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Case Law Database

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

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. 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 The Workers' Compensation Appeals Board (WCAB) granted the applicant's petition for removal, rescinded the prior decision, and found that the applicant's chiropractic QME panel request was proper while the defendant's orthopedic surgery panel request was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. 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. 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. MISSING
Regular Panel Decision

Fernandez v. North Shore Orthopedic Surgery & Sports Medicine, P.C.

Frank Fernandez, an x-ray technician, sued his former employer, North Shore Orthopedic Surgery & Sports Medicine, P.C., for retaliation under Title VII after filing a national origin discrimination complaint. A jury found in favor of Fernandez, awarding back pay, front pay, and punitive damages. North Shore subsequently moved for judgment as a matter of law, a new trial, and to modify the damage awards. The court denied North Shore's motions for judgment and a new trial, affirmed the jury's back pay award, but vacated and reduced the front pay award from $160,000 to $50,000, and the punitive damages award from $100,000 to $50,000.

RetaliationTitle VIIEmployment DiscriminationBack PayFront PayPunitive DamagesMitigation of DamagesFederal Rules of Civil ProcedureJudicial DiscretionEquitable Relief
References
27
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
Case No. ADJ12347424
Regular
Nov 09, 2020

DANIELLE LOOMIS-LYONS vs. COUNTY OF MENDOCINO

This case concerns applicant Danielle Loomis-Lyons' injury to her right knee. The WCJ initially found injury AOE/COE, ordered a replacement QME panel in orthopedic surgery, and deemed the prior pain management QME report inadmissible. The Appeals Board granted reconsideration, affirming the injury finding and the need for a replacement panel, but corrected the panel specialty to pain medicine. The Board rescinded findings regarding the appropriate panel specialty due to lack of notice and opportunity to be heard.

QME panelpain managementorthopedic surgeryAOE/COEinadmissible reportPetition for ReconsiderationremovalLabor Code section 4062.1AD Rule 31.3AD Rule 31.5
References
12
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. ADJ9317724
Regular
Jul 23, 2015

JUAN TORRES vs. LINEAGE LOGISTICS COLD STORAGE, TRAVELERS INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the applicant's Petition for Removal. The applicant sought to overturn a Minute Order compelling an orthopedic QME evaluation, arguing the existing orthopedic panel was improperly obtained and preferred a treating doctor. The Board adopted the WCJ's recommendation, finding no substantial prejudice or irreparable harm, as removal is an extraordinary remedy not warranted here. The applicant's preference for a treating doctor did not override the WCJ's order for a QME evaluation requested to clarify a prior medical opinion regarding potential knee surgery.

Petition for RemovalQualified Medical EvaluatorOrthopedic QMEChiropractic QMEKnee SurgeryIndependent Medical OpinionMPNMedical Treatment AuthorizationPrimary Treating PhysicianReconsideration
References
2
Case No. MISSING
Regular Panel Decision

Lawliss v. Quellman

Plaintiff sustained a right shoulder injury at work, leading his orthopedic specialist to recommend immediate surgery for a ruptured biceps. However, his employer's workers' compensation carrier disputed the need for surgery and mandated an independent medical examination (IME) by the defendant, an orthopedic specialist. The defendant reported to the carrier that surgery was unnecessary, advocating physical therapy instead. This advice resulted in the carrier denying surgery, and the plaintiff's subsequent physical therapy proved ineffective, as did delayed surgery, allegedly causing an 80% loss of shoulder use. Consequently, plaintiff initiated a medical malpractice action against the defendant, asserting that the negligent advice given during the IME caused the detrimental delay in his treatment. The Supreme Court denied the defendant's motion for summary judgment, a decision which the appellate court affirmed, citing the presence of factual questions regarding an implied physician-patient relationship, negligence, and foreseeable reliance.

medical malpracticeindependent medical examinationphysician-patient relationshipsummary judgmentworkers' compensationappellate decisionorthopedic injurynegligent advicedelayed surgeryloss of use
References
10
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