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

Case No. ADJ8897698
Regular
Feb 19, 2015

MICHAEL GIBSON vs. ORANGE COUNTY TRANSIT AUTHORITY

In this workers' compensation case, the Appeals Board granted reconsideration and reversed the initial denial of the applicant's appeal concerning tinnitus masking treatment. The Board found that the Administrative Director's (AD) Independent Medical Review (IMR) determination was invalid because the reviewer failed to follow the statutorily mandated hierarchy of standards for assessing medical necessity. Specifically, the IMR reviewer improperly relied on Medicare guidelines without first considering peer-reviewed scientific and medical evidence, as required by Labor Code section 4610.5(c)(2). Consequently, the case was remanded to the AD for a new IMR by a different reviewer.

Independent Medical ReviewLabor Code section 4610.6(h)Tinnitus masking treatmentMedical necessityPlainly erroneous finding of factOrdinary knowledgeExpert opinionAdministrative DirectorUtilization ReviewSection 4610.5(c)(2) hierarchy
References
0
Case No. MISSING
Regular Panel Decision
Aug 10, 2012

Williams v. Woodhull Medical & Mental Health Center

Valerie E. Williams filed an action against Woodhull Medical and Mental Health Center and other defendants, alleging discrimination and retaliation under federal and state laws, including Title VII and 42 U.S.C. §§ 1981, 1983, 1985, and 1986. Magistrate Judge Lois Bloom issued a Report and Recommendation, advising to grant the defendants' motion for summary judgment on all claims. Plaintiff Williams filed objections to the R&R, particularly contesting the recommendation on her Title VII retaliation claim. District Judge Nicholas G. Garaufis, upon de novo review of the contested portions and clear error review of the uncontested, adopted the R&R in its entirety. The court granted summary judgment to the defendants, finding no genuine dispute of material fact regarding Williams's claims, specifically noting a lack of causal connection for retaliation and insufficient evidence for a hostile work environment or due process violations.

Employment DiscriminationTitle VII RetaliationSummary JudgmentProcedural Due ProcessHostile Work EnvironmentMedical Negligence AllegationsPublic Health LawHospital EmploymentMagistrate Judge ReviewFederal Rules of Civil Procedure 56
References
80
Case No. MISSING
Regular Panel Decision

Jesa Medical Supply, Inc. v. GEICO Insurance

Plaintiff commenced this action against GEICO to recover first-party no-fault benefits for medical services totaling $796.46. GEICO denied the claims, citing lack of medical necessity and charges exceeding the workers' compensation fee schedule. The court granted summary judgment to the plaintiff for $16.46, finding GEICO failed to provide sufficient evidence for its fee schedule defense on that specific amount. Conversely, the court denied plaintiff's motion for the $780 claim and dismissed that cause of action, accepting GEICO's timely mailed denial and an admissible peer review report by Dr. Andrew R. Miller establishing lack of medical necessity. The court also ruled that defects in the defendant's attorney affirmation did not warrant summary judgment for the plaintiff.

no-fault benefitsmedical necessityfee schedulesummary judgmentpeer reviewelectronic signatureinsurance claimsNew York Civil Courtmedical provider reimbursementtimely denial
References
15
Case No. MISSING
Regular Panel Decision
Oct 03, 2002

Depew v. Lancet Arch, Inc.

This case involves an appeal from a Workers’ Compensation Board decision that denied the claimant's application for reconsideration and/or full Board review. Previously, the Board had found that the claimant did not sustain an accidental injury in the course of employment and denied workers’ compensation benefits. The claimant sought to reopen the matter based on "newly discovered evidence," including a coworker's testimony from a discrimination suit and medical reports prepared after the case was closed. The court affirmed the Board's denial, concluding that the "newly discovered evidence" did not meet the standards set forth in 12 NYCRR 300.14, as the coworker's information was not new, and the medical evidence was not shown to be unavailable at the original hearings. The court limited its review to whether the denial of reconsideration was arbitrary and capricious or an abuse of discretion.

Workers’ Compensation BoardAppealReconsiderationFull Board ReviewNewly Discovered EvidenceCausally Related DisabilityProcedural StandardsMedical EvidenceAbuse of DiscretionArbitrary and Capricious
References
4
Case No. ADJ3156337 (FRE 0209931) ADJ4199467 (FRE 0209932)
Regular
Nov 20, 2008

FRANK FLORES vs. NICKEL'S PAYLESS STORES, WAUSAU INSURANCE COMPANIES, EVEREST NATIONAL INSURANCE COMPANY, AMERICAN COMMERCIAL CLAIMS ADMINSITRATORS

The Workers' Compensation Appeals Board granted reconsideration of an award for a 1999 right foot and ankle injury, specifically addressing the defendant's claims of error in permanent disability calculation without apportionment and the exclusion of medical evidence. The Board intends to admit the Agreed Medical Evaluator's reports into evidence, which the WCJ had previously excluded. This decision will allow the Board to review all relevant medical evidence before making a final determination on apportionment and the applicant's claimed injuries.

Workers Compensation Appeals BoardIndustrial InjuryPermanent Partial DisabilityApportionmentAgreed Medical EvaluatorSubstantial Medical EvidenceAdmissibility of EvidencePetition for ReconsiderationAmended Findings Award and OrderMinutes of Hearing
References
0
Case No. MISSING
Regular Panel Decision

Claim of Coratti v. Jon Josef Hair & Colour Group

The Workers' Compensation Board denied a claimant's motion to preclude a workers’ compensation carrier’s consultant report, which was based solely on a review of medical records, not an independent medical examination (IME). The claimant argued non-compliance with Workers’ Compensation Law § 137 (1) (b), a provision requiring notice if an IME is performed. The Board concluded the statute does not apply to records-review-only reports. An appellate court affirmed, holding that the plain language of § 137 (1) (b) explicitly refers to practitioners who have performed or will perform an IME, thereby excluding those who solely review records. The court emphasized that statutory interpretation must adhere to plain language, leaving policy arguments to the Legislature.

IME reportsrecords reviewWorkers' Compensation Lawstatutory interpretationpreclusion motioncausationoccupational illnessdue processlegislative intent
References
3
Case No. ADJ8518632
Regular
May 09, 2017

HORACIO MONTOYA vs. CBC FRAMING, INC., ARCH INSURANCE COMPANY, A B GALLAGHER BASSETT

The WCAB granted the defendant's Petition for Removal regarding a prior WCJ order compelling a Functional Capacity Evaluation. Removal was granted because the WCJ's order was based on a medical report that had not been formally admitted into evidence, preventing meaningful review. The Board will now admit the defendant's medical report into evidence for the limited purpose of determining the Petition for Removal. This action is an extraordinary remedy due to the prejudice caused by relying on unadmitted evidence.

RemovalFunctional Capacity EvaluationIndustrial InjuryPrejudiceIrreparable HarmAdmitted EvidenceQualified Medical EvaluationExhibit AAdministrative Law JudgePetition for Removal
References
4
Case No. ADJ10917168 (MF)
Regular
Oct 21, 2019

JACOB PIKE vs. CITY OF LONG BEACH

This case concerns an applicant seeking reconsideration of a Workers' Compensation Appeals Board decision denying a right knee meniscal transplantation. The judge found the requested treatment did not fall within presumptively correct Medical Treatment Utilization Standards (MTUS) or present sufficient scientific evidence to rebut the presumption. Applicant argued the physician's report constituted scientific evidence and supported medical necessity, but the Board affirmed the denial. The Board found the applicant failed to meet the burden of proof by a preponderance of scientific medical evidence for treatment outside MTUS guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Findings of Factindustrial injuryright knee meniscal transplantationUtilization Review (UR)Medical Treatment Utilization Standards (MTUS)Labor Code sections 4604.55307.27medically necessary
References
4
Case No. MISSING
Regular Panel Decision

Queens Blvd. Medical, P.C. v. Travelers Indemnity Co.

The plaintiff, Queens Blvd. Medical, P.C., sought $950 in first-party no-fault benefits for biofeedback medical services provided to its assignor for lower back and chronic pain syndrome. The central issue at trial was the medical necessity of these services under Insurance Law § 5102 (a) (1). The plaintiff established a prima facie case with expert testimony from a board-certified neurologist affirming the medical appropriateness of biofeedback. The defendant insurance company failed to present admissible evidence to disprove medical necessity, as its expert was deemed incompetent to testify on biofeedback for back pain. Consequently, the court granted the plaintiff's motion for a directed verdict, awarding judgment for $950 along with statutory costs, interest, and attorney's fees.

No-fault benefitsMedical necessityBiofeedback treatmentExpert testimonyDirected verdictInsurance lawChronic pain syndromeBack injuryCPT codesBurden of proof
References
9
Case No. MISSING
Regular Panel Decision

Hason v. Department of Health

The petitioner, a physician, sought review of a determination by the Administrative Review Board for Professional Medical Conduct (ARB) which suspended his medical license. The ARB's decision was based on a prior California Board finding that the petitioner's ability to practice medicine was impaired by mental illness (bipolar affective disorder and narcissistic personality disorder). The court upheld the ARB's finding of professional misconduct, applying collateral estoppel to the California determination. However, the court found the penalty imposed by the ARB—a one-year suspension "and thereafter until such time as [petitioner] can demonstrate his fitness to practice medicine"—was not authorized by Public Health Law § 230-a. Consequently, the court modified the determination by annulling the penalty and remitted the matter to the ARB for the imposition of a statutorily appropriate penalty.

Medical License SuspensionProfessional MisconductPsychiatric ImpairmentMental IllnessBipolar Affective DisorderNarcissistic Personality DisorderCollateral EstoppelArticle 78 ProceedingAdministrative ReviewPenalty Annulment
References
26
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