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

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. 2018-01-0036
Regular Panel Decision
Jan 16, 2020

Swafford, Carl v. Wal-Mart Associates, Inc

Carl Swafford, an employee, filed for an expedited hearing after sustaining a right hip injury while working for Wal-Mart. He sought a valid panel of physicians and penalty assessment against Wal-Mart for an initially invalid panel. The Court found Wal-Mart's first panel, which included a physician sixty-seven miles away, to be invalid under Tenn. Code Ann. § 50-6-204(a)(3)(A)(i). However, the Court determined that Wal-Mart subsequently remedied the defect by offering a new panel with physicians reasonably within Mr. Swafford's community (Chattanooga and Cleveland). Consequently, the Court denied Mr. Swafford's request for another panel and declined to impose penalties on Wal-Mart.

Medical PanelExpedited HearingHip InjuryOrthopedicPhysician SelectionEmployer ObligationsTennessee LawChattanoogaStatutory InterpretationWorkers' Compensation Claims
References
0
Case No. ADJ14953769
Regular
Feb 28, 2023

MANUEL DE JESUS CHAVAC vs. 99 CENTS ONLY STORES, LLC, ATHENS ADMINISTRATORS

The applicant sought reconsideration of a WCJ's finding that QME Panel No. 7480460 was valid. The applicant argued the panel was invalid because the defendant failed to serve the denial letter on the applicant's attorney, thus violating due process and Labor Code section 4062.2. The Appeals Board granted reconsideration, finding the defendant's denial letter was improperly served, preventing the applicant's attorney from objecting. Consequently, QME Panel No. 7480460 was deemed invalid, and the parties were ordered to proceed with Panel No. 7483530.

Workers' Compensation Appeals BoardQualified Medical EvaluatorQME PanelLabor Code section 4060Administrative Director Rule 30(b)Petition for ReconsiderationFindings of Fact and OrderInjury AOE/COEDenial of LiabilityService of Process
References
8
Case No. 2021-05-0644
Regular Panel Decision
Nov 21, 2022

Cook. Lisa v. Newton Nissan of Gallatin/Newton Ford, LLC

Lisa Cook, an automobile salesperson, injured her left wrist at work. Her employer, Newton Nissan, failed to offer timely medical treatment, leading Ms. Cook to seek care independently. After multiple physician consultations, including Dr. Kyle Joyner, Dr. Jeffrey Hazlewood, and Dr. Michael Bowman, Ms. Cook was referred to the Vanderbilt Pain Management Center. Newton subsequently provided a pain management panel, which Ms. Cook challenged as invalid. The Court found the panel invalid because it included Dr. Hazlewood, who had previously stated he had no further treatment to offer. The Court ordered Newton to provide a new pain management panel, excluding Dr. Hazlewood, and referred the employer to the Compliance Program for investigation due to repeated failures to provide physician panels.

Workers' Compensation BenefitsMedical Panel DisputePain Management ReferralComplex Regional Pain SyndromeEmployer Medical ResponsibilityPhysician Selection RulesStatutory ComplianceExpedited Hearing DecisionCompliance Program ReferralInjured Worker Treatment
References
3
Case No. 2015-05-0619
Regular Panel Decision
Jun 28, 2017

Baumgardner, William v. UPS

William Baumgardner, a delivery driver, sustained a left-knee injury while working for UPS in 2014. He sought permanent disability benefits, arguing the injury, including a medial meniscus tear, was compensable and that the employer's provided medical panel was invalid. The Workers' Compensation Judge denied the claim for permanent disability benefits, finding Mr. Baumgardner failed to prove the medial meniscus tear was primarily caused by the work injury and did not establish entitlement to PTD or PPD benefits under the AMA Guides. However, the court found the employer's initial medical panel invalid due to geographic limitations and ordered UPS to provide a new panel of orthopedic specialists for ongoing medical treatment.

Knee InjuryMedical Panel DisputePermanent Disability DenialCausation of InjuryAMA GuidesTreating Physician OpinionIME ReportVocational DisabilityTennessee LawWorkers' Compensation Judge
References
7
Case No. 03-21-00074-CV
Regular Panel Decision
Feb 28, 2023

Texas Department of Insurance, Division of Workers' Compensation// Accident Fund Insurance Company of America and Texas Cotton Ginners' Trust v. Accident Fund Insurance Company of America and Texas Cotton Ginners' Trust// Cross-Appellee, Texas Department of Insurance, Division of Workers' Compensation

This declaratory-judgment action involves a dispute between the Texas Department of Insurance, Division of Workers’ Compensation (the Division) and insurance carriers, Accident Fund Insurance Company of America and Texas Cotton Ginners’ Trust, regarding rules for workers’ compensation supplemental income benefits (SIB). The carriers challenged the validity of a Division rule, 28 Texas Administrative Code Section 130.102, which governs eligibility for SIB, specifically concerning the "work search efforts" requirement for injured employees. The district court had ruled a section of the rule (d)(1)(D) invalid and another section (f) inapplicable to independent job seekers. On appeal, the Court of Appeals reversed the district court's finding that Section (d)(1)(D) was invalid, concluding it was facially valid. However, the appellate court affirmed the district court's ruling that Section (f)'s "work search contacts" language does not qualitatively apply to independent job seekers, but only for setting a numerical standard. Additionally, the court found certain parts of the Division's preamble to the rule and its Appeals Panel Decision Manual to contain invalid ad hoc rules, reversing the district court on this point, while affirming that an Appeals Panel Decision and the SIB application form were not ad hoc rules. The court also found the exclusion of an expert witness to be harmless.

Workers’ CompensationSupplemental Income BenefitsAgency Rule ValidityAdministrative LawDeclaratory Judgment ActionStatutory InterpretationWork Search RequirementsAd Hoc RulesAppellate ProcedureTexas Government Code
References
22
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. MISSING
Regular Panel Decision

Texas Workers' Compensation Insurance Fund v. Texas Workers' Compensation Commission

The Texas Workers’ Compensation Insurance Fund, now Texas Mutual, challenged an appeals panel decision by the Texas Workers’ Compensation Commission which awarded lifetime income benefits to claimant Leonard D. Watts. Watts, a truck driver for Mono Chem Corporation, sustained a leg injury in 1994, leading to severe medical conditions and ultimately the loss of use of both feet. A hearing officer initially denied lifetime benefits due to insufficient evidence of a causal connection to the original injury, but the appeals panel twice reversed this decision, rendering a new decision in favor of Watts. Texas Mutual sought judicial review, arguing the appeals panel exceeded its statutory authority and improperly engaged in factual-sufficiency review. The district court set aside the appeals panel's decision. This court, however, reversed the district court's decision, affirming the appeals panel’s award of lifetime income benefits to Watts, holding that the appeals panel acted within its statutory authority.

Workers' CompensationLifetime Income BenefitsAppeals Panel ReviewJudicial ReviewFactual SufficiencyStatutory AuthorityCausationRes JudicataCollateral EstoppelTexas Labor Code
References
13
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. ADJ9539560
Regular
May 14, 2015

OSCAR MELENDEZ vs. B&D UPHOLSTERY, PROCENTURY INSURANCE COMPANY, MIDWEST INSURANCE COMPANY

In this workers' compensation case, the defendant sought to invalidate the applicant's requested QME panel. The defendant argued that the applicant's request was invalid because it was not served on their attorney. The Appeals Board denied the petition for removal, finding that while service on the attorney was required, the defendant's own QME request contained material defects, including misidentifying the treating physician's specialty and the reason for the request. Therefore, the WCJ's finding of the applicant's panel's validity did not cause irreparable harm.

Petition for RemovalQualified Medical EvaluatorQME PanelLabor Code section 4060Compensability examWCAB Rule 10510(b)Service on attorneyRule 31.1(b)Specialty disputeMaterial defects
References
0
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