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

Case No. ADJ11861160
Regular
Oct 25, 2019

ADRIANA MARTINEZ vs. AVITUS, AMERICAN ZURICH INSURANCE COMPANY, GALLAGHER BASSETT SERVICES

This case involves a dispute over the selection of Qualified Medical Evaluator (QME) panels for an applicant with claimed injuries to multiple body parts. The Workers' Compensation Appeals Board (WCAB) granted the applicant's petition for removal, rescinded the prior decision, and found that the applicant's chiropractic QME panel request was proper while the defendant's orthopedic surgery panel request was improper. The WCAB determined that chiropractic medicine is the appropriate specialty and struck the orthopedic surgery panel, ordering the parties to proceed with the chiropractic QME. The WCAB clarified that while chiropractors cannot perform surgery or prescribe medication, they are qualified to evaluate injuries within their scope of practice.

QME panel disputeremoval petitionchiropractic specialtyorthopedic surgery specialtyLabor Code 4062.2Medical Directoradministrative law judgeWorkers' Compensation Appeals Boardproper panel selectioninvalid panel request
References
Case No. ADJ12910087
Regular
Dec 28, 2020

ESTHER LEMUS SALDANA vs. TAO TAI HOMES CORPORATION, INSURANCE COMPANY OF THE WEST

This case concerns a dispute over the correct Qualified Medical Evaluator (QME) panel for applicant Esther Lemus Saldana. The defendant sought reconsideration of an order finding the applicant's chiropractic QME panel valid and the defendant's orthopedic panel invalid. The Workers' Compensation Appeals Board denied the petition, upholding the administrative law judge's decision. The Board found the applicant properly requested a new panel after retaining counsel, and despite a service error on the chiropractic panel, the defendant had opportunity to contest the specialty. Therefore, the applicant's chiropractic QME panel remains the correct one for the medical-legal evaluation.

QME PanelChiropractic QMEOrthopedic QMEPetition for ReconsiderationFindings of Fact and OrdersMedical-Legal EvaluationQualified Medical EvaluatorAdministrative Director RuleRomero v. Costco WholesaleLabor Code Section 4062.1
References
Case No. ADJ7578707; ADJ7578722
Regular
Jul 06, 2011

Melissa Voisenat vs. COUNTY OF FRESNO

This case involves a dispute over the specialty of a Qualified Medical Evaluator (QME) for applicant Melissa Voisenat, who claims industrial injuries as a police officer. Defendant County of Fresno seeks to remove an administrative order denying their request for an orthopedic QME panel. The Appeals Board granted removal due to an insufficient record, lacking crucial documents needed to assess compliance with QME panel selection rules. The case is returned to the trial level for further proceedings to allow parties to submit relevant evidence on the QME specialty issue.

Petition for RemovalQualified Medical Evaluator (QME) panelspecialty disputeorthopedic QMEchiropractic QMEAdministrative Director's Medical Unit (MU)EAMSrescinded ordertrial levelindustrial injuries
References
Case No. ADJ11446545
Regular
Dec 03, 2019

ROSA LOPEZ RODRIGUEZ vs. UNIVERSAL BUILDING SERVICES SUPPLY COMPANY, INSURANCE COMPANY OF THE WEST

This case concerns a dispute over the appropriate medical specialty for a Qualified Medical Evaluator (QME) panel. The applicant, Rosa Lopez Rodriguez, initially requested a chiropractic QME panel, which was issued first. The defendant objected, arguing that chiropractic was inappropriate due to the applicant's prior surgery and lack of full recovery. The Medical Unit then invalidated the chiropractic panel and issued an orthopedic surgery panel. The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board held that the party who first requests a QME panel has the right to designate the specialty and that the defendant failed to provide sufficient grounds to invalidate the chiropractic panel. Therefore, the Board amended the findings to sustain the applicant's objection and affirm chiropractic as the appropriate panel specialty.

AD Rule 31.5(a)(10)AD Rule 31.5(a)(9)AD Rule 31.1(b)Labor Code section 4062Labor Code section 4062.2Qualified Medical Evaluator (QME)QME panel specialtyPetition for RemovalPetition for ReconsiderationMedical Unit determination
References
Case No. ADJ9349353
Regular
Aug 27, 2014

JOSE DIEGUEZ vs. KING HARVEST PRODUCE, INC., EMPLOYERS COMPENSATION INSURANCE COMPANY

The Appeals Board granted the employer's Petition for Removal, rescinding the WCJ's order that removed the case from calendar. The Board found that while Labor Code section 4060 does not prohibit an applicant from requesting a QME panel before claim denial, the applicant may have failed to properly request a medical evaluation ten days prior. Furthermore, the Board noted insufficient information regarding the applicant's treating physician's specialty to determine the validity of the chiropractic QME panel. The case was returned to the trial level for further proceedings to resolve these issues.

Petition for RemovalWorkers' Compensation Appeals BoardQualified Medical EvaluatorQME panelLabor Code section 4060Administrative Director Rule 30Medical Unitorthopedic surgeonchiropractic panelmedical evaluation
References
Case No. ADJ11426145
Regular
Aug 16, 2019

MARIA RESENDIZ vs. TAMBRO, INC., INSURANCE CO. OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration, reversing a WCJ's finding and ruling that a chiropractic QME panel, not an orthopedic one, is appropriate for this claim. The Board found the Medical Director's basis for invalidating the chiropractic panel was insufficient, as QMEs cannot provide treatment or opine on disputed treatment issues. The case now requires the parties to utilize the chiropractic QME panel for evaluation. This decision aligns with persuasive reasoning from a prior panel decision regarding specialty disputes.

QME panelchiropractic specialtyorthopedic surgeryspecialty disputeMedical Directorutilization reviewpermanent and stationary statusscope of practicescope of evaluationAD Rule 31.1(b)
References
Case No. ADJ3218661 (OAK 0339889)
Regular
Feb 07, 2011

CHANCE ROLLINS vs. JOHN MARTIN STABLES, INC.; AMERICAN HOME ASSURANCE administered by AIG, CLAIMS SERVICES

The Appeals Board vacated its prior order granting reconsideration and dismissed the defendant's petition for reconsideration, finding the WCJ's ruling was not a final order. However, the Board granted removal, rescinded the WCJ's order, and denied the applicant's request for a neurology consultation under Labor Code §4601(a). The matter was returned to the trial level with instructions to issue an order for a new QME panel in neurology, as Dr. Jamasbi's request for a consultative neurological evaluation constituted good cause for a new panel under 8 Cal. Code Regs. §31.7. Attorney fees for the ex parte communication were upheld.

WCABPetition for ReconsiderationPetition for RemovalLabor Code 4601(a)Labor Code 4062.3QMEAgreed Medical EvaluatorNeurological ConsultMedical DirectorSpecialty Panel
References
Case No. ADJ9178558 ADJ9178559
Regular
Feb 05, 2015

JAVIER RIVERA vs. JACO ENVIRONMENTAL, INC., ZURICH AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a Petition for Removal filed by Zurich American Insurance Company concerning a dispute over Qualified Medical Evaluator (QME) panel selection. The administrative law judge had found both parties requested QME panels timely, but ruled the defendant's request invalid for seeking a different specialty without justification. The Board agreed that removal was not warranted and upheld the decision to assign a QME in pain management, the same specialty as the primary treating physician. The Board also clarified the interpretation of Rule 31.1(b), emphasizing the requirement for supporting documentation when requesting a QME in a different specialty.

Petition for RemovalQualified Medical Evaluator (QME) panelprimary treating physicianspecialtypain managementMedical Directortimely requestjustificationRule 31.1(b)extraordinary remedy
References
Case No. ADJ10887226
Regular
Sep 12, 2018

Alma Ramirez vs. Jaguar Farm Labor Contracting, Inc., Star Insurance Company

The applicant sought reconsideration of a WCJ's decision that a chiropractic QME panel was inappropriate. The Board granted reconsideration, finding the applicant's initial QME panel request was valid due to the employer's failure to provide proper notice of her rights when unrepresented. The Board determined that while chiropractors cannot perform surgery or prescribe medication, this does not inherently make them inappropriate QMEs for disputes concerning diagnosis, prognosis, or work status. Therefore, the Board amended the WCJ's findings to deem the chiropractic QME panel appropriate and ordered the parties to proceed with it.

QME panelchiropractic specialtyorthopedic specialtyMedical Unit determinationAdministrative Director RulesLabor Code 4062treating physician report objectionapplicant representationpermanent disabilitymedical evaluation
References
Case No. ADJ11745461
Regular
Dec 11, 2019

ANTONIO VIRRUETA vs. STATE OF CALIFORNIA, DEPARTMENT OF CORRECTIONS & REHABILITATION, legally uninsured, administered by STATE COMPENSATION INSURANCE FUND

This case concerns a dispute over the appropriate medical specialty for evaluating an applicant's claimed bilateral knee injury. The Workers' Compensation Appeals Board (WCAB) affirmed the Workers' Compensation Judge's (WCJ) decision, holding that the defendant's petition challenging the WCJ's determination on QME panel specialty was subject to the removal standard, not reconsideration. The majority found that while the employment relationship finding was final, the challenge to the panel specialty was an interlocutory issue. They concluded that removal was not warranted as the defendant failed to demonstrate irreparable harm or significant prejudice.

Workers' Compensation Appeals BoardReconsiderationRemovalThreshold IssueInterlocutory IssueQualified Medical Evaluator (QME)QME Panel SpecialtyMedical DirectorOrthopedic SurgeonChiropractor
References
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