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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. MISSING
Regular Panel Decision
Apr 07, 1988

De Coste v. Champlain Valley Physicians Hospital

Decedent, Darwin A. De Coste, experienced chest pain and elevated blood pressure, leading him to Champlain Valley Physicians Hospital where he was seen by Dr. William Amsterlaw. Amsterlaw diagnosed reflux esophagitis despite an abnormal electrocardiogram, discharging De Coste, who subsequently suffered a fatal cardiopulmonary arrest 12 hours later. The administrator of De Coste's estate filed a wrongful death action, alleging medical malpractice and that the misdiagnosis was the proximate cause of death. A jury awarded pecuniary damages and funeral expenses, which the defendants appealed. The appellate court affirmed the verdict, finding rational support for the jury's malpractice finding and rejecting the defendants' argument to reduce the award by Social Security benefits due to the effective date of CPLR 4545 (c).

Medical MalpracticeWrongful DeathProximate CauseCollateral Source RuleCPLR 4545Jury VerdictEmergency Room CareMisdiagnosisArteriosclerosisMyocardial Infarction
References
3
Case No. MISSING
Regular Panel Decision

Tesillo v. Emergency Physician Associates, Inc.

Manuel Tesillo sued Emergency Physician Associates, Inc. (EPA) for medical malpractice, alleging vicarious liability for the negligence of Dr. William C. Shepherd, an emergency physician at Schuyler Hospital. EPA moved for summary judgment, arguing Dr. Shepherd was an independent contractor. The court found material issues of fact regarding the extent of EPA's control over Dr. Shepherd and its managerial obligations to the Emergency Department, which could establish an employer-employee relationship despite contractual terms. Consequently, the court denied EPA's motion for summary judgment, indicating that the determination of Dr. Shepherd's employment status requires further discovery and possibly a trial.

Medical MalpracticeVicarious LiabilityRespondeat SuperiorIndependent ContractorAgency by EstoppelSummary JudgmentPhysician NegligenceEmergency DepartmentControl TestMaterial Issues of Fact
References
18
Case No. ADJ9606608, ADJ9606605
Regular
Nov 27, 2017

Elsa Cordon vs. Renaissance Los Angeles Hotel Airport, Marriott Claims Services

The Appeals Board denied the defendant's Petition for Removal, finding it an extraordinary remedy not warranted here. The defendant failed to demonstrate substantial prejudice or irreparable harm from denial, or that reconsideration would be an inadequate remedy. Specifically, the applicant's primary treating physician was stipulated, and no evidence showed a subsequent establishment of care with a different physician. The defendant retains other available legal remedies.

Petition for RemovalExtraordinary RemedySubstantial PrejudiceIrreparable HarmReconsiderationQualified Medical EvaluatorPrimary Treating PhysicianMedical-Legal EvaluatorAdmissibilityFinal Decision
References
2
Case No. ADJ7897857
Regular
Feb 29, 2012

ALFONSO PONCE DE LEON vs. BARRETT BUSINESS SERVICES, CORVEL INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a trial judge's order allowing applicant treatment outside the defendant's Medical Provider Network (MPN). The WCAB found the judge improperly investigated the facts himself, violating judicial ethics. The evidence gathered by the judge did not definitively prove MPN non-compliance, and the judge failed to contact all listed physicians. Therefore, the case was returned for a new hearing where parties must present their own evidence regarding MPN physician availability.

MPNMedical Provider NetworkWorkers' Compensation Appeals BoardWCJReconsiderationAccess StandardsRegular PhysicianIndustrial InjuryOrthopedic SpecialistExpedited Hearing
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
Jun 12, 2002

Claim of Crisci v. IBM Corp.

This case concerns an employer's appeal from two decisions by the Workers' Compensation Board. The Board initially granted the claimant's request to compel the employer to provide samples of chemicals to the claimant's physician for allergy testing related to dermatitis. The employer had refused, citing company policy and the commercial availability of the chemicals. After some back-and-forth decisions by Workers' Compensation Law Judges, the Board ultimately required the employer to produce samples of six specific chemicals that the physician could not obtain. The employer also appealed the Board's denial of reconsideration. The Appellate Division affirmed both Board decisions, finding no abuse of discretion in ordering the production of samples to ascertain the parties' substantial rights under Workers’ Compensation Law § 118, and no arbitrariness in denying reconsideration.

Workers’ Compensation BoardAppealsChemical SamplesDermatitisAllergy TestingEmployer ObligationsDiscoveryWorkers’ Compensation LawAbuse of DiscretionReconsideration
References
2
Case No. MISSING
Regular Panel Decision

Gallishaw v. Comm'r of Soc. Sec.

Plaintiff William Gallishaw sought judicial review of the Social Security Administration's denial of Social Security Disability Insurance (SSDI) benefits. An Administrative Law Judge (ALJ) had previously found Plaintiff not disabled, a decision affirmed by the Appeals Council. The District Court determined that the ALJ erred by improperly discounting the opinions of Plaintiff's treating and examining physicians (Dr. Nangia, Dr. Thukral, Dr. Fkiaras) and his credibility, while unduly relying on a non-examining physician (Dr. Fuchs). The Court found the ALJ's residual functional capacity (RFC) determination and step-five findings regarding available jobs to be unsupported by substantial evidence. Consequently, the Court granted Plaintiff's motion for judgment on the pleadings, denied the Commissioner's cross-motion, and remanded the case for a determination of benefits, concluding there was persuasive proof of disability.

Disability benefitsSocial Security ActAdministrative Law JudgeResidual Functional CapacityTreating Physician RuleMedical evidenceCredibility assessmentLumbar spine myofascitisChronic synovitisLeft knee derangement
References
31
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. MISSING
Regular Panel Decision

Melson v. Secretary of Health and Human Services

The plaintiff, Mrs. Melson, initiated this action against the Secretary of Health and Human Services, seeking Medicare benefits for her husband, James Melson, following a heart attack and subsequent brain damage. Mr. Melson was hospitalized, and his treating physician, Dr. William C. Baker, determined he no longer required acute inpatient care after December 26, 1984, recommending transfer to a skilled nursing facility (SNF). Despite the availability of SNF beds, Mrs. Melson refused the transfer, preferring to wait for placement at the Veterans Administration Hospital. Medicare benefits for the extended hospital stay were consequently terminated. Both an Administrative Law Judge and the Secretary found that SNF beds were available, making Mr. Melson ineligible for reimbursement for the continued hospital care. The court ultimately granted summary judgment to the defendant, affirming the Secretary's decision based on substantial evidence.

Medicare benefitsSkilled Nursing FacilityAcute inpatient carePatient transfer refusalAdministrative Law JudgeSecretary of Health and Human ServicesJudicial reviewSubstantial evidenceMedicare coverage denialTreating physician's certification
References
4
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