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

Case No. ADJ9145724
Regular
Jun 01, 2015

ARZAGA, JOSE vs. CROWN AUTOMOTIVE, INC., AMTRUST NORTH AMERICA

This case involves an applicant seeking to select a pain management specialist outside his employer's Medical Provider Network (MPN). The applicant argued the MPN failed to provide a qualifying specialist within the required 15-mile/30-minute access standard for a primary treating physician. The Board denied the employer's petition for reconsideration, affirming the applicant's right to choose an out-of-network physician and reimbursement for investigative costs. The majority reasoned that the MPN must meet the closer access standard for a primary treating physician, even if that physician is a specialist. A dissenting opinion argued that a specialist, when chosen as a primary treating physician, should fall under the 30-mile/60-minute access standard for specialists.

Medical Provider NetworkMPNprimary treating physicianpain management specialistaccess standardAdministrative Director's Rule 9767.5investigative costsLabor Code section 5703Lescallett v. Wal-MartMartinez v. New French Bakery
References
2
Case No. ADJ9798663
Regular
Sep 02, 2015

ALEJANDRO SAUCEDO SAHAGUN vs. TXC LOUTER'S DAIRY, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the applicant's petition for reconsideration, rescinding the previous award. The applicant sought to change treating physicians outside the defendant's Medical Provider Network (MPN), arguing the MPN failed to meet access standards for primary treating physicians within 15 miles or 30 minutes of his home or work. The Board found the trial judge applied an incorrect, less stringent access standard, and remanded the case for application of the proper standard. The applicant's injury and initial treatment within the MPN were admitted.

Workers' Compensation Appeals BoardMedical Provider NetworkMPN access standardsAdministrative Director's Rule 9767.5rural areasprimary treating physicianorthopedic physiciansoccupational health servicesLab. Code § 4600Lab. Code § 4616
References
5
Case No. ADJ8759396
Regular
Feb 27, 2015

Jose Diaz vs. Timber Works Construction, Berkshire Hathaway

This Workers' Compensation Appeals Board case involves applicant Jose Diaz seeking reconsideration of a prior order regarding his employer's Medical Provider Network (MPN). The primary issue is whether the MPN's physician accessibility standards, which are tied to the "workplace" or residence, are met. The Board granted reconsideration, rescinded the previous order, and remanded the case, finding the MPN may be defective if it doesn't comply with physician access standards relative to the applicant's residence, given the employer's failure to meet the "workplace" standard. The Board also noted that the applicant's inability to travel, while a factor, was not the deciding point in this decision to remand.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNWorkplaceResidencePhysician Access StandardsTitle 8 Section 9767.5Pain ManagementPhysical MedicineCannot Travel Exception
References
1
Case No. ADJ9052223
Regular
Aug 05, 2016

Joel Rodriguez Luna vs. The Home Depot, Helmsman Management

Here's a summary of the case for a lawyer in a maximum of four sentences: The Workers' Compensation Appeals Board denied Joel Rodriguez Luna's Petition for Removal, affirming the WCJ's finding that Home Depot's Medical Provider Network (MPN) complied with access standards. The WCJ determined that for a specialist, like an orthopedist, the MPN only needed to meet the 30-mile/60-minute access standard, not the stricter 15-mile/30-minute standard for a general primary treating physician. The Board agreed, concluding that since there was at least one orthopedic surgeon within the 30-mile radius, the MPN satisfied its obligations, despite the applicant's preference for a specialist within a closer distance. The dissenting opinion argued the MPN failed by not having at least three specialists readily available to serve as primary treating physicians for the applicant's specific orthopedic injuries.

Workers' Compensation Appeals BoardPetition for RemovalMedical Provider Network (MPN)Access StandardsPrimary Treating PhysicianSpecialistGeographic AreaAdministrative Director's RuleLabor CodeIndustrial Injury
References
3
Case No. ADJ7422993
Regular
Apr 06, 2015

SHIRLEY LESCALLETT vs. WAL-MART, ACE AMERICAN INSURANCE, YORK RISK SERVICES

In this workers' compensation case, the applicant sought to select a pain management specialist as her primary treating physician. The employer's Medical Provider Network (MPN) did not have any pain management specialists within the 15-mile/30-minute access standard for primary physicians, though it did have specialists within a 30-mile/60-minute radius. The Appeals Board affirmed the WCJ's decision, holding that if an applicant chooses a specialist for their primary care, the MPN must provide at least three physicians of that specialty within a 15-mile/30-minute radius. Since the defendant's MPN failed to meet this standard for pain management specialists, the applicant was permitted to choose one outside the MPN. A dissenting opinion argued that the 30-mile/60-minute standard for specialists should apply, allowing the applicant to select a physician within that broader radius from the MPN.

MPNMedical Provider NetworkPrimary Treating PhysicianSpecialistAccess StandardsAdministrative Director's RulePain Management PhysicianGeographic RadiusLabor CodeWorkers' Compensation Appeals Board
References
3
Case No. 2025 NY Slip Op 03615
Regular Panel Decision
Jun 12, 2025

Breslin v. Access Auto Sales & Serv., LLC

Matthew M. Breslin, a cable technician, was injured after falling from an extension ladder while installing new cable service. He and his wife filed an action alleging violations of Labor Law §§ 240(1), 241(6), 200, and common-law negligence against Access Auto Sales, Spectrum, and National Grid entities. The Supreme Court denied all parties' motions for summary judgment, citing numerous questions of fact. On appeal, the Appellate Division modified the order, granting summary judgment to defendants for claims under Labor Law § 200 and common-law negligence, and dismissing Access Auto's cross-claims for indemnification/contribution, finding no evidence of their negligence or supervisory control. However, the denials of summary judgment for Labor Law §§ 240(1) and 241(6) claims were affirmed, as factual disputes remained regarding the adequacy of safety equipment and the proximate cause of the accident.

Labor Law Section 240(1)Labor Law Section 241(6)Labor Law Section 200Common-law negligenceSummary judgmentLadder accidentElevation-related hazardConstruction workProximate causeIndemnification
References
30
Case No. ADJ9627339, ADJ9627342
Regular
Mar 26, 2018

Esteban Escobar vs. PRN AMBULANCE, INSURANCE COMPANY OF THE WEST

This case concerns whether the defendant's Medical Provider Network (MPN) met access standards for a chiropractor as a primary treating physician. The Appeals Board granted the applicant's petition for removal, overturning the WCJ's decision. The Board found the MPN must provide three chiropractors within 30 minutes or 15 miles of the applicant's residence or workplace. Since the MPN did not meet this closer standard, the applicant is authorized to select a chiropractor outside the MPN.

MPNchiropractorsprimary treating physicianaccess standardsreconsiderationremovalWCJAdministrative Director's Ruleexpedited hearingstipulate
References
4
Case No. SRO 0139219
Regular
Aug 11, 2008

JENNIFER BALKOWITSCH vs. HOME DEPOT

This case involves an applicant denied self-procured medical treatment by her employer, Home Depot, after failing to secure an MPN physician within reasonable proximity who would accept her. The Appeals Board reversed the initial finding, holding Home Depot liable for self-procured treatment. This decision was based on Home Depot's failure to prove it reasonably provided an MPN physician in accordance with accessibility standards, constituting a neglect or refusal to provide reasonable medical treatment.

Medical Provider NetworkMPN access standardsself-procured medical treatmentreasonable medical treatmentneglect or refusalapplicant's residenceemployment dutiesadministrative regulationemployer's obligationphysician availability
References
9
Case No. MISSING
Regular Panel Decision

Smith v. Apfel

The plaintiff applied for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefits, alleging disability since August 1993 due to bipolar disorder, attention deficit hyperactivity disorder (ADHD), and phobias. The Administrative Law Judge (ALJ) denied the claim, a decision upheld by the Appeals Council. The plaintiff subsequently brought this matter to the District Court, contending that the ALJ misapplied legal standards by failing to properly weigh his treating physician's opinion, incorrectly concluding his impairments did not meet a listed impairment, and inadequately describing his work capabilities. The court found that the ALJ failed to apply the proper legal standard to the treating physician's opinion and improperly discredited the plaintiff's subjective complaints by mischaracterizing evidence in the record. As a result, the court reversed the ALJ's decision and remanded the case, ordering reconsideration of the treating physician's opinion, the plaintiff's functional limitations, and further development of the record concerning the plaintiff's residual functional capacity.

Disability BenefitsSocial Security ActSSISSDIBipolar DisorderADHDPhobiasTreating Physician RuleALJ ErrorRemand
References
24
Case No. 533089
Regular Panel Decision
Oct 07, 2021

Matter of Barden v. General Physicians PC

Claimant, a patient services representative, sought to amend her workers' compensation claim to include left shoulder aggravation after a work-related injury to her right shoulder. The Workers' Compensation Board disallowed this request, finding that claimant failed to provide sufficient credible medical evidence to establish a causal relationship between her employment and the left shoulder condition. The Appellate Division, Third Department, affirmed the Board's decision. The court noted that the claimant's treating physician opined the left shoulder pathology was largely preexisting and unrelated to the work injury, and other medical opinions either lacked sufficient weight or were based on inaccurate information, providing no basis to disturb the Board's finding.

Workers' CompensationShoulder InjuryCausationMedical EvidencePreexisting ConditionAppellate ReviewBoard DecisionClaim AmendmentPatient Services Representative
References
10
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