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

Case No. MISSING
Regular Panel Decision

Pizzo v. Barnhart

Plaintiff Kathleen Pizzo appealed the Commissioner of the Social Security Administration's final determination denying her disability insurance benefits. The District Court reviewed the ALJ's decision, which had assigned no weight to the treating physician's opinion and significant weight to a consulting physician's report. The court found that the ALJ erred by failing to give appropriate weight to the treating physician's opinion, not adequately developing the administrative record to obtain missing medical notes, and giving undue weight to the consulting physician's report which did not explicitly support the capacity for sedentary work. Consequently, the Commissioner's determination was remanded for further administrative proceedings consistent with the District Court's decision, granting the plaintiff's motion for judgment on the pleadings to the extent of the remand and denying the Commissioner's cross-motion.

Social Security ActDisability Insurance BenefitsAdministrative Law JudgeTreating Physician RuleResidual Functional CapacitySedentary WorkMedical EvidenceRemandSubstantial EvidenceRecord Development
References
23
Case No. ADJ9343248
Regular
Dec 07, 2017

LONNY BUBAK vs. SOLANO COUNTY SHERIFFS DEPARTMENT

This case, concerning a workers' compensation claim by Lonny Bubak against Solano County Sheriff's Department, involves the application of Labor Code section 4062.9, which presumes the correctness of a treating physician's opinion. The Appeals Board denied the defendant's petition for reconsideration, affirming the administrative law judge's finding that the defendant failed to rebut this presumption. This means the defendant did not provide sufficient evidence to disprove the industrial nature of the injury as determined by the treating physician. Therefore, the Appeals Board was bound to accept the treating physician's opinion as correct.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgePresumptionLabor Code Section 4062.9Treating PhysicianBurden of ProofRebuttalIndustrial RelationshipSolano County Sheriffs Department
References
2
Case No. ADJ7207861
Regular
May 06, 2011

STEVE TORDINI vs. JAMES DIEDRICH, PREFERRED EMPLOYERS INS. CO.

The Workers' Compensation Appeals Board granted reconsideration to address the defendant's contention that the WCJ erred in relying on the treating physician's opinion over the PQME's regarding permanent disability and apportionment. The Board found the treating physician's opinion unsubstantiated, as it included unqualified legal conclusions and improperly utilized AMA Guides criteria for apportionment. Consequently, the WCAB rescinded the prior award and returned the case for a new decision, directing the WCJ to base findings on the PQME's report. A dissenting opinion argued that both medical opinions were flawed and recommended further medical development.

PQMEWCJWPIapportionmentLabor Code sections 46634664Almaraz IIAMA GuidesDRE Lumbar Category IVdisc protrusion
References
4
Case No. ADJ3321482 (SAC 0347549)
Regular
May 29, 2012

MARYLOU SMITH vs. COUNTY OF SACRAMENTO

This case involves an applicant seeking workers' compensation for sinus injuries allegedly caused by workplace mold exposure. The defendant, County of Sacramento, sought reconsideration after an administrative law judge found the injury AOE/COE, relying on the applicant's treating physician's opinion. The defendant argued that the agreed medical examiner's opinion should have prevailed and that there was insufficient evidence of a materially greater workplace mold exposure. The majority of the Workers' Compensation Appeals Board denied reconsideration, finding the treating physician's opinion persuasive and sufficiently supported by medical evidence.

Agreed Medical ExaminerCausationMold ExposureFungal SinusitisIndustrial InjuryOccupational NexusMedical ProbabilitySubstantial EvidenceWorkers' Compensation Appeals BoardReconsideration
References
7
Case No. MISSING
Regular Panel Decision
Jan 27, 1998

Grubb v. Chater

Plaintiff Charisse Grubb initiated a challenge under the Social Security Act against the Commissioner's final decision regarding Supplemental Security Income (SSI) benefits. The court initially denied the Commissioner's Rule 12(c) motion, reversing the Administrative Law Judge's (ALJ) decision, finding it lacked substantial evidence, particularly in rejecting the treating physician's opinion about the plaintiff's disability due to Type I diabetes. The case was remanded for benefits calculation. Subsequently, the Commissioner moved for reconsideration under Rule 59(e), revealing that the treating physician's report, central to the court's initial ruling, might have been altered. Citing potential fraud, the court granted the reconsideration motion, overriding its previous reversal. The case is now remanded to the Commissioner for further administrative proceedings, with specific instructions for the ALJ to verify the treating physician's report and potentially involve a medical advisor, all within 30 days. The court retains jurisdiction.

Social Security BenefitsDisability ClaimAdministrative Law JudgeTreating Physician RuleSubstantial Evidence ReviewPro Se RepresentationDiabetes MellitusReconsideration MotionRemandFunctional Capacity
References
22
Case No. ADJ9145724
Regular
Jun 01, 2015

ARZAGA, JOSE vs. CROWN AUTOMOTIVE, INC., AMTRUST NORTH AMERICA

This case involves an applicant seeking to select a pain management specialist outside his employer's Medical Provider Network (MPN). The applicant argued the MPN failed to provide a qualifying specialist within the required 15-mile/30-minute access standard for a primary treating physician. The Board denied the employer's petition for reconsideration, affirming the applicant's right to choose an out-of-network physician and reimbursement for investigative costs. The majority reasoned that the MPN must meet the closer access standard for a primary treating physician, even if that physician is a specialist. A dissenting opinion argued that a specialist, when chosen as a primary treating physician, should fall under the 30-mile/60-minute access standard for specialists.

Medical Provider NetworkMPNprimary treating physicianpain management specialistaccess standardAdministrative Director's Rule 9767.5investigative costsLabor Code section 5703Lescallett v. Wal-MartMartinez v. New French Bakery
References
2
Case No. ANA 0400833
Regular
Aug 18, 2008

WILLIAM GEORGE THOMAS JULIE THOMAS as GUARDIAN AD LITEM and TRUSTEE vs. H&A AUTO, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration of an award finding industrial injury and permanent total disability. The employer challenged the reliance on the applicant's treating physician's medical reports. The Board affirmed the findings, holding that treating physician reports are admissible under Labor Code sections 4060(b) and 4061.5. The employer failed to rebut the treating physician's opinions by properly invoking independent medical evaluation procedures.

Workers Compensation Appeals BoardGuardian Ad LitemTrusteeIndustrial InjuryAuto MechanicNeck InjuryQuadriplegiaTemporary DisabilityPermanent Total DisabilityTreating Physician
References
1
Case No. ADJ6575307
Regular
Jan 21, 2011

NANCY ANDREWS vs. LAW OFFICES OF KENNETH REYNOLDS, OAK RIVER INSURANCE COMPANY

This case involves a workers' compensation applicant who sustained industrial injuries to her back and upper extremities. The defendant sought reconsideration of a prior award, arguing they were not obligated to conduct utilization review or obtain a second opinion regarding a spinal surgery recommendation from Dr. Anderson. The Appeals Board denied the petition, finding the defendant failed to timely object or initiate the required processes after Dr. Anderson recommended the same surgery previously suggested by a second-opinion physician. The Board clarified that utilization review and second opinion obligations extend to any physician's treatment recommendations, not solely the primary treating physician.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryBack InjuryUpper ExtremitiesPrimary Treating PhysicianUtilization Review (UR)Second Opinion ProcessLabor Code Section 4062
References
1
Case No. ADJ8193963
Regular
Mar 28, 2018

JERRY HUNTER vs. STATE OF CALIFORNIA DEPARTMENT OF JUSTICE

This case involves a petition for reconsideration by the defendant, the State Compensation Insurance Fund, concerning a workers' compensation award for Jerry Hunter. The defendant contested the finding that skin cancer was part of the original stipulated injury and challenged the permanent disability rating based on the treating physician's opinion. The Workers' Compensation Appeals Board denied the petition, adopting the Administrative Law Judge's report. The Board affirmed that the skin cancer was correctly considered part of the original cumulative injury and that the treating physician's opinion constituted substantial evidence for the permanent disability rating.

Petition for ReconsiderationSkin CancerCumulative InjuryLabor Code Section 5803Petition to ReopenNew and Further DisabilityGood CauseStipulations with Request for AwardTreating PhysicianPermanent Disability
References
8
Case No. ADJ1337418 (GOL 0091701) ADJ850408 (GOL 0091702)
Regular
May 26, 2009

DAWAYNE MOGENSEN vs. SANTA YNEZ RIVER WATER DISTRICT, ACWA/JOINT POWERS INSURANCE AUTHORITY

This case concerns an applicant's claim for reimbursement for an orthopedic bed following a stipulated award for future medical treatment for industrial neck and back injuries. The applicant's treating physician supported the need for the bed for pain relief and improved sleep. However, the Agreed Medical Evaluator (AME) opined that there was no evidence-based research to support the medical necessity of such a bed, which the majority decision followed. The dissenting opinion argues the AME's opinion was not substantial evidence as it was based on a legally incorrect premise that beds are never compensable, and that the treating physician's recommendation, coupled with the absence of a negative guideline, should have been sufficient.

Workers' Compensation Appeals BoardDawayne MogensenSanta Ynez River Water DistrictACWA/Joint Powers Insurance AuthorityADJ1337418ADJ850408Petition for ReconsiderationFuture Medical TreatmentOrthopedic BedDr. Richard Kahmann
References
10
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