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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 The Workers' Compensation Appeals Board (WCAB) granted the applicant's petition for removal, rescinded the prior decision, and found that the applicant's chiropractic QME panel request was proper while the defendant's orthopedic surgery panel request was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. 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. ADJ10912079
Regular
Aug 21, 2018

BENEDICT LOZADA vs. UNITED TECHNOLOGIES CORPORATION, AIG

This case involves a dispute over the appropriate specialty for a Qualified Medical Evaluator (QME). The applicant requested a chiropractic QME, while the defendant argued it was inappropriate for a hand injury and sought a replacement panel. The WCJ initially found chiropractic to be appropriate, but the Appeals Board granted removal. The Board rescinded the WCJ's order and returned the matter to the trial level, emphasizing that the Medical Director must first rule on the specialty dispute, and any appeal of that decision can then proceed.

Petition for RemovalQualified Medical EvaluatorQME panel specialtychiropractichand injuryMedical Directoradministrative remediesreplacement panelsubstantial evidenceFindings Award and Order
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. 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. ADJ12347424
Regular
Nov 09, 2020

DANIELLE LOOMIS-LYONS vs. COUNTY OF MENDOCINO

This case concerns applicant Danielle Loomis-Lyons' injury to her right knee. The WCJ initially found injury AOE/COE, ordered a replacement QME panel in orthopedic surgery, and deemed the prior pain management QME report inadmissible. The Appeals Board granted reconsideration, affirming the injury finding and the need for a replacement panel, but corrected the panel specialty to pain medicine. The Board rescinded findings regarding the appropriate panel specialty due to lack of notice and opportunity to be heard.

QME panelpain managementorthopedic surgeryAOE/COEinadmissible reportPetition for ReconsiderationremovalLabor Code section 4062.1AD Rule 31.3AD Rule 31.5
References
Case No. ADJ7481566
Regular
May 16, 2012

LINDA LOFTIN vs. COUNTY OF SACRAMENTO

Here's a summary of the case for a lawyer: The Appeals Board denied the defendant's Petition for Removal, upholding the WCJ's order that the applicant retains the right to select the QME specialty. The defendant failed to properly "request" the applicant to obtain a QME panel, which is a prerequisite for the employer to designate the specialty. Furthermore, the Board found extraordinary circumstances prevented discovery from closing at the Mandatory Settlement Conference due to the applicant's lack of representation and understanding. No substantial prejudice to the defendant was demonstrated.

Petition for RemovalWorkers' Compensation Appeals BoardPQMEpanel qualified medical evaluatormandatory settlement conferenceDeclaration of Readiness to Proceeddiscovery closingQME panel specialtyLabor Code section 4062.1(b)Administrative Director Rule 31(a)
References
Case No. ADJ9368263, ADJ9380293
Regular
Sep 15, 2015

JOSE MELCHOR vs. BRUTOCAO VINEYARDS, STAR INSURANCE COMPANY

This case involves a defendant's petition for removal regarding an order for a second Qualified Medical Examiner (QME) panel concerning the applicant's head injury. The Workers' Compensation Appeals Board (WCAB) granted removal to correct a clerical error in the original order. The WCAB affirmed the necessity of a second QME to further develop the medical record on the head injury claim, specifically in the specialty of Psychology-Clinical Neuro Psychology.

Petition for RemovalSecond QME PanelHead InjuryMedical Record DevelopmentWCJ Duty to Develop RecordPQME SpecialtyPSNPsychology-Clinical Neuro PsychologyMandatory Settlement ConferenceLack of Diligence
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
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