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Case Law Database

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

Case No. MISSING
Regular Panel Decision

Diaz v. Secretary of the Department of Health & Human Services

The plaintiff sought judicial review of a final determination by the Secretary of Health and Human Services, which had denied her claim for disability insurance benefits under the Social Security Act. The District Court addressed the plaintiff's arguments that the Administrative Law Judge (ALJ) failed to properly weigh the opinion of her treating chiropractor, Dr. Sadigh, and that the determination lacked substantial supporting evidence. Citing circuit precedent, the court affirmed that a treating chiropractor's opinion on disability diagnosis and impairment should be binding unless contradicted by substantial evidence. After a thorough review of various medical reports, the court concluded that the evidence presented did not substantially contradict Dr. Sadigh's consistent findings of the plaintiff's total disability. Consequently, the court granted the plaintiff's motion for judgment on the pleadings and remanded the case for the calculation of benefits.

Disability Insurance BenefitsSocial Security ActTreating Physician RuleChiropractor Opinion WeightSubstantial Evidence ReviewFederal Rule of Civil Procedure 12(c)Administrative Law Judge (ALJ)Medical ReportsLumbar RadiculopathyCervical Disc Syndrome
References
7
Case No. MISSING
Regular Panel Decision

Santiago v. Bowen

The plaintiff, a 58-year-old man with an 8th-grade education and a history of physical labor, sought Supplemental Security Income (SSI) disability benefits after injuring his lumbar spine in 1986. His treating chiropractor, Dr. Serafín Izquierdo, opined he was totally disabled due to acute low back derangement, a possible herniated disc, and other related conditions. A consultative physician, Dr. Shu-mofsky, found minimal x-ray findings but noted severe pain during a straight leg raising test. The ALJ initially found the plaintiff capable of light work, a decision upheld by the Appeals Council. The District Court reversed this decision, ruling that the treating chiropractor's opinion on disability, within their field of expertise, should be given binding effect, especially when supported by evidence and not substantially contradicted. The court found Dr. Izquierdo's opinion uncontradicted and remanded the case for the calculation and disbursement of benefits.

Disability benefitsSupplemental Security Income (SSI)Chiropractor's opinionTreating physician ruleMedical evidenceLumbar spine injuryResidual functional capacityAdministrative Law JudgeAppeals CouncilReversal and remand
References
8
Case No. ADJ9627339, ADJ9627342
Regular
Mar 26, 2018

Esteban Escobar vs. PRN AMBULANCE, INSURANCE COMPANY OF THE WEST

This case concerns whether the defendant's Medical Provider Network (MPN) met access standards for a chiropractor as a primary treating physician. The Appeals Board granted the applicant's petition for removal, overturning the WCJ's decision. The Board found the MPN must provide three chiropractors within 30 minutes or 15 miles of the applicant's residence or workplace. Since the MPN did not meet this closer standard, the applicant is authorized to select a chiropractor outside the MPN.

MPNchiropractorsprimary treating physicianaccess standardsreconsiderationremovalWCJAdministrative Director's Ruleexpedited hearingstipulate
References
4
Case No. ADJ9884969
Regular
Aug 07, 2015

FERNANDO RUIZ-LUCERO vs. GCA SERVICES GROUP, INC.; ACE AMERICAN INSURANCE COMPANY, administered by ESIS FREMONT

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, upholding the finding that the applicant could treat outside the defendant's Medical Provider Network (MPN). The MPN failed to meet access standards by not having three primary treating chiropractors within a 15-mile or 30-minute radius of the applicant's residence. This failure constitutes good cause for the applicant to seek treatment outside the MPN, as required by regulations ensuring timely access to appropriate medical care. The Board agreed with the WCJ's reasoning that the defendant's inadequate MPN access justified the applicant's out-of-network treatment.

MPNAccess StandardsPrimary Treating PhysicianMedical Provider NetworkChiropractorAdministrative Director RuleWCJReconsiderationLabor CodeSpecialty
References
4
Case No. MISSING
Regular Panel Decision

Claim of Feliciano v. Copstat Security Corp.

Claimant, a security dispatcher, sought workers' compensation benefits following a motor vehicle accident, alleging work-related neck and back injuries. The Workers' Compensation Law Judge (WCLJ) disallowed the claim, citing a lack of medical evidence demonstrating disability, and precluded the testimony and medical reports of the treating neurologist, Sherwood Jacobson, and treating chiropractor, Bonnie Glassman, due to their repeated failure to appear for scheduled hearings. The Workers’ Compensation Board upheld this decision. The appellate court affirmed, finding no error in the Board's decision to preclude the medical professionals' testimony and reports given their non-appearances despite due notice and subpoenas, in accordance with 12 NYCRR 300.10 [c].

Workers' CompensationMedical TestimonyPreclusion of EvidenceTreating PhysicianChiropractorNeurologistDisability ClaimAppellate ReviewProcedural RulesNon-Appearance
References
4
Case No. VNO 0462079
Regular
Jul 11, 2007

JONAS MORENO vs. FILTERCOR, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's untimely petition for reconsideration of an approved compromise and release settlement. Despite the untimeliness, the WCAB remanded the matter to the administrative law judge to treat the petition as a request to reopen the case. This allows for further proceedings on the merits of the lien claimant's claim.

Petition for ReconsiderationPetition to ReopenUntimely FilingService by MailDefective ServiceLabor Code Sections 5803Labor Code Sections 5804Compromise and ReleaseLien ClaimantWorkers' Compensation Appeals Board
References
1
Case No. ADJ1377755 (FRE 0242857) ADJ1891281 (FRE 0242858)
Regular
Oct 11, 2010

RUDOLPH GUTIERREZ vs. DERREL'S MINI STORAGE, BERKSHIRE HATHAWAY HOMESTATE, CO.

The Workers' Compensation Appeals Board dismissed Applicant Gutierrez's petition for reconsideration of a January 19, 2010 stipulation and order. Applicant contended the settlement was not secured with his consent. The Board treated his petition as a motion to set aside the award. The case is returned to the trial level for the judge to consider the set-aside petition and conduct further proceedings.

Workers' Compensation Appeals BoardReconsiderationPetition to Set AsideStipulation and OrderPro SeAdministrative Law JudgeDismissedReturned to Trial LevelAwardConsent
References
0
Case No. ADJ9834159 (MF) ADJ9834161
Regular
Jul 30, 2018

ESAU HERNANDEZ vs. D.L. BONE AND SONS PAINTING, ICW GROUP/EXPLORER INSURANCE COMPANY, STATE COMPENSATION INSURANCE FUND

This case concerns a defendant's attempt to obtain a replacement Qualified Medical Evaluator (QME) panel after the applicant initially objected to the timeliness of the original QME's report. The Appeals Board treated the defendant's petition as one for removal and denied it. The Board found that the defendant, having failed to timely object to the QME's report itself, could not rely on the applicant's subsequent objection to request a new panel. The Board concluded that the defendant's failure to act promptly meant they were not entitled to a replacement QME panel, and no substantial prejudice or irreparable harm warranting removal was demonstrated.

Workers' Compensation Appeals BoardReconsiderationRemovalQualified Medical EvaluatorQME panelAdministrative Director RuleTimeliness objectionReplacement QME panelLabor CodeFindings of Fact
References
1
Case No. ADJ8829857 ADJ8829856
Regular
Apr 18, 2016

DULCE ESPINOZA vs. JENCO PRODUCTIONS, INC., FIRST NATIONAL INSURANCE COMPANY OF AMERICA

The Workers' Compensation Appeals Board dismissed the defendant's petition for reconsideration because the appealed finding, deferring development of the record on psychiatric injury, was not a final order. The Board then treated the petition as one for removal, granted it, and rescinded the deferral. Ultimately, the Board found that the applicant failed to prove industrial injury to her psyche, citing a lack of objective evidence and inconsistencies in her reporting, as well as a conflicted medical opinion.

WORKERS' COMPENSATION APPEALS BOARDDULCE ESPINOZAJENCO PRODUCTIONSINC.FIRST NATIONAL INSURANCE COMPANY OF AMERICAADJ8829857ADJ8829856Petition for ReconsiderationPetition for RemovalDecision After Removal
References
10
Case No. MISSING
Regular Panel Decision

Stephens v. Cooper

Plaintiffs, a group of chiropractors, medical doctors, and PTS Thermal Imaging, brought an action against the Superintendent of the New York State Department of Insurance. They challenged a regulation establishing a fee schedule for thermography services under New York's no-fault automobile insurance law, alleging violations of the New York Administrative Procedure Act, due process, equal protection, and the Sherman Act. The Superintendent moved to dismiss the Sherman Act claims and for abstention. The court granted the motion to dismiss, abstaining under the Burford doctrine, finding that New York has a comprehensive insurance regulatory scheme and that the case involves a challenge to the Superintendent's implementation of state law, thus warranting federal court abstention.

Abstention DoctrineBurford AbstentionNo-Fault InsuranceFee Schedule RegulationThermography ServicesInsurance LawFederal Court JurisdictionSherman Antitrust ActDue Process ChallengeEqual Protection Challenge
References
9
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