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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

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. 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. 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
Case No. MISSING
Regular Panel Decision

Burger v. Bladt

The infant plaintiff suffered personal injuries resulting in serious learning disabilities and neurological problems following a collision. The defendant moved to compel additional medical examinations by a psychologist, psychiatrist, and a teacher of the neurologically handicapped, as well as a parent intake evaluation by a psychiatric social worker, after the plaintiffs refused to submit to more than a single examination. The Supreme Court partially denied this motion, deeming it overly burdensome. On appeal, the order was modified to grant the defendant's request for an examination by Annella Stevens, a teacher of the neurologically handicapped, and an interview by a psychiatric social worker to obtain the child's developmental history, affirming the order as modified.

Personal InjuryMedical ExaminationDiscoveryAppellate ProcedureInfant PlaintiffNeurological ProblemsLearning DisabilitiesSupreme CourtPre-Trial DiscoveryCourt Order Modification
References
4
Case No. ADJ9344182, ADJ9344101
Regular
Jul 29, 2019

ROSA COREAS vs. LANGER JUICE COMPANY, INC., SEABRIGHT INSURANCE COMPANY, ENSTAR (US), INC.

This case involved applicant Rosa Coreas's claim for workers' compensation benefits for injuries sustained while employed by Langer Juice Company. The core dispute concerned whether the defendant acted in bad faith by refusing to agree to an Agreed Medical Evaluator (AME) or a joint request for additional Qualified Medical Evaluator (QME) panels for psychiatric and neurological evaluations. The Workers' Compensation Appeals Board affirmed the initial decision, finding that the defendant's refusal did not constitute bad faith or frivolous tactics under Labor Code Section 5813. The Board noted that both parties could have handled the situation better and that the case was distinguishable from prior precedent requiring such agreements. Ultimately, the Board determined there was no good cause to overturn the administrative law judge's decision denying sanctions.

Workers' Compensation Appeals BoardJoint Findings and OrderAgreed Medical ExaminersQualified Medical EvaluatorsPetition for ReconsiderationSanctionsBad Faith ActionsLabor Code Section 5813Administrative Director Rule 31.7Medical-Legal Report
References
1
Case No. ADJ2834861 (GRO 00349120) ADJ3453107 (GRO 0031731) ADJ405168 (GRO 0034913)
Regular
Nov 14, 2019

TOM JANISE vs. DSH ATASCADERO, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted applicant's Petition for Removal, rescinding an order that closed discovery and set a trial date. This was because a court-ordered neurology panel Qualified Medical Evaluator (QME) was not selected until after discovery was closed, despite delays from the Medical Unit. The Board agreed that applicant should not be prejudiced by this delay and allowed for the QME evaluation to proceed. Consequently, the trial was converted to a status conference.

Petition for RemovalAppeals BoardWCJQualified Medical EvaluatorDWC Medical Unitneurologydiscovery closureproof of serviceStatus Conferencerescinded order
References
0
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