network (MPN), is subject to Utilization Review (UR) and Independent Medical Review (IMR). The Workers' Compensation Appeals Board (WCAB) rescinded the administrative law judge's award of treatment, holding that MPN treatment is indeed subject to UR and IMR. The WCAB clarified that statutory provisions for UR and IMR apply to all medical treatment disputes, regardless of whether the physician is within an MPN. The matter was returned to the trial level for further proceedings consistent with this decision.

Workers' Compensation Appeals BoardThomas HogensonVolkswagen of AmericaInsurance Company of the State of PennsylvaniaExpedited Findings Of Fact And AwardUtilization ReviewMedical Provider NetworkIndependent Medical ReviewMedical TreatmentLabor Code
References
13
Case No. MISSING
Regular Panel Decision
Oct 17, 2012

Douyon v. NY Medical Health Care, P.C.

Plaintiff Gabrielle Douyon sued Seymour Schneider, N.Y. Medical Health Care, P.C., Faraidoon Daniel Golyan, M.D., and Kourosh Golyan, alleging unfair debt collection practices under the FDCPA and NY GBL § 349, along with intentional infliction of emotional distress and negligence. The lawsuit stemmed from attempts to collect an alleged medical debt following Douyon's emergency heart surgery performed by Dr. Golyan. Both parties sought summary judgment. The court granted Plaintiff partial summary judgment on FDCPA violations related to statutory disclosures and a threatening voicemail. However, many other FDCPA and NY GBL claims were denied due to factual disputes, and the intentional infliction of emotional distress claim was dismissed for lack of medical evidence, with negligence claims partially allowed to proceed on the basis of fear for physical safety.

Fair Debt Collections Practices ActNew York General Business Law § 349Debt CollectionSummary JudgmentEmotional DistressNegligenceAgency RelationshipVicarious LiabilityFreelance Debt CollectorUnfair and Deceptive Practices
References
105
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