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Case Law Database

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

Case No. TI11710087
Regular
Nov 20, 2018

Theodore Davis vs. CITY OF MODESTO, YORK INSURANCE SERVICES, GROUP, INC.

This case involves applicant Theodore Davis's prostate cancer claim against the City of Modesto. The core dispute centers on the admissibility and review of a medical report by Dr. Besses. The Appeals Board initially denied review of Dr. Besses' report but, following a court of appeal remittitur, is now granting removal. The matter is returned to the trial level for the WCJ to re-evaluate the admissibility of Dr. Besses' report under Labor Code section 4605 and related rules, and whether it can be provided to the QME. This decision clarifies that while QME evaluations are required for compensability disputes, privately obtained medical reports may still be admissible.

RemittiturPetition for RemovalPetition for ReconsiderationQualified Medical EvaluatorLabor Code Section 4060Labor Code Section 4605Admissibility of Medical ReportsEx Parte CommunicationCumulative TraumaSpecific Injury
References
9
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. 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. ADJ6754074
Regular
Dec 14, 2010

BARBARA JACOME vs. DURHAM SCHOOL SERVICES, OLD REPUBLIC, SEDGWICK CMS

This case involves an applicant's petition for removal challenging a WCJ's order granting the defendant's request for a replacement Qualified Medical Evaluator (QME). The applicant argued the defendant's objection to the QME's report timeliness was conditional and not properly served, thereby waiving their right to a replacement. The Appeals Board granted removal, finding the defendant's objection, made after receiving the report, was insufficient and void. Therefore, the defendant was not entitled to a replacement panel, and the QME's report was deemed admissible.

Petition for RemovalQualified Medical EvaluatorReplacement PanelTimeliness ObjectionConditional ObjectionLabor Code SectionsCalifornia Code of RegulationsMedical DirectorAdministrative DirectorComprehensive Medical-Legal Evaluation
References
0
Case No. ADJ6632043 ADJ6580510
Regular
Jul 01, 2010

DARRYL PILLORS vs. PENSKE TRUCK LEASING CO., OLD REPUBLIC INSURANCE COMPANY

The Appeals Board granted removal, rescinded the WCJ's order, and returned the case to the trial level. This was because the WCJ improperly ordered a second QME panel before adjudicating the admissibility of the first panel's report. Defendant argued prejudice from incurring costs for two evaluations, and the Appeals Board agreed this raised irreparable harm. The WCJ must now determine the admissibility of the initial QME report and any subsequent orthopedic evaluations.

RemovalQualified Medical EvaluatorQME panelAdmissibility of reportTimeliness of objectionPetition for RemovalWCJ decisionMedical UnitIndustrial injuryBack injury
References
1
Case No. ADJ7555685
Regular
Apr 02, 2012

RAHUL ROY vs. GALLO SALES COMPANY INC.

This case concerns the admissibility of a Qualified Medical Evaluator's (QME) reports due to alleged violations of Labor Code section 4062.3 and AD Rule 35. The defendant, Gallo Sales Company, Inc., sent medical information and sub rosa films to the QME without timely providing copies or notice of objection rights to the applicant, Rahul Roy. The Workers' Compensation Appeals Board affirmed the finding that the QME's reports were inadmissible due to these ex parte communications, disqualifying the QME. The applicant is entitled to a new QME panel.

PQMEAD Rule 35Ex parte communicationLabor Code section 4062.3Medical informationNon-medical recordsSupplemental reportSub rosa filmsQME panelAdmissibility
References
12
Case No. AD.J9467074, AD.J9468922
Regular
Oct 03, 2016

THEODORE DAVIS vs. CITY OF MODESTO, YORK INSURANCE SERVICES GROUP, INC.

This case concerns the admissibility of a medical report by Dr. Besses and whether it can be reviewed by a panel qualified medical examiner (QME). The applicant sought reconsideration and removal of a prior decision that found the report inadmissible due to improper procedure under Labor Code section 4060. The Appeals Board treated the applicant's filing as a Petition for Reconsideration, finding that the admissibility of the report presented a critical issue in the case. Ultimately, the Board denied the Petition for Reconsideration and dismissed the Petition for Removal, upholding the prior decision.

Petition for ReconsiderationPetition for RemovalLabor Code section 4060Batten v. Workers' Comp. Appeals Bd.Qualified Medical Examiner (QME)Panel QMEAdmissibility of Medical ReportInterim OrdersFinal OrderThreshold Issues
References
7
Case No. ADJ14263093
Regular
Apr 12, 2023

CECILIA OJEDA vs. AMY'S KITCHEN, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

Here's a summary of the case for a lawyer: The applicant claimed cumulative injury to her neck, bilateral wrists, shoulders, and upper extremities, which the employer initially denied for all body parts except the neck. The WCJ found injury to all claimed body parts, relying on treating physicians' reports, and found the QME's reports unsubstantial due to inconsistencies and admissions of uncertainty during deposition. The defendant sought reconsideration, arguing the QME's opinion was substantial evidence regarding injured body parts and permanent disability. The Appeals Board denied reconsideration, adopting the WCJ's reasoning that the QME's testimony was too speculative and contradictory to constitute substantial evidence for the disputed body parts.

AOE/COEPetition for ReconsiderationFindings and AwardOrthopedic Qualified Medical Examiner (QME)Substantial EvidenceCumulative InjuryBilateral WristsBilateral ShouldersBilateral Upper ExtremitiesCervical Radiculopathy
References
3
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. ADJ8149685
Regular
Oct 03, 2016

Mike Amaireh vs. ALDEX TRANSPORT, INC., PROTECTIVE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration of a WCJ's decision that excluded Dr. Greils' reports as inadmissible due to improper QME selection. The Board found that Dr. Greils was properly selected as a psychiatric QME, emphasizing substance over form in procedural matters. Therefore, the WCJ's findings were rescinded, and Dr. Greils' reports were deemed admissible.

QME selectionadmissibility of reportspetition for reconsiderationsubstance over formpsychiatric claimorthopedic injuryagreed medical evaluatorqualified medical evaluatorWCJ findingspetition to rescind
References
9
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