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

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. MISSING
Regular Panel Decision

Kuppersmith v. Dowling

This appeal challenged regulations and procedures of the New York State Department of Social Services (DSS) concerning home care services authorized under the Medicaid program. Petitioners, including Jennie Kuppersmith, sued DSS and the New York City Human Resources Administration, arguing that the regulation (18 NYCRR 505.14 [b] [3] [i] [a] [3]), which prohibits treating physicians from recommending the number of hours of home care, was arbitrary and capricious. They also sought a judicially created presumption in favor of the treating physician’s estimate. The Court affirmed the Appellate Division's decision, concluding that the regulation is rational, reasonable, and consistent with the broad discretion granted to states under the Medicaid Act. The Court rejected the adoption of a "treating physician’s rule" in this context, emphasizing that home care assessments involve a complex mix of expertise beyond purely medical determinations.

Medicaid ProgramHome Care ServicesRegulations ChallengeAdministrative ReviewTreating Physician RuleState DiscretionAppellate ReviewSocial Services LawHealth BenefitsPersonal Care
References
12
Case No. 533089
Regular Panel Decision
Oct 07, 2021

Matter of Barden v. General Physicians PC

Claimant, a patient services representative, sought to amend her workers' compensation claim to include left shoulder aggravation after a work-related injury to her right shoulder. The Workers' Compensation Board disallowed this request, finding that claimant failed to provide sufficient credible medical evidence to establish a causal relationship between her employment and the left shoulder condition. The Appellate Division, Third Department, affirmed the Board's decision. The court noted that the claimant's treating physician opined the left shoulder pathology was largely preexisting and unrelated to the work injury, and other medical opinions either lacked sufficient weight or were based on inaccurate information, providing no basis to disturb the Board's finding.

Workers' CompensationShoulder InjuryCausationMedical EvidencePreexisting ConditionAppellate ReviewBoard DecisionClaim AmendmentPatient Services Representative
References
10
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. ADJ11995067
Regular
Jul 25, 2025

ADELINA PEREZ vs. KYONG AE YUN, CHONG MYON YUN, ZENITH INSURANCE COMPANY

Applicant Adelina Perez sought removal of a May 9, 2022, Findings & Order (F&O) by a workers’ compensation administrative law judge (WCJ), which found Dr. Marcel Ponton's medical-legal report inadmissible and ordered his replacement, arguing Dr. Ponton was a treating physician to whom Labor Code section 4062.3 did not apply. The Workers' Compensation Appeals Board (WCAB) treated the petition as one for reconsideration and found that Dr. Ponton was indeed a treating physician, not a panel-selected medical-legal evaluator, rendering section 4062.3 inapplicable. Consequently, the WCAB rescinded the WCJ's F&O, substituted new findings affirming Dr. Ponton's role as a treating physician, and ordered his continuation as the medical-legal neuropsychological evaluator.

RemovalReconsiderationLabor Code section 4062.3Ex parte communicationMedical-legal evaluatorTreating physicianMPNNeuropsychological assessmentTraumatic brain injuryAdmissibility of evidence
References
17
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. ADJ6948621 ADJ7946738
Regular
Apr 22, 2013

STEFANO MUSETTI vs. GOLDEN GATE DISPOSAL & RECYCLING dba RECOLOGY, permissibly self-insured, administered by CORVEL CORP.

In this workers' compensation case, the employer sought reconsideration of an award ordering a total knee replacement. The applicant's treating physician recommended the surgery, but the employer argued the award was premature as a panel qualified medical evaluator's report was pending and the treating physician's report lacked proper authorization markings. The Appeals Board denied reconsideration, finding the employer had sufficient time to obtain the PQME report and that the treating physician's report constituted substantial medical evidence supporting the surgery. The Board also noted that the employer failed to initiate utilization review despite being aware of the treatment request.

Workers' Compensation Appeals Boardindustrial injuryright kneegarbage collectortotal knee replacementsupplemental reportpanel qualified medical evaluator (PQME)treating physiciansubstantial medical evidencePetition for Reconsideration
References
7
Case No. MISSING
Regular Panel Decision

Sutherland v. Barnhart

Plaintiff Blossom Sutherland challenged the Commissioner of Social Security's denial of disability benefits. The District Court, presided over by Judge Garaufis, reviewed cross-motions for judgment on the pleadings. The court found that the Administrative Law Judge (ALJ) Kenneth Levin failed to adequately consider the entire medical record and did not give proper weight to the treating physician's opinion. Furthermore, the court identified a perceived hostility from the ALJ towards the plaintiff and her treating physician. Consequently, the Commissioner's motion was denied, Sutherland's motion was granted, and the case was remanded for a new ALJ to re-evaluate all medical evidence and properly consider the treating physician's findings.

Disability benefitsSocial Security ActAdministrative Law JudgeTreating physician ruleResidual functional capacityMedical evidenceCredibility assessmentRemandJudicial reviewALJ bias
References
18
Case No. ADJ7925931, ADJ7925917
Regular
Sep 27, 2017

LUISA SEQUEIRA vs. RANDSTAD PLACEMENT PROS, ACE AMERICAN

This case involved an applicant seeking reconsideration of a workers' compensation award, arguing that the declaration of readiness to proceed was defective due to a lack of a primary treating physician's report on permanent disability. The Appeals Board affirmed the original award, finding that Labor Code section 4061(i) does not require all treating physicians to find maximum medical improvement before proceeding to trial. The Board reasoned that the applicant's Panel Qualified Medical Evaluator (PQME) provided substantial medical evidence sufficient to support the permanent disability award, even though primary treating physicians had not yet found MMI. Therefore, the WCJ correctly relied on the PQME's report.

Declaration of readinessPermanent disabilityPrimary treating physicianQualified Medical EvaluatorMaximum medical improvementLabor Code section 4061(i)Substantial medical evidenceFindings Award and OrderReconsiderationIndustrial injury
References
3
Case No. MISSING
Regular Panel Decision
Jun 24, 1991

Marziliano v. Sullivan

Plaintiff Josephine Marziliano sought review of a determination by the Secretary of the United States Department of Health and Human Services that denied her request to waive recovery of an overpayment of Supplemental Security Income benefits. The Magistrate Judge recommended that the matter be referred to the Secretary for a new hearing, emphasizing the importance of giving required deference to the treating physician’s opinions in such overpayment waiver proceedings. The defendant objected to the application of the treating physician rule in these proceedings. District Judge Goettel adopted the Magistrate Judge's report and recommendation, affirming that the treating physician rule applies with full force when determining whether a claimant was 'at fault' in accepting an overpayment and ordered the case remanded for a new hearing.

Supplemental Security Income (SSI)Overpayment WaiverTreating Physician RuleMental ImpairmentAdministrative Law Judge (ALJ)RemandSocial Security Administration (SSA)Disability BenefitsResource LimitationsReporting Requirements
References
8
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