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

Case No. ADJ9683216
Regular
Sep 30, 2016

DUNIA DE LA CRUZ vs. SOOD ENTERPRISES, INC. dba JACK IN THE BOX, SECURITY NATIONAL INSURANCE COMPANY ADMINISTERED BY AMTRUST NORTH AMERICA

The Workers' Compensation Appeals Board (WCAB) denied defendant's petition for reconsideration and dismissed its petition for removal. The WCAB found that an additional Qualified Medical Examiner (QME) panel in rheumatology was appropriate to further develop the medical record on causation, as recommended by the initial orthopedic QME. Defendant argued the WCJ erred by ordering this without first determining applicant's credibility and AOE/COE, but the Board deemed the need for a rheumatological evaluation a critical issue justifying reconsideration. Therefore, the WCAB upheld the WCJ's order for an additional QME panel.

QME panelrheumatologyAOE/COEcredibilitymedical causationdepositionsupplemental evaluationgood causethreshold issuesreconsideration
References
Case No. VNO 0386181
Regular
Apr 05, 2007

SUSAN PASCALE vs. BLUE CROSS/WELLPOINT DENTAL, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION on behalf of FREMONT INDEMNITY

This case concerns applicant Susan Pascale's claim for workers' compensation benefits due to industrial injuries resulting in fibromyalgia and other conditions. The WCJ awarded 80% permanent disability, apportioning 20% to applicant's pre-existing personality traits based on medical opinions. The Appeals Board affirmed this decision, finding the apportionment was supported by substantial medical evidence of causation, as allowed by recent statutory changes.

Workers' Compensation Appeals BoardSusan PascaleBlue Cross/Wellpoint DentalCalifornia Insurance Guarantee AssociationFremont IndemnityVNO 0386181Opinion and Decision After ReconsiderationApplicantDefendantWCJ
References
Case No. ADJ8491619 ADJ9586677
Regular
May 17, 2019

Edward GAA vs. Intercare Holdings Insurance, The Hartford

The Workers' Compensation Appeals Board granted applicant's petition for removal, overturning a prior order that denied a rheumatological evaluation. While dismissing the petition for reconsideration, the Board found good cause for an additional QME panel in rheumatology, acknowledging the orthopedic QME's limited expertise in this specialty. The applicant must still attend a re-evaluation with the orthopedic QME, who must review a job analysis.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalQualified Medical Evaluator (QME)Rheumatological evaluationOrthopedic QMECumulative traumaIndustrial injuryMedical-legal issuesBias
References
Case No. ADJ1 0127152
Regular
Jun 26, 2017

ROBERT CARLOS vs. GENESIS LOGISTICS INC., NEW HAMPSHIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) denied applicant Robert Carlos's Petition for Removal. Carlos sought to rescind an order that took his case off calendar pending a supplemental report from an orthopedic QME and requested a rheumatology QME panel or a hearing. The WCAB adopted the Workers' Compensation Judge's report, finding that Carlos failed to demonstrate substantial prejudice or irreparable harm required for removal. Consequently, the WCAB affirmed the order and denied the petition.

WORKERS' COMPENSATION APPEALS BOARDPetition for RemovalWCJQualified Medical EvaluatorQME panelorthopedicrheumatologytaken off calendarsupplemental reportdiscretionary power
References
Case No. ADJ2580958 (MON 0351589)
Regular
Feb 16, 2016

ESTRELLA LOPEZ vs. OUTRIGGER LOGGING SERVICES, dba THE CRACIELA BURBANK, WAUSAU INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration of an award of 100% permanent total disability. The Board found that the medical opinions supporting the award were not substantial evidence because they failed to consider the latest orthopedic report which identified some complaints as non-industrial. Furthermore, the vocational expert's report was deficient as it relied on inadmissible rheumatology reports and did not account for the orthopedic findings. Consequently, the award was rescinded, and the case was returned to the trial level for further proceedings to develop the record.

Workers Compensation Appeals BoardPetition for ReconsiderationDecision After ReconsiderationFindings and AwardPetition to ReopenNew and Further DisabilityPermanent Total DisabilityIndustrial InjuryPsycheBack
References
Case No. ADJ10633327
Regular
Jul 31, 2019

JUANITA PONCE DE LEON vs. SOUTHERN CALIFORNIA EDISON

The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior Findings and Orders. The Board found that the applicant's physician's report was improperly excluded as evidence, as it did not rebut a prior QME's opinion but addressed a separate, unaddressed medical condition. Consequently, the Board overruled the objection to this report and the primary treating physician's subsequent report adopting its findings. The Board also found good cause for an additional Qualified Medical Evaluator panel in rheumatology to address the applicant's disputed fibromyalgia claim.

AOE/COEfibromyalgiaQME panelrheumatologyDr. SalickDr. AunadmissibilityLabor Codemedical evaluationreconsideration
References
Case No. ADJ11645837
Regular
Dec 07, 2020

NAVIN RAZO vs. STATE OF CALIFORNIA, DEPARTMENT OF INSURANCE, Legally Uninsured, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration of a decision finding the applicant temporarily totally disabled. The defendant argued that the medical reports relied upon were not substantial evidence. The Board adopted the judge's report, which found the opinions of Drs. Hannani and Levine to be substantial evidence based on reasonable medical probability. These doctors were new treating physicians who assessed the applicant as temporarily totally disabled and in need of further treatment.

Petition for ReconsiderationDeniedSubstantial Medical EvidenceReasonable Medical ProbabilityTemporary Total DisabilityExpedited HearingQMEPrimary Treating PhysicianFibromyalgiaEczema
References
Case No. ADJ2073428 (VNO 0465400) ADJ1610465 (VNO 0540972) ADJ3247765 (VNO 00384869)
Regular
Apr 04, 2011

JAY ZAVERI vs. STATE COMPENSATION INSURANCE FUND; Legally Uninsured

The applicant sought reconsideration of a workers' compensation award, arguing for a 100% permanent disability rating and challenging the permanent disability start date used for attorney fee commutation. The Appeals Board denied the petition, finding insufficient evidence to establish total permanent disability, as the applicant was currently employed and medical opinions did not definitively support such a rating. The Board also ruled that the applicant waived arguments regarding the rating of specific injuries by failing to properly object, and that even if considered, separate ratings for back, knee, and plantar fasciitis conditions would not result in a higher award due to fibromyalgia being the primary cause and rating higher. Finally, the Board clarified that the July 2, 2000 date was only relevant to the attorney fee commutation calculation and not to the determination of permanent disability indemnity payments.

WCABPetition for ReconsiderationJoint Findings and AwardWorkers' Compensation Judge (WCJ)Industrial InjuryBack InjuryHip InjuryBilateral Knee InjuryBilateral Foot InjuryBilateral Plantar Fasciitis
References
Case No. ADJ916227 (VNO 0474238)
Regular
Jun 11, 2009

JOANNA LEE FRADY vs. MAGIC FORD AUTO NATIONS, ZURICH, Adjusted By UNIVERSAL UNDERWRITERS GROUP

This case concerns an applicant's entitlement to further medical treatment for an admitted industrial injury to her back, neck, and right hand. The defendant sought reconsideration of a prior award finding the applicant entitled to treatment recommended by her treating physician, Dr. Caro, specifically a brain MRI, muscle and skin biopsies, and a neurological evaluation. The Appeals Board granted reconsideration, finding Dr. Caro's report conclusory and not substantial evidence, and instead amended the award to grant treatment as recommended by panel Qualified Medical Examiner Dr. Yousefi. Dr. Yousefi's reports, based on thorough examination and testing, concluded that invasive procedures like muscle and skin biopsies were not indicated and recommended an independent neurological evaluation for further clarification.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardAdministrative Law JudgeFuture Medical TreatmentIndustrial InjuryPermanent DisabilityTreating PhysicianQualified Medical ExaminerSubstantial Evidence
References
Case No. ADJ4145263 (VEN 0120366) ADJ2903274 (OXN 0124883)
Regular
Jul 16, 2012

SHARON ANGELL vs. MARYMOUNT ACADEMY, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION (CIGA) by its servicing agent SEDGWICK CMS, for FREMONT INDEMNITY in liquidation

The Workers' Compensation Appeals Board granted reconsideration and rescinded the original decision, remanding the case for further proceedings. The primary issue is whether applicant's fibromyalgia should be rated separately from her orthopedic injuries. The Board found no clear evidence in the record supporting the WCJ's conclusion that fibromyalgia was solely a consequence of the orthopedic conditions. On remand, the WCJ must determine the causation of the fibromyalgia and whether it warrants separate rating. The Board deferred ruling on other issues raised by the parties.

Workers' Compensation Appeals BoardCIGAFremont Indemnityliquidationreconsiderationfibromyalgiaorthopedic injuryapportionmentvocational evidencetemporary disability
References
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