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Case Law Database

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

Case No. ADJ10917207
Regular
Aug 13, 2019

CARMEN ROJO vs. K & M MEAT COMPANY, STARR INDEMNITY & LIABILITY COMPANY

This case involves a dispute over the necessity of an additional Qualified Medical Evaluator (QME) panel in orthopedic surgery. The Applicant sought reconsideration of an administrative law judge's (ALJ) order for a new orthopedic QME panel, arguing it was an abuse of discretion and prejudicial. The Appeals Board granted reconsideration, finding the original QME's referral for an orthopedic evaluation was for treatment, not a recommendation for a new medical-legal evaluation. Consequently, the Board amended the ALJ's findings, holding there was no good cause for an additional orthopedic QME panel and denying the defendant's request.

QME panelorthopedic surgeryreconsiderationremovalFindings & Orderchiropractic QMEmedical-legal evaluationgood causesupplemental pleadingmedical dispute
References
9
Case No. ADJ11913752
Regular
Nov 19, 2019

LAURA DOW vs. UCSF, administered by SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns a dispute over the proper procedure for requesting a Qualified Medical Evaluator (QME) panel after a workers' compensation claim was denied. The Workers' Compensation Appeals Board (WCAB) granted removal, reversing a WCJ's decision. The WCAB found that the defendant's request for an orthopedic surgery QME panel was valid, initiated after the denial notice and statutory waiting period. They also determined that orthopedic surgery was an appropriate specialty, overriding the WCJ's order for a pain medicine panel. The parties are now directed to proceed with the orthopedic surgery QME panel.

QME panelPetition for RemovalOpinion and OrderFindings and OrdersMedical UnitPain MedicineOrthopedic SurgeryDenial NoticeQualified Medical EvaluatorLabor Code Section 4060
References
4
Case No. ADJ9975590; ADJ9976116
Regular
Feb 25, 2016

Ana Nieto vs. Avitus, Inc., American Zurich Insurance Company

The Workers' Compensation Appeals Board (WCAB) dismissed the defendant's petition for reconsideration, finding the appealed order was interlocutory and not subject to reconsideration. The WCAB treated the petition as one for removal and denied it, as the defendant failed to demonstrate substantial prejudice or irreparable harm. The defendant's contention that their trial exhibits and an orthopedic QME panel were erroneously stricken was rejected, as was their claim that the orthopedic QME panel was improperly denied. The defendant failed to provide sufficient evidence to support their request for an orthopedic QME panel over a chiropractic one.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalJoint Findings of Fact & OrdersQualified Medical Evaluator (QME)Orthopedic Surgery QMEChiropractic QMETrial ExhibitsAdministrative Law Judge (WCJ)Labor Code § 4062.2
References
6
Case No. ADJ11861160
Regular
Oct 25, 2019

ADRIANA MARTINEZ vs. AVITUS, AMERICAN ZURICH INSURANCE COMPANY, GALLAGHER BASSETT SERVICES

This case involves a dispute over the selection of Qualified Medical Evaluator (QME) panels for an applicant with claimed injuries to multiple body parts. The Workers' Compensation Appeals Board (WCAB) granted the applicant's petition for removal, rescinded the prior decision, and found that the applicant's chiropractic QME panel request was proper while the defendant's orthopedic surgery panel request was improper. The WCAB determined that chiropractic medicine is the appropriate specialty and struck the orthopedic surgery panel, ordering the parties to proceed with the chiropractic QME. The WCAB clarified that while chiropractors cannot perform surgery or prescribe medication, they are qualified to evaluate injuries within their scope of practice.

QME panel disputeremoval petitionchiropractic specialtyorthopedic surgery specialtyLabor Code 4062.2Medical Directoradministrative law judgeWorkers' Compensation Appeals Boardproper panel selectioninvalid panel request
References
9
Case No. G107 435
Regular Panel Decision
Jun 02, 2023

Matter of Marku v. ABM Industries

This case concerns the claim of Denise Perry under the Workers' Compensation Law. The Workers' Compensation Law Judge (WCLJ) previously found that the employer, Adventist Home Care, established a violation of Workers' Compensation Law § 114-a by the claimant for willfully making false statements to obtain benefits. Consequently, the WCLJ disallowed indemnity benefits and imposed both mandatory and discretionary penalties. A Board Panel decision filed on February 17, 2022, affirmed the WCLJ's findings. The claimant subsequently filed an application for reconsideration on March 18, 2022, which the Board Panel reviewed. After considering the claimant’s arguments, the Board Panel determined that the application did not raise new issues or present new material evidence, nor did it demonstrate an erroneous statement of material fact or law in the prior decision. Therefore, the Board Panel, by a majority vote, affirmed its prior decision.

Workers' Compensation FraudFalse RepresentationIndemnity Benefits DisallowanceWCL § 114-a PenaltyApplication for Reconsideration DeniedBoard Panel AffirmationWillful MisrepresentationWorkers' Compensation Law Judge DecisionEmployer Established Violation
References
0
Case No. ADJ11134833, ADJ11134852
Regular
Apr 15, 2019

PETER LUCKHARDT vs. CITY OF TRACY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration regarding an order for applicant to proceed with a pain management QME panel. The Board found that the applicant, having become represented by counsel after an initial orthopedic panel issued, was entitled to request a new panel specialty. Defendant's arguments concerning unilateral panel changes and due process were rejected, as the issues addressed were framed for adjudication and the applicant's request for a new panel was permissible under current law. The Board also denied the petition concerning an internal medicine panel, adopting the reasoning of the WCJ.

QME panelremovalreconsiderationinterlocutory orderdue processsubstantial complianceirreparable harmlabor codemedical evaluationmedical unit
References
15
Case No. ADJ11446545
Regular
Dec 03, 2019

ROSA LOPEZ RODRIGUEZ vs. UNIVERSAL BUILDING SERVICES SUPPLY COMPANY, INSURANCE COMPANY OF THE WEST

This case concerns a dispute over the appropriate medical specialty for a Qualified Medical Evaluator (QME) panel. The applicant, Rosa Lopez Rodriguez, initially requested a chiropractic QME panel, which was issued first. The defendant objected, arguing that chiropractic was inappropriate due to the applicant's prior surgery and lack of full recovery. The Medical Unit then invalidated the chiropractic panel and issued an orthopedic surgery panel. The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board held that the party who first requests a QME panel has the right to designate the specialty and that the defendant failed to provide sufficient grounds to invalidate the chiropractic panel. Therefore, the Board amended the findings to sustain the applicant's objection and affirm chiropractic as the appropriate panel specialty.

AD Rule 31.5(a)(10)AD Rule 31.5(a)(9)AD Rule 31.1(b)Labor Code section 4062Labor Code section 4062.2Qualified Medical Evaluator (QME)QME panel specialtyPetition for RemovalPetition for ReconsiderationMedical Unit determination
References
1
Case No. ADJ12910087
Regular
Dec 28, 2020

ESTHER LEMUS SALDANA vs. TAO TAI HOMES CORPORATION, INSURANCE COMPANY OF THE WEST

This case concerns a dispute over the correct Qualified Medical Evaluator (QME) panel for applicant Esther Lemus Saldana. The defendant sought reconsideration of an order finding the applicant's chiropractic QME panel valid and the defendant's orthopedic panel invalid. The Workers' Compensation Appeals Board denied the petition, upholding the administrative law judge's decision. The Board found the applicant properly requested a new panel after retaining counsel, and despite a service error on the chiropractic panel, the defendant had opportunity to contest the specialty. Therefore, the applicant's chiropractic QME panel remains the correct one for the medical-legal evaluation.

QME PanelChiropractic QMEOrthopedic QMEPetition for ReconsiderationFindings of Fact and OrdersMedical-Legal EvaluationQualified Medical EvaluatorAdministrative Director RuleRomero v. Costco WholesaleLabor Code Section 4062.1
References
9
Case No. ADJ8182717, ADJ8253375, ADJ8253377
Regular
May 18, 2018

VICTOR MCGILL vs. COUNTY OF FRESNO

This case involves a workers' compensation applicant seeking reconsideration of a judge's decision invalidating a chiropractic QME panel. The Appeals Board dismissed the petition for reconsideration as the judge's order was not a final determination. However, the Board granted removal, finding that an orthopedic QME panel was necessary for the applicant's foot and Achilles tendon injuries, as chiropractic was not the appropriate specialty. The decision rescinds the judge's order and returns the matter for further proceedings to obtain an additional orthopedic QME evaluation.

WCABRemovalReconsiderationQMEMedical DirectorChiropracticOrthopedic SurgeryPanelFindings of Fact and OrderMedical Unit
References
0
Case No. ADJ9099536
Regular
Sep 09, 2014

MARIA SOTO vs. CCC HOSPITALITY PISMO, LLC dba SEACREST OCEANFRONT HOTEL, STAR INSURANCE COMPANY

In this case, the defendant hospital sought removal after the WCJ ordered a chiropractic QME panel, arguing chiropractors were unqualified for the applicant's knee injury. The defendant had initially requested an orthopedic surgeon QME, but their request was rejected by the Medical Unit as incomplete. The Appeals Board found the defendant's initial request substantially complied with regulations and was improperly rejected. Therefore, the Board granted removal, rescinded the WCJ's order, and directed the Medical Unit to issue a panel of orthopedic surgery QMEs.

Petition for RemovalPQMEMedical UnitChiropractic QMEOrthopedic Surgery QMERequest for QME PanelAdministrative Director Rule 30(b)Labor Code section 4062.2Messele v. Pitco FoodsInc.
References
1
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