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Case Law Database

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

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
Case No. ADJ8331259
Regular
Dec 21, 2012

MARIELA GOMEZ vs. PROVIDENCE FARMS, LLC, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The Board adopted the WCJ's report, emphasizing that the defendant's failure to properly notify the applicant about changing treating physicians within the Medical Provider Network (MPN) resulted in a denial of necessary medical treatment. This failure to inform the applicant of her rights, particularly regarding physician selection and dispute resolution processes within the MPN, constituted a neglect or refusal to provide reasonable medical treatment, as established by precedent. Consequently, the applicant was permitted to continue receiving treatment outside the MPN until she could begin care with a designated physician within the network.

Workers' Compensation Appeals BoardProvidence FarmsLLCZenith Insurance CompanyMariela GomezADJ8331259Order Denying ReconsiderationPetition for ReconsiderationMedical TreatmentMedical Provider Network
References
2
Case No. MISSING
Regular Panel Decision

Yuhas v. Provident Life & Casualty Insurance

Deborah Yuhas sued Provident Life and Casualty Insurance Company under ERISA for long-term disability benefits, claiming physical disability. Yuhas, a graphic designer, initially received benefits for a mental condition, which ceased after 24 months due to policy limitations. She subsequently appealed, claiming physical disabilities from a car accident, leading to a retroactive award of benefits for a specific period (October 1991 through May 1993) but no further benefits. Provident repeatedly denied her claim for benefits beyond May 1993, citing lack of objective physical disability and the expiration of appeal periods. Yuhas filed suit in September 2000, but the court granted Provident's motion for summary judgment, ruling that her claim was barred by the three-year statute of limitations, which had accrued by December 13, 1993, at the latest.

ERISALong Term Disability BenefitsSummary JudgmentStatute of LimitationsAccrual of Cause of ActionDisability Insurance PolicyMental DisorderPhysical InjuryAppeals ProcessRepudiation of Claim
References
13
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. ADJ7091667
Regular
Jan 31, 2013

THOMAS HERRERA vs. AMERI-COLD LOGISTICS, LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board reconsidered a decision allowing the applicant to treat outside the defendant's Medical Provider Network (MPN). The Board found the employer failed to notify the applicant of his right to predesignate a personal physician as required by law. However, the remedy for this failure is limited to treatment with that specific personal physician, not any physician outside the MPN. Therefore, the original order was rescinded, and the applicant is now entitled to treatment from his identified personal physician, Dr. Aceves, provided he meets the statutory criteria, and not outside the MPN otherwise.

ADJ7091667Americo LogisticsLiberty Mutual InsuranceMedical Provider Network (MPN)Petition for Reconsiderationcumulative injurypsyche injuryinternal injuryheadachessleep disorder
References
2
Case No. ADJ4189084 (AHM 0150210), ADJ2609035 (MON 0237343), ADJ2256301 (MON 0237524), ADJ4536480 (MON 0315454)
Regular
Feb 05, 2015

Dennis Pasquel vs. The Boeing Company, ACE American Insurance Company, Sedgwick Claims Management Services, Inc.

The Workers' Compensation Appeals Board overturned a judge's decision and allowed a lien for medical treatment provided by Dr. Powers at Griffin Medical Group. The Board found that while Dr. Powers was listed in the employer's Medical Provider Network (MPN) at a specific facility, there was no explicit restriction in the MPN listing prohibiting him from treating patients elsewhere. The Board concluded that contract disputes between a physician and an MPN provider should not prevent payment for medically necessary treatment when the MPN itself acknowledged the physician as a provider. This decision allows Griffin Medical Group to be paid for Dr. Powers' services rendered at their facility.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNLien claimantPrimary treating physicianJoint Findings and OrderReconsiderationStipulated awardsCumulative trauma injuryIndependent Contractor Agreement
References
3
Case No. MISSING
Regular Panel Decision
Apr 07, 1998

Marange v. Slivinski

This case involves an appeal concerning a malpractice action filed by a plaintiff against a physician who was a co-employee at CBS. The plaintiff alleged that the physician negligently failed to diagnose his late wife's breast cancer, causing her death. Both individuals were employed by CBS, and the physician provided medical services exclusively to CBS employees on its premises. The Workers’ Compensation Board had previously dismissed the decedent's compensation claim. The Supreme Court initially denied the defendant's motion to dismiss based on the 'fellow-employee rule' of Workers’ Compensation Law § 29 (6). The appellate court, however, unanimously reversed this decision, granting the motion to dismiss the complaint. The court found that the fellow-employee rule applied, establishing Workers' Compensation benefits as the exclusive remedy, given that the physician's services were employer-provided and limited to employees.

Medical MalpracticeWorkers' Compensation LawFellow-employee ruleExclusivity of RemedyEmployer-provided medical servicesFailure to diagnoseBreast CancerCo-employeesMotion to DismissAppellate Review
References
6
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. ADJ9338499
Regular
Jun 03, 2015

JOVANNI MONTELONGO vs. PHIL BRUNO ENTERPRISES, INC., dba EXCLUSIVE FRESH, INC., PROCENTURY INSURANCE COMPANY

This case involves a dispute over the proper Medical Provider Network (MPN) for an injured worker. The defendant argued that the applicant's chosen physicians were not part of the correct MPN, Midwest Rising. The Appeals Board granted reconsideration, reversing the original findings. They found that the defendant provided sufficient notice of the correct MPN and that the applicant's chosen physicians were not within it. The Board determined that the applicant was not misled and the defendant did not neglect to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider NetworkMPN disputeRising InterplanMidwest RisingProcentury Insurance CompanyIllinois Midwest Insurance AgencyAdministrative Directorprimary treating physicianindustrial injury
References
3
Case No. ADJ13096148
Regular
Dec 03, 2020

JUSTINO MONTIEL vs. SOCAL FRAMINGS, INC., REDWOOD FIRE & CASUALTY INSURANCE, BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANIES

The applicant properly selected Dr. Patterson at Casa Colina as his treating physician for his admitted injury, as Casa Colina is listed as a provider within the defendant's Medical Provider Network (MPN). The Board affirmed the WCJ's decision, finding that an acknowledgment of MPN membership is not required for physicians who are shareholders, partners, or employees of a medical group that has elected to participate in the MPN. The defendant failed to provide evidence that Casa Colina's participation was limited to ancillary services. Therefore, the defendant's petition for reconsideration was denied.

Medical Provider NetworkMPNTreating PhysicianLabor Code Section 4600Expedited HearingFindings of FactAncillary ServicesMedical GroupUtilization ReviewPetition for Reconsideration
References
1
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