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

Case No. SAL 96100; 96096
Regular
Jul 03, 2007

JEANNE LAWRENCE vs. CYPRESS URGENT CARE and PREFERRED EMPLOYERS INSURANCE, TENET/DOCTORS HOSPITAL OF MANTECA

This case involves a worker who sustained two industrial injuries, the first in 2001 with Cypress Urgent Care and the second in 2001 with Tenet/Doctors Hospital of Manteca. The defendant, Tenet/Doctors Hospital, sought reconsideration of a joint findings and award that attributed 25% of the worker's temporary disability and vocational rehabilitation costs to their injury. The WCAB granted reconsideration, finding that while the second injury occurred after the first, evidence indicated the first injury contributed to the worker's need for benefits, thus supporting the apportionment.

WCABReconsiderationJoint Findings and AwardPetition for ReconsiderationTemporary Total Disability (TTD)Vocational RehabilitationApportionmentConsecutive InjuriesMedical TreatmentSelf-Insured
References
0
Case No. ADJ11315508
Regular
Sep 12, 2018

SIERRA PRADO vs. PCG HOSPITALITY, TRAVELERS INSURANCE CO.

This case concerns an applicant's request to treat outside her employer's Medical Provider Network (MPN) due to alleged difficulties in scheduling an appointment with an MPN physician. The applicant argued the Medical Access Assistant (MAA) failed to secure an appointment with available MPN doctors, leading to a denial of care. The Workers' Compensation Appeals Board affirmed the WCJ's decision, finding no denial of care because the MPN list is not a guarantee of immediate appointment and the MAA reasonably attempted to find a suitable physician. The majority determined that the applicant did not exhaust reasonable efforts to find an MPN doctor, and a dissenting opinion argued the inaccurate MPN list constituted a failure to provide care, justifying out-of-network treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Medical Access Assistant (MAA)Primary Treating Physician (PTP)Denial of CareOut-of-Network TreatmentLabor Code Section 4600Labor Code Section 4616Cal. Code Regs. tit. 8§ 9767.5
References
18
Case No. MISSING
Regular Panel Decision

Stephens v. Cooper

Plaintiffs, a group of chiropractors, medical doctors, and PTS Thermal Imaging, brought an action against the Superintendent of the New York State Department of Insurance. They challenged a regulation establishing a fee schedule for thermography services under New York's no-fault automobile insurance law, alleging violations of the New York Administrative Procedure Act, due process, equal protection, and the Sherman Act. The Superintendent moved to dismiss the Sherman Act claims and for abstention. The court granted the motion to dismiss, abstaining under the Burford doctrine, finding that New York has a comprehensive insurance regulatory scheme and that the case involves a challenge to the Superintendent's implementation of state law, thus warranting federal court abstention.

Abstention DoctrineBurford AbstentionNo-Fault InsuranceFee Schedule RegulationThermography ServicesInsurance LawFederal Court JurisdictionSherman Antitrust ActDue Process ChallengeEqual Protection Challenge
References
9
Case No. ADJ9415335
Regular
Oct 21, 2014

ALICIA LYNCH vs. COUNTY OF KERN

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior finding that the applicant was entitled to treat outside the defendant's Medical Provider Network (MPN). The Board found that the applicant failed to meet her burden of proving that the defendant neglected or refused to provide medical care within the MPN. Specifically, the applicant's unsubstantiated claim of one failed appointment attempt with an MPN physician and subsequent designation of an out-of-network doctor was insufficient. Therefore, the defendant retains control of the applicant's medical treatment within the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPetition for ReconsiderationPetition for RemovalFindings and OrderPrimary Treating PhysicianPTPKnight v. United Parcel ServiceSB 863
References
2
Case No. ADJ9048259
Regular
Dec 30, 2015

Antonio Avila vs. Barrett Business Services, Inc., Corvel Insurance Company

Here's a summary of the case in four sentences for a lawyer: The Workers' Compensation Appeals Board denied reconsideration, upholding the judge's decision that the applicant must treat within the employer's Medical Provider Network (MPN). The Board found that while there were some informational deficiencies, they did not amount to a denial of medical treatment that would justify treating outside the MPN. Crucially, the applicant admitted he liked his MPN physician and only sought to change doctors based on his attorney's recommendation. Evidence showed the employer promptly provided medical treatment and confirmed the applicant's treating physician was within their MPN.

Workers' Compensation Appeals BoardPetition for ReconsiderationMPNMedical Provider NetworkWCJHealth First Medical GroupDr. Eliasattorney's recommendationBBSI MPNCorvel Insurance Company
References
1
Case No. ADJ916063 (VNO 0541860)
Regular
Mar 10, 2011

TERRY SCUDDER vs. VERIZON CALIFORNIA, INC.; Permissibly Self-Insured, Administered by SEDGWICK CMS

This case concerns an applicant who sustained industrial injuries and pre-designated a physician outside of the employer's established Medical Provider Network (MPN). The applicant's attorney subsequently referred him to physicians outside the MPN, whose reports were admitted by the WCJ. The Appeals Board overturned this, ruling that only the pre-designated physician, or referrals from that physician, could be outside the MPN and that referrals by an attorney were invalid. Consequently, the reports of these outside physicians were inadmissible, and the issues decided based on them were returned for further proceedings.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPre-designationTreating PhysicianQualified Medical EvaluatorQMEPermanent and Stationary DateApportionmentSelf-Procured Medical Treatment
References
1
Case No. MISSING
Regular Panel Decision
May 14, 1986

Claim of MacMullan v. Associated Press

William Von Stein appealed a Workers’ Compensation Board decision filed May 14, 1986, which denied his application to reopen Philip MacMullan’s previously closed compensation case. The Board determined that any new claim for compensation related to MacMullan's ulcer was barred by the two-year Statute of Limitations under Workers’ Compensation Law § 28. This appeal originated from a medical malpractice action in Supreme Court, where Von Stein, a coemployee and doctor, was accused of failing to inform MacMullan of an ulcer discovered during an employer-conducted medical examination. The Appellate Division affirmed the Board's decision, holding that Von Stein lacked standing to reopen MacMullan’s case and that the requested declaratory ruling on the ulcer's compensability fell outside the Board's authority. Consequently, the court concluded that the judicial forum, not the Workers’ Compensation Board, was the appropriate venue for resolving the dispute concerning MacMullan's injury.

Workers' Compensation Law § 28Statute of LimitationsReopening Closed CaseMedical MalpracticeStanding to SueBoard JurisdictionDeclaratory RulingUlcer ConditionAngina PectorisCoemployee Immunity
References
2
Case No. MISSING
Regular Panel Decision

Claim of Baldassari v. Greenwich Mills Co.

This case involves an appeal from a Workers’ Compensation Board decision from December 6, 1977, which reversed a referee's finding by determining that the claimant's decedent's death was not causally related to their work. The core issue was conflicting medical testimony regarding the cause of death. The treating physician linked it to work effort via a myocardial infarction, while Doctor Cutler and Doctor Fischl, an impartial specialist, testified that death resulted from unrelated abdominal disease and found no evidence of myocardial infarction. The court affirmed the Board’s determination, finding that the testimony of Doctor Cutler and Doctor Fischl provided substantial evidence to support the Board’s conclusion.

Workers' CompensationCausal RelationshipMedical TestimonyMyocardial InfarctionAbdominal DiseaseConflicting EvidenceSubstantial EvidenceAppellate ReviewAffirmation
References
1
Case No. ADJ10223631
Regular
May 31, 2019

SOUNG UE KIM vs. ELITE 4 PRINT, INC., BENCHMARK INSURANCE COMPANY

The WCAB reconsidered an order regarding applicant's treatment outside the employer's Medical Provider Network (MPN). Applicant sought to continue treatment with a physician not in the MPN after the claim was initially denied and later accepted. The Board amended the prior order to clarify that applicant was "improperly" treating outside the MPN, finding that Labor Code section 4603.2(a)(2) does not apply when the employer exercises medical control after accepting the claim, absent a prior final determination of entitlement to an outside physician. One commissioner dissented, arguing the case should be remanded to determine if the employer's significant delays in accepting the claim constituted a failure to provide medical care, which would allow continued treatment outside the MPN.

MPNPetition for Reconsiderationbilateral upper extremity injuriesAdministrative Director Rule 9767.9Labor Code section 4603.2Agreed Medical Examinerprimary treating physicianAOE/COEtransfer of caremedical control
References
8
Case No. MISSING
Regular Panel Decision

People v. Diaz

This opinion addresses whether narcotics found on the outside sill of a broken kitchen window are considered "in open view in a room" under Penal Law § 220.25(2), concerning the room presumption for criminal possession of a controlled substance. During a search warrant execution, police found cocaine on a kitchen table and a plastic bag of cocaine on the outside windowsill. The prosecution sought to include the windowsill narcotics under the "room presumption" to elevate the criminal charge against the defendants. The court strictly construed the phrase "in open view in a room," concluding that an object on an outside windowsill, hidden from ordinary sight and outside the room's normal perimeters, does not meet this definition. The court denied the People's request, distinguishing this interpretation from the more liberal construction of "in close proximity" in the same statute, citing no public policy justification for an expansive reading in this context.

Criminal Possession of Controlled SubstanceRoom PresumptionOpen View DoctrineStatutory InterpretationNarcotics TraffickingDrug ParaphernaliaSearch Warrant ExecutionEvidence AdmissibilityClose ProximityLegislative Intent
References
7
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