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Case Law Database

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

Case No. SAL SJO 252436 (MF); SJO 246192
Regular
Jul 02, 2007

NIHAL HORDAGODA vs. State Compensation Insurance Fund

This case involves an employer's petition for reconsideration of an order authorizing medical treatment and admitting the Qualified Medical Examiner's (QME) reports. The employer argued the QME reports were inadmissible due to an alleged ex parte communication between the applicant and the QME, and that the awarded treatments were improper. The report recommends denying the petition, finding the communication was permissible under LC § 4062.3(h) and that the QME's opinions and awarded treatments for chronic pain were reasonable and not governed by ACOEM guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationQualified Medical EvaluatorLabor Code Section 4062.3Ophthalmological evaluationFunctional capacity evaluationUtilization ReviewACOEM GuidelinesChronic spinal conditionTreating physician
References
0
Case No. ADJ6470549
Regular
Feb 27, 2012

KATHRYN BENSON vs. CITY OF SAN DIEGO

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior decision, allowing a Qualified Medical Examiner's (QME) report into evidence. The original decision excluded the QME report, finding no ratable permanent disability based on the treating physician's opinion. The Appeals Board found the QME report should have been admitted, as there are no explicit time limits for objecting to a treating physician's report or obtaining a QME evaluation for permanent disability. The case is remanded for further proceedings on permanent disability and attorney's fees with the QME report now part of the record.

Workers Compensation Appeals BoardFindings and AwardPetition for ReconsiderationQualified Medical Examiner (QME)Permanent DisabilityFuture Medical TreatmentTreating PhysicianAgreed Medical Examiner (AME)Labor Code Section 4061Strawn v. Golden Eagle Insurance Co.
References
1
Case No. ADJ7899192, ADJ7902366
Regular
Oct 21, 2019

VALERIE DAILEY vs. SCRIPPS HEALTH

The applicant sought reconsideration of a finding that her psychiatric injury was not a compensable consequence of her industrial neck and elbow injuries. The Board found that the prior QME's report, which applicant sought to admit, should have been considered as it was not properly excluded. The Board also noted that the subsequent QME's report did not review the prior QME's findings, potentially rendering it incomplete. Consequently, the Board rescinded the award and returned the matter for further proceedings to admit the prior QME's report and allow the subsequent QME to review it.

Workers Compensation Appeals BoardPsychiatric InjuryCompensable ConsequenceQualified Medical EvaluatorQME ReportAdmissibility of EvidenceMedical EvaluationFurther ProceedingsFindings and AwardReconsideration
References
9
Case No. ADJ2328508 (FRE 0173522)
Regular
Mar 09, 2009

BETTY DORN vs. HEILIG MANUFACTURING, LUMBERMENS MUTUAL CASUALTY COMPANY

This case involves a lien claimant seeking reconsideration of a WCJ's decision to deny most of its claim for chiropractic services. The WCJ limited the award to treatment rendered before the applicant was notified to seek care within the employer's Medical Provider Network (MPN). The lien claimant argued the WCJ improperly relied on a QME's report and should have considered a second QME's report finding a "serious chronic condition" justifying out-of-MPN treatment. The Appeals Board affirmed the WCJ's decision, finding the first QME's report constituted substantial evidence, the request for a second QME was improperly made by the lien claimant after objections to the first report's timeliness were waived, and the lien claimant failed to prove its MPN membership.

Medical Provider Network (MPN)Qualified Medical Evaluator (QME)Serious Chronic ConditionLien ClaimantPetition for ReconsiderationFindings of Fact and AwardLabor Code Section 4616.2Substantial Medical EvidencePanel QMETimeliness of Report
References
3
Case No. ADJ7294109
Regular
Jun 07, 2013

MANSOUREH AZIMZADEH vs. BURG & BROCK, EMPLOYERS COMPENSATION CO.

This case involves an applicant challenging a Workers' Compensation Judge's decision to disregard the Qualified Medical Examiner's (QME) reports due to flawed apportionment analysis and ordering a new QME panel. The Appeals Board granted removal, rescinded the order for a new QME panel, and returned the matter for further development of the record. The Board agreed that the QME's reports lacked substantial medical evidence due to a misunderstanding of apportionment law and that further development with the same QME would be unhelpful. The Board emphasized that new medical-legal reporting would be necessary to properly weigh evidence.

RemovalReconsiderationPetitionPanel Qualified Medical ExaminerPQMESubstantial Medical EvidenceApportionmentFindings and OrderMedical UnitDiscovery
References
9
Case No. ADJ1934243 (FRE 0221043)
Regular
Apr 25, 2011

MARIA RAYOS vs. WALGREENS, ZURICH INSURANCE COMPANY

This case concerns a dispute over a second Qualified Medical Examiner (QME) for an applicant with a work-related knee, back, and hip injury. The defendant sought removal, arguing that allowing a second QME without striking the first QME's reports violated due process and would taint the new evaluation. The Appeals Board granted removal, amended the prior order, and clarified that a new QME is allowed. However, the admissibility of the first QME's reports is deferred to the trial judge, and those reports, unlike diagnostic study results, are not to be provided to the new evaluator.

Petition for RemovalQualified Medical Evaluator (QME)Admissibility of ReportsDue ProcessWorkers' Compensation Appeals Board (WCAB)Administrative Law Judge (WCJ)Industrial InjuryMedical EvaluationsDiscoveryMandatory Settlement Conference (MSC)
References
0
Case No. ADJ4696795 (SJO 0266117)
Regular
Aug 10, 2012

RUDOLPH GARCIA vs. PEPSI BOTTLING GROUP, OLD REPUBLIC INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted removal and rescinded a WCJ's order for a replacement QME panel. The WCAB found that the applicant's attorney erred in sending a request for a supplemental report to an incorrect address for the QME, despite the QME's report listing two addresses. Consequently, the QME did not receive the request and did not issue a supplemental report within 60 days. The WCAB determined that allowing a new panel would cause prejudice and unnecessary cost to the defendant.

Workers' Compensation Appeals BoardRemovalQME panelsupplemental reportcompensable consequenceindustrial injurydelivery driveradministrative law judgePetition for Removalfindings and order
References
4
Case No. ADJ9836001; ADJ9836002 ADJ9836004; ADJ9836542 ADJ10301695
Regular
Sep 28, 2016

BEATRIZ HERNANDEZ vs. RAMCO ENTERPRISES

This case concerns whether the applicant is entitled to a new Qualified Medical Evaluator (QME) for a later reported injury. The defendant argued that under *Navarro v. City of Montebello*, the same QME should evaluate all injuries reported prior to an initial evaluation. However, the Board found *Navarro* distinguishable because the applicant's fifth injury was reported *after* the initial QME evaluation, despite occurring earlier. Therefore, the applicant is entitled to a new PQME for the later reported injury, and the defendant's petition for reconsideration was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderQualified Medical Evaluator (QME)Panel QME (PQME)Navarro v. City of MontebelloLabor CodeMedical-Legal EvaluationsApplication for Adjudication of ClaimDeclaration of Readiness to Proceed
References
1
Case No. ADJ9163491; ADJ9163494
Regular
Jan 09, 2015

RIGOBERTO NORIEGA vs. BEST WESTERN TOWN & COUNTRY

This case concerns an applicant's petition for removal after the WCJ denied his objection to a QME's report. The applicant argued the QME report was untimely and prejudicial because it issued a zero impairment rating. The Appeals Board denied removal, finding the applicant waived his objection by not requesting a replacement QME panel until after receiving the unfavorable report. The Board cited precedent preventing parties from waiting to see if a report is favorable before objecting to its timeliness. Commissioner Zalewski dissented, believing the applicant could object after receipt as long as the objection preceded the replacement panel request.

Petition for RemovalQualified Medical EvaluatorQME reportuntimely filingservice of reportreplacement panelobjectionstatutory timeframesLabor CodeAdministrative Director Rule
References
3
Case No. ADJ7643460
Regular
May 01, 2017

Tracy Lee vs. XCHANGING, GRANITE STATES INSURANCE COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.

This case concerns Defendant's Petition for Removal seeking a new Qualified Medical Evaluator (QME) panel due to a QME's untimely supplemental report. The Appeals Board denied the petition, finding Defendant failed to demonstrate substantial prejudice or irreparable harm. While the QME's report was late, Labor Code Section 4062.5 and Rule 31.5(a)(12) do not mandate replacement for untimely supplemental reports, making the decision discretionary. The WCJ's decision not to order a replacement was reasonable given the QME's extensive involvement and the lack of a mandatory replacement provision.

Workers' Compensation Appeals BoardPetition for RemovalQualified Medical EvaluatorQME panelsupplemental reportuntimelysubstantial prejudiceirreparable harmLabor Code section 4062.5Rule 31.5(a)(12)
References
5
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