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Case Law Database

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

Case No. ADJ1880234 (GOL 0097047)
Regular
Oct 06, 2014

HSING TEREK vs. EMBASSY SUITES/WINDSOR CAPITAL GROUP

In this workers' compensation case, the applicant suffered an admitted industrial injury from a slip and fall as a housekeeper. The defendant sought reconsideration of the findings of total permanent disability and injury to the "psyche, head, internal, and neurological/cognitive impairment." The Appeals Board granted reconsideration to address the ambiguity of the "internal" injury finding, which they found insufficiently specified. While affirming the total permanent disability finding and injury to psyche, head, and neurological/cognitive impairment, the Board rescinded the "internal" injury finding and returned the case for further proceedings to clarify the specific internal systems or conditions injured.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact and AwardIndustrial InjuryPsycheNeurological/Cognitive ImpairmentTotal Permanent DisabilityApportionmentHousekeeperSlip and Fall
References
1
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. MISSING
Regular Panel Decision

Claim of Giudi v. New Paltz Fire Department

The Workers' Compensation Board's finding that the claimant remains unable to perform their prior employment duties as a chef, or those of a reasonable substitute, due to cognitive impairments, is supported by substantial evidence. This evidence includes the claimant's testimony and the opinion of a clinical neuropsychologist, who stated that the cognitive impairments prevent the claimant from working as a chef or military police officer. The Board's crediting of this evidence, which justified the finding of over 75% earning capacity loss, was upheld. The employer's argument that the Board applied an incorrect legal standard was rejected. The decision is affirmed.

cognitive impairmentsearning capacity lossdisability benefitsneuropsychologyoccupational injurymedical opinionappellate reviewsubstantial evidenceworkers' compensation lawemployment duties
References
5
Case No. ADJ4397000
Regular
Jun 10, 2011

MARIA MERCEDES FELIX vs. SEA DWELLING CREATURES, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration, upholding the finding that applicant Maria Mercedes Felix has 0% whole person impairment for her back injury and requires no further medical treatment. This decision was based on the opinion of a qualified medical evaluator (PQME) whose findings were consistent with a prior medical report. The PQME's report concluded that various diagnostic tests were normal and revealed no significant clinical findings, structural alterations, or neurological impairment. Crucially, the Appeals Board clarified that a 3% pain add-on for whole person impairment is legally permissible only to increase an already established impairment rating, which was not the case here as the initial rating was zero.

Workers' Compensation Appeals BoardReconsideration deniedExpert medical evidencePanel Qualified Medical Evaluator (PQME)American Medical Association Guides (AMA Guides)Permanent ImpairmentWhole Person Impairment (WPI)DRE Lumbar Category IMedical treatmentPain add-on
References
2
Case No. ADJ10558753
Regular
Apr 25, 2018

DIANE SCHRADER vs. THE HETTENA LAW FIRM, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The applicant sought to set aside a Compromise and Release (C&R) settlement, alleging severe cognitive impairment at the time of signing. The Workers' Compensation Appeals Board (WCAB) denied reconsideration of the original decision. The WCAB found that the physician's report, which formed the basis of the applicant's claim of impairment, was speculative as the physician was not present at the settlement. Furthermore, the WCAB deferred to the administrative law judge's credibility determination, who found the claims of incompetence not credible.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact & OrderCompromise and ReleaseOrder Approving Compromise and ReleaseSet AsideGood CauseCognitive ImpairmentSubstantial EvidencePrimary Treating Physician
References
3
Case No. ADJ6619965 ADJ9843987
Regular
Jul 16, 2018

JESUS ZARAGOZA vs. KOOL KOUNTRY, LLC, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Board granted reconsideration to review the finding of injury to the bladder, sleep disorder, sexual dysfunction, and cognitive disability/headaches, as well as the applicant's earnings. The Board affirmed the finding of injury to the bladder, sleep disorder, and sexual dysfunction but reversed the finding of injury related to cognitive impairment/headaches, finding insufficient medical evidence. Additionally, the Board amended the applicant's earnings to $270.00 per week, based on the parties' stipulation regarding the permanent disability rate, and affirmed the overall award except for these specific modifications.

Workers' Compensation Appeals BoardReconsiderationFindings of FactAwardAdministrative Law JudgePermanent DisabilityAverage Weekly EarningsStipulationAgreed Medical ExaminerQualified Medical Examiner
References
0
Case No. ADJ7449576
Regular
May 11, 2016

MANNY WINNINGHAM vs. STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS

This case concerns an applicant seeking total permanent disability benefits based on a brain injury. The applicant argued for conclusive total disability under Labor Code section 4662(a)(4) due to permanent mental incapacity. The Board affirmed the WCJ's finding that while the applicant suffered serious psychiatric impairments leading to overall total disability, the specific cognitive impairments did not meet the threshold for the *conclusive* presumption of total disability under section 4662(a)(4). Therefore, apportionment was still applicable, and the previous award of $84\%$ permanent disability was upheld.

Permanent total disabilityLabor Code section 4662(a)(4)Conclusive presumptionApportionmentBrain injuryPermanent mental incapacityGlobal Assessment of Functioning ScaleCognitive impairmentPsychiatric impairmentCorrectional officer
References
1
Case No. MISSING
Regular Panel Decision

the Claim of Brigandi v. Town & Country Linoleum & Carpet

This case involves an appeal by an employer and its compensation carrier against decisions made by the Workers’ Compensation Board. The decedent, a carpet layer, died from cardiac arrest during work, with an autopsy revealing underlying coronary atherosclerotic disease. His widow was awarded death benefits. The employer’s carrier sought reimbursement from the Special Disability Fund under Workers’ Compensation Law § 15 (8), asserting a preexisting permanent physical impairment. However, the Board determined that there was no evidence that the decedent’s heart condition hindered his job potential before his death, thus releasing the Special Disability Fund from liability and holding the compensation carrier responsible. The employer's subsequent application for reconsideration was denied by the Board, leading to these appeals. The appellate court affirmed the Board's decisions, concluding that the Board rationally found no proof that the decedent's heart disease impaired his job potential, a necessary condition for reimbursement under WCL § 15 (8) (d).

Special Disability FundPreexisting Permanent ImpairmentCardiac ArrestCoronary Atherosclerotic DiseaseDeath Benefits ClaimEmployer ReimbursementCarrier LiabilityBoard Decision ReviewAppellate AffirmationMedical Evidence Interpretation
References
2
Case No. ADJ11269770
Regular
Mar 08, 2023

RYAN GASKINS vs. WET DIRT INC., NATIONAL FIRE AND LIABILITY INSURANCE COMPANY, GALLAGHER BASSETT

The Workers' Compensation Appeals Board affirmed the original finding of 100% permanent total disability for the applicant, Ryan Gaskins, due to a work-related brain injury. Despite the defendant's contention that medical evidence did not explicitly state "permanent mental incapacity," the Board adopted the WCJ's reasoning that the physicians' reports detailing severe cognitive impairment and need for continuous 24/7 care constituted substantial evidence. The Board amended the award to correctly identify the insurer as National Liability and Fire Insurance Company and removed the administrator Gallagher Bassett. The defendant's arguments regarding the AMA Guides impairment rating were rejected as inconsistent with the medical findings of total disability.

Permanent mental incapacityLabor Code section 4662(a)(4)Permanent total disabilityTraumatic brain injuryPanel Qualified Medical EvaluatorAMA GuidelinesVocational rehabilitationAOE/COECraniotomySeizure disorder
References
2
Case No. MISSING
Regular Panel Decision

In re Anonymous

This case concerns an adoption proceeding in Nassau County for a neurologically handicapped child. The petitioners, an approved adoptive family, sought to finalize the adoption. Former foster parents, the intervenors, challenged this, claiming a statutory preference for adoption due to their long-term care of the child. The court found that the intervenors had previously declined to adopt the child and failed to take affirmative steps to gain statutory preference while the child was in their care. The decision emphasized that intervention rights apply to current foster parents in custody disputes, and ultimately, the court prioritized the child's best interests by granting the petitioners' adoption application.

AdoptionFoster CareChild WelfareNeurological HandicapBest Interests of ChildInterventionStatutory PreferenceSocial Services LawAgency Discretion
References
3
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