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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

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. 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

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
Case No. 02-12-00122-CV
Regular Panel Decision
Jan 17, 2013

Clinton Brunson, M.D. v. Ellvan Johnston

In this interlocutory appeal, Clinton Brunson, M.D., challenged the denial of his motion to dismiss a healthcare liability claim filed by Ellvan Johnston. Johnston alleged Dr. Brunson was negligent in interpreting an MRI scan, which resulted in a delayed diagnosis of a spinal cord injury, ultimately leading to permanent neurological damage. Dr. Brunson contended that the expert reports from Drs. Lustgarten and Shalen were insufficient in establishing their qualifications and adequately detailing proximate causation. The Court of Appeals affirmed the trial court's order, concluding that the expert reports provided sufficient information regarding the standards of care, breach, causation, and the experts' qualifications.

Healthcare LiabilityMedical MalpracticeExpert ReportStandard of CareProximate CauseMRI InterpretationSpinal Cord InjuryNeurological InjuryInterlocutory AppealAbuse of Discretion
References
11
Case No. 2015-02-0222
Regular Panel Decision
Feb 25, 2016

Bradley Booker v. Mid-City Grill

Bradley Booker, a delivery driver for Mid-City Grill, was robbed and struck in the head on January 14, 2015, leading to a seizure and diagnosis of a subarachnoid hemorrhage two days later. He received medical treatment, with East Tennessee Brain and Spine Center noting a normal neurological exam and near-complete resolution of the hemorrhage upon his discharge on March 4, 2015. Mr. Booker sought workers' compensation benefits, and during an expedited hearing, Mid-City Grill, an uninsured employer, acknowledged responsibility. The parties reached an agreement for the employer to cover Mr. Booker's medical bills and pay $5,000.00 in temporary disability benefits, resolving the disputed issues.

Workers' CompensationExpedited HearingUninsured EmployerMedical BenefitsTemporary Disability BenefitsSubarachnoid HemorrhageSeizureRobberyHead InjurySettlement Agreement
References
1
Case No. MISSING
Regular Panel Decision

Ballou v. Southworth-Milton, Inc.

Claimant, a mechanic for 26 years, suffered second-degree burns and other injuries in February 2010. He returned to work in May 2010 with restrictions but felt unsafe due to concentration and memory problems from a post-concussion syndrome diagnosis. He retired the same month, seeking workers’ compensation benefits. The employer and carrier controverted the claim, arguing voluntary withdrawal from the labor market. The Workers’ Compensation Board established the claim and awarded continuing benefits, finding claimant's retirement was involuntary due to his disability. The appellate court affirmed the Board's decision, citing substantial evidence that his disability contributed to his retirement, and found no violation of *Matter of Zamora v New York Neurologic Assoc.* regarding the inference of reduced earnings due to disability.

Workers' CompensationInvoluntary RetirementLabor Market WithdrawalPost-Concussion SyndromeDisability BenefitsAppellate ReviewSubstantial EvidenceCausationReduced EarningsMedical Opinion
References
4
Case No. 2017-06-1826
Regular Panel Decision
May 03, 2018

Bedwell, Donna v. Richland Country Club

Donna Bedwell filed an expedited hearing request for medical and temporary disability benefits following a September 2016 work injury where she was struck by a door. Her initial diagnosis was a mild concussion, but her neurologist, Dr. Steven Graham, later concluded her symptoms were "predominantly functional" and related to stress/depression, releasing her at maximum medical improvement with no neurological impairment. Despite a subsequent car accident and a suspected occipital condyle fracture that was later ruled out, Dr. Graham maintained her current condition was not related to the work injury. The Court, noting the absence of countervailing medical evidence, denied her request for benefits, asserting it could not substitute its own judgment for that of the sole medical professional's opinion, even with concerns regarding Dr. Graham's documentation and the employer's failure to provide a proper physician panel.

Workers' Compensation LawExpedited HearingMedical Benefits ClaimTemporary Disability BenefitsWork-Related InjuryConcussion RecoveryNeurological ExaminationMedical CausationSomatoform DisorderMaximum Medical Improvement (MMI)
References
5
Case No. MISSING
Regular Panel Decision

Depczynski v. Adsco/Farrar & Trefts

This case addresses a workers' compensation claim for occupational hearing loss, focusing on the interpretation of Workers’ Compensation Law § 49-bb concerning the 90-day limitations period. The central question is whether 'knowledge' to trigger this period requires a formal medical diagnosis or the claimant's admitted awareness of the injury and its work-related cause is sufficient. The claimant, employed by Farrar & Trefts (later Adsco Manufacturing Corp.), experienced significant noise exposure and recognized his hearing loss and its occupational link in 1980. However, he did not receive a medical diagnosis until January 1991, having filed his claim in December 1989. The Workers’ Compensation Board dismissed the claim as untimely, finding the claimant had knowledge in 1980, but the Appellate Division reversed, requiring a medical diagnosis for 'knowledge.' The Court of Appeals reversed the Appellate Division, ruling that the claimant's admitted awareness of his injury and its cause in 1980 initiated the limitations period, irrespective of a formal medical diagnosis. Consequently, the court deemed the claim, filed over two years from the disablement date, as untimely and dismissed it.

Occupational hearing lossWorkers' Compensation LawStatute of LimitationsDelayed discovery ruleMedical diagnosis requirementCausation awarenessEmployer liabilityInsurance carrierJudicial interpretationWorkers' Compensation Board
References
12
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
Case No. ADJ3218661 (OAK 0339889)
Regular
Feb 07, 2011

CHANCE ROLLINS vs. JOHN MARTIN STABLES, INC.; AMERICAN HOME ASSURANCE administered by AIG, CLAIMS SERVICES

The Appeals Board vacated its prior order granting reconsideration and dismissed the defendant's petition for reconsideration, finding the WCJ's ruling was not a final order. However, the Board granted removal, rescinded the WCJ's order, and denied the applicant's request for a neurology consultation under Labor Code §4601(a). The matter was returned to the trial level with instructions to issue an order for a new QME panel in neurology, as Dr. Jamasbi's request for a consultative neurological evaluation constituted good cause for a new panel under 8 Cal. Code Regs. §31.7. Attorney fees for the ex parte communication were upheld.

WCABPetition for ReconsiderationPetition for RemovalLabor Code 4601(a)Labor Code 4062.3QMEAgreed Medical EvaluatorNeurological ConsultMedical DirectorSpecialty Panel
References
0
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