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Case Law Database

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

Case No. 2016-03-0413
Regular Panel Decision
Oct 05, 2017

Dodson, Deborah v. LHC Group

Deborah Dodson, an employee of LHC Group, injured her left ankle and right knee in May 2015. She underwent knee surgery and was placed at maximum medical improvement by Dr. Johnson. She later developed small fiber neuropathy, and despite a referral, faced difficulties obtaining a neurologic impairment evaluation. The Court granted Ms. Dodson's request for a neurologic impairment evaluation, either by Dr. Butler or another neurologist, referring Dr. Butler to the Penalty Program for failure to provide an impairment opinion. However, the Court denied her claim for additional temporary total disability benefits, finding she reached MMI on March 23, 2017, when Dr. Butler ceased active treatment.

Workers' CompensationNeurologic Impairment EvaluationTemporary Total Disability BenefitsMaximum Medical ImprovementSmall Fiber NeuropathyPain ManagementExpedited HearingMedical TreatmentImpairment RatingPenalty Program
References
3
Case No. MISSING
Regular Panel Decision

Main Evaluations, Inc. v. State

The claimant, Main Medical Evaluations, entered into contracts with the New York State Office of Temporary and Disability Assistance (OTDA) to perform consultative medical evaluations. OTDA terminated these contracts, alleging the claimant failed to disclose professional disciplinary proceedings against its chief medical officer, Arvinder Sachdev, and submitted false information during the bidding process. Following the dismissal of its claim in the Court of Claims, the claimant appealed. The appellate court affirmed the lower court's judgment, concluding that OTDA had legitimate grounds for termination due to the claimant's misrepresentations and failure to report substantial contract-related issues concerning Sachdev's integral role. Additionally, the court rejected the claimant's equal protection argument, finding no evidence of selective enforcement based on impermissible considerations.

Contract TerminationProfessional MisconductFalse RepresentationEqual ProtectionGovernment ContractsAppellate ReviewBreach of ContractMedical LicensingAdministrative ProceedingsDue Diligence
References
5
Case No. 2016-08-1106
Regular Panel Decision
Feb 16, 2018

McDonough, James v. Phillips General and Mechanical

Mr. James McDonough, a steamfitter, suffered a head injury on January 8, 2015, while working for Phillips General and Mechanical (PGM), leading to psychiatric and neurological symptoms. PGM initially accepted the claim but later denied Mr. McDonough's requests for psychological counseling and neurological evaluations, based on opinions from doctors who conducted record reviews and surveillance, suggesting malingering. However, Mr. McDonough's treating psychiatrist, Dr. Jim Pang, who had extensive contact with him, concluded his conditions were work-related and assigned a 15% permanent impairment rating, also recommending further treatment. The Court, prioritizing the treating physician's presumed correctness, found Mr. McDonough likely to prevail and granted his requested benefits for psychological therapy and neurological evaluation.

Head InjuryPsychiatric InjuryNeurological InjuryPost-concussion SyndromeMaximum Medical ImprovementPermanent ImpairmentCausation DisputeTreating Physician PresumptionMedical Records ReviewSurveillance Evidence
References
5
Case No. MISSING
Regular Panel Decision

Davis v. Medical Evaluation Specialists, Inc.

Justice Wilson dissents from the majority's decision on a motion for rehearing, arguing that the majority improperly considered non-evidence and engaged in speculation. The dissent contends that Lennie Davis's controverting affidavit by Dr. Bergeron, which stated a 17% impairment rating compared to the defendants' 0%, was conclusory and insufficient to establish bad faith by Medical Evaluation Specialists, Inc., Dr. DeFrancesco, and Dr. Dozier. Justice Wilson believes that the affidavit failed to meet the objective 'no reasonable doctor' standard for controverting good faith, and therefore, the trial court's summary judgment in favor of the defendants should have been affirmed based on official immunity.

Summary JudgmentOfficial ImmunityGood FaithImpairment RatingMedical AffidavitConclusory StatementsTexas Workers' Compensation ActAppellate ReviewDissenting OpinionPermanent Disability
References
7
Case No. MISSING
Regular Panel Decision

55th Management Corp. v. Goldman

This case addresses whether an out-of-court statement made to a court evaluator in an Article 81 guardianship proceeding is protected by absolute privilege, thereby defeating a defamation claim. The defendant, a tenant, made allegedly defamatory remarks about a landlord to a court evaluator during the evaluator's investigation for a guardianship proceeding. The court considered if the remarks were pertinent, if a statement to a court evaluator is considered part of a judicial proceeding, and if the speaker had standing. The court found the remarks pertinent, extended the absolute privilege to statements made to court evaluators given their role as court agents, and affirmed the defendant's standing as a potential witness. Consequently, the defendant's motion to dismiss the defamation complaint was granted.

DefamationAbsolute PrivilegeJudicial ProceedingsCourt EvaluatorGuardianshipMental Hygiene Law Article 81Tenant-Landlord DisputeMotion to DismissCPLR 3211 (a) (7)Scope of Privilege
References
44
Case No. MISSING
Regular Panel Decision

Long Island Neurological Assocs., P.C. v. Highmark Blue Shield & Reed Smith LLP

Plaintiff Long Island Neurological Associates, P.C. sued Highmark Blue Shield and Reed Smith LLP for under-reimbursement of surgical services under ERISA. The case involved a 4-year-old patient who received complex out-of-network surgery from Dr. Schneider due to the unavailability of in-network providers. Highmark significantly under-reimbursed the billed amount and denied multiple appeals, failing to provide requested documentation. The patient's parents assigned their rights to the Plaintiff, leading Defendants to move for dismissal, asserting an anti-assignment provision in their Administrative Service Agreement (ASA). The Court denied the motion, ruling that the ASA is not an ERISA plan document and thus its anti-assignment clause is not binding on plan participants, confirming Plaintiff's standing. The Rule 12(b)(6) motion was also denied as abandoned.

ERISAMotion to DismissAnti-assignment clauseAdministrative Service Agreement (ASA)Plan DocumentSubject Matter JurisdictionStandingUnder-reimbursementOut-of-network providerHealth Insurance
References
27
Case No. ADJ6820021, ADJ6820115, ADJ6820640, ADJ6820664
Regular
May 11, 2012

GENOVEVA AYALA vs. WARNER BROTHERS

This case involves Genoveva Ayala's workers' compensation claims against Warner Brothers for multiple injuries. The Administrative Law Judge (WCJ) found some injuries to be established but excluded applicant's medical evidence regarding neurological and internal injuries due to alleged procedural violations. The Appeals Board granted reconsideration, finding that the applicant should have an opportunity to obtain admissible medical reports through the Qualified Medical Evaluator (QME) process, as defendants allegedly interfered with this process. Consequently, the issue of neurological and internal injuries is deferred for further evaluation.

Workers' Compensation Appeals BoardGenoveva AyalaWarner BrothersPermissibly Self-InsuredJoint Partial Findings of FactOrders and Notice of Intention to Appoint Regular PhysicianWorkers' Compensation Administrative Law Judge (WCJ)orthopedic injurycumulative traumaneurological system
References
5
Case No. ADJ916227 (VNO 0474238)
Regular
Jun 11, 2009

JOANNA LEE FRADY vs. MAGIC FORD AUTO NATIONS, ZURICH, Adjusted By UNIVERSAL UNDERWRITERS GROUP

This case concerns an applicant's entitlement to further medical treatment for an admitted industrial injury to her back, neck, and right hand. The defendant sought reconsideration of a prior award finding the applicant entitled to treatment recommended by her treating physician, Dr. Caro, specifically a brain MRI, muscle and skin biopsies, and a neurological evaluation. The Appeals Board granted reconsideration, finding Dr. Caro's report conclusory and not substantial evidence, and instead amended the award to grant treatment as recommended by panel Qualified Medical Examiner Dr. Yousefi. Dr. Yousefi's reports, based on thorough examination and testing, concluded that invasive procedures like muscle and skin biopsies were not indicated and recommended an independent neurological evaluation for further clarification.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardAdministrative Law JudgeFuture Medical TreatmentIndustrial InjuryPermanent DisabilityTreating PhysicianQualified Medical ExaminerSubstantial Evidence
References
0
Case No. 2018-03-0282
Regular Panel Decision
Jul 26, 2018

Teague, James v. Proimage Wholesale Signs, LLC

James Teague, an employee, sought an expedited hearing for medical benefits related to bilateral hand numbness and weakness, which he attributed to chemical exposure at work. Earlier, he was diagnosed with allergic contact dermatitis by treating dermatologists, Drs. Quyn Rahman and Kemunto Mokaya. An independent medical evaluation by Dr. C.M. Salekin suggested chemical-induced peripheral neuropathy, but the authorized treating physician, Dr. Mokaya, later expressed uncertainty regarding the causal link between his work exposure and neurological issues, recommending a neurologist's evaluation. The Court concluded that Mr. Teague failed to establish a likelihood of prevailing on the merits for causation of his neurological symptoms. Nevertheless, it ordered the employer, Prolmage Wholesale Signs, LLC, and its carrier, EMC Insurance Company, to provide medical treatment, specifically an appointment with a panel-selected neurologist, based on Dr. Mokaya's recommendation.

Workers' CompensationMedical BenefitsExpedited HearingNeuropathyContact DermatitisChemical ExposureCausation DisputeTreating Physician OpinionIMEPanel of Physicians
References
2
Case No. ADJ9379623
Regular
May 18, 2018

ETHERY AMARI vs. CHILDREN'S HOSPITAL OF LOS ANGELES

The Workers' Compensation Appeals Board granted the applicant's petition for removal, rescinding a prior order that denied her request for an additional neurology Qualified Medical Evaluator (QME). The applicant sustained admitted injuries including to her spine and shoulder, and also claimed headaches. Her treating physician recommended a neurology consult twice, and the applicant testified about worsening headaches post-injury. The Board found that these factors constituted good cause and demonstrated significant prejudice, warranting the appointment of a neurology QME panel.

Petition for RemovalPanel Qualified Medical EvaluatorNeurology QMEWCABFindings and OrderIndustrial InjuryCervical SpineLumbar SpineHeadachesPrimary Treating Physician
References
1
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