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Case Law Database

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

Case No. 03-14-00726-CV
Regular Panel Decision
Oct 30, 2014

Texas San Marcos Treatment Center, L.P. D/B/A San Marcos Treatment Center v. Veronica Payton

Texas San Marcos Treatment Center appeals the trial court's denial of its motion to dismiss Veronica Payton's health care liability claim. Payton alleged negligence after being assaulted by a patient at the treatment center. The appellant argues that the expert report provided by Dr. William H. Reid is deficient, lacking factual support and specificity concerning the standard of care, its breach, and causation, as required by Chapter 74 of the Texas Civil Practices and Remedies Code. The appellant asserts the trial court abused its discretion by finding the report adequate and requests dismissal of the claims.

Medical MalpracticeExpert ReportMotion to DismissAbuse of DiscretionStandard of CareBreach of DutyCausationHealth Care Liability ClaimPsychiatric FacilityEmployee Assault
References
25
Case No. 08-11-00264-CV
Regular Panel Decision
Oct 08, 2014

Maria G. Thompson/Luis Marioni, D.C. v. Jaime Stolar, M.D., Alivio Medical Center, Alivio Treatment Centers, P.A. and Luis Marioni, D.C./Maria G. Thompson

This multi-party appeal originated from a medical and chiropractic malpractice lawsuit filed by Maria G. Thompson against Dr. Jaime Stolar, Dr. Luis Marioni, and Alivio Medical Center and Alivio Treatment Centers, P.A. Thompson alleged negligence resulting in severe knee injuries, including infection and fusions, following injections and treatment. A jury found Dr. Stolar and Dr. Marioni negligent, awarding damages. On appeal, the court reversed the judgment against Dr. Marioni due to insufficient evidence of causation but affirmed the judgment against Dr. Stolar. The court also upheld the denial of Thompson's claims regarding damages and apparent agency against Alivio.

Medical MalpracticeChiropractic MalpracticeKnee InjuryKnee InfectionSpontaneous FusionSurgical FusionNegligenceCausationDamages AssessmentApparent Agency
References
48
Case No. E2014-00302-COA-R3-CV
Regular Panel Decision
Jan 30, 2015

American Heritage Apartments, Inc. v. The Hamilton County Water and Wastewater Treatment Authority, Hamilton County, Tennessee

The plaintiff, American Heritage Apartments, Inc., challenged a monthly flat charge imposed by the Hamilton County Water and Wastewater Treatment Authority (County WWTA) for sewer lateral repairs. The trial court granted summary judgment to the County WWTA, finding no private right of action under the Utility District Law of 1937 (UDL). On appeal, the Court of Appeals reversed the summary judgment, concluding the UDL was inapplicable as the County WWTA was formed under the Tennessee Water and Wastewater Treatment Authority Act (WWTA Act). The appellate court held that the WWTA Act implicitly provides a private right of action for ultra vires and contract claims. The court also affirmed the trial court's alternative ruling that class action certification for affected customers was appropriate.

Water UtilityWastewater TreatmentFlat Rate ChargeClass Action CertificationSummary Judgment ReversalPrivate Right of ActionUltra Vires ClaimGovernmental ImmunityUtility District LawWater and Wastewater Treatment Authority Act
References
48
Case No. ADJ6444600
Regular
Jan 22, 2020

PAUL AGUILAR vs. CITY OF LOS ANGELES

This case involved a dispute over the timeliness of a utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, finding the original WCJ erred by concluding the UR denial was untimely solely due to lack of telephone/fax communication. While the WCAB agreed the UR denial was untimely because it wasn't communicated to the physician as required by law, it found the record incomplete regarding the medical necessity of the treatment. Therefore, the WCAB rescinded the order authorizing treatment and returned the matter to the WCJ for further proceedings to determine medical necessity.

Utilization ReviewRequest for AuthorizationTimelinessCommunicationProspective TreatmentLabor Code Section 4610Administrative Director RuleBodam v. San Bernardino CountyMedical NecessitySubstantial Evidence
References
9
Case No. MISSING
Regular Panel Decision

Brynien v. Governor's Office of Employee Relations

This case is an appeal of a Supreme Court judgment that dismissed petitioner’s applications to review denials of out-of-title work grievances. The petitioner, representing five state employees at the Office of Mental Health (OMH), alleged that employees were improperly assigned duties of a Treatment Team Leader, a higher-grade position, violating their collective bargaining agreement and Civil Service Law § 61 (2). OMH and the Governor’s Office of Employee Relations (GOER) denied the grievances, finding the duties appropriate to the employees' titles. The Appellate Division affirmed the Supreme Court's decision, holding that GOER's determination was rational. The court found that the assigned duties were a reasonable extension of the employees' in-title duties and that the employees did not meet the minimum requirements for the higher-grade Treatment Team Leader position.

Out-of-title workGrievanceCivil Service LawCollective Bargaining AgreementEmployee ClassificationJob DutiesSupervisory DutiesRational Basis ReviewAdministrative LawJudicial Review
References
5
Case No. ADJ10084576
Regular
Oct 06, 2016

ROSE SMITH vs. MEGGITT SENSING SYSTEMS PLC, THE HARTFORD

This case involves Rose Smith's workers' compensation claim where the defendant, Meggit Sensing Systems and its insurer, The Hartford, seek reconsideration of an order allowing Smith to obtain medical treatment outside their Medical Provider Network (MPN). The Appeals Board denied the petition, affirming the WCJ's finding that the defendant's failure to authorize a requested third medical opinion constituted a denial of care. This denial entitled the applicant to seek treatment outside the MPN at the defendant's expense. The defendant argued the request was procedurally deficient and not a request for treatment, but the Board found the failure to respond to the RFA for a third opinion, in context, was a failure to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Request for Authorization (RFA)Petition for ReconsiderationDenial of Medical TreatmentThird Medical OpinionUtilization Review (UR)Primary Treating PhysicianCumulative TraumaLoss of Control
References
3
Case No. ADJ3854591 (VNO 0264467)
Regular
Jan 07, 2020

ANDRZEJ WASOWICZ vs. J.L. FISHER, INC., STATE COMPENSATION INSURANCE FUND

This case concerns the timeliness of a Utilization Review (UR) denial for requested medical treatment. The applicant argued the UR denial was untimely because it was issued on the 15th calendar day, exceeding the 14-day statutory limit under Labor Code section 4610(i)(1). The Appeals Board granted reconsideration, rescinding the prior decision that found the UR timely. The Board determined the UR denial was indeed untimely and remanded the case for a new decision on the medical necessity of the treatment.

Utilization ReviewRequest for Authorizationtimelinesscalendar daysworking daysjurisdictionmedical necessityLabor CodeFindings of FactPetition for Reconsideration
References
3
Case No. ADJ1140810 (OAK 0206395)
Regular
Jul 22, 2009

FRANCISCA KOUMARIANOS vs. HADCO/ZYCON CORPORATION, ALLIANZ INSURANCE COMPANY

This case involves a dispute over attorney's fees awarded for defending an applicant's right to continuing medical treatment. The defendant sought reconsideration, arguing that Labor Code section 4607 only allows fees when an applicant *resists an attempt to terminate* an existing award, not when they challenge an informal denial of specific treatment. The Appeals Board granted reconsideration, citing *Smith v. Workers' Comp. Appeals Bd.*, which clarified that section 4607 does not permit fees for challenging a denial of specific treatment requests. Consequently, the Board rescinded the award of attorney's fees.

Workers' Compensation Appeals BoardReconsiderationAttorney's FeesLabor Code Section 4607Continuing Medical TreatmentAwardPetition to EnforceInformal DenialUtilization ReviewAgreed Medical Examiner
References
2
Case No. ADJ6507434
Regular
Jun 07, 2013

GABINO DANIEL MARTINEZ MONTES vs. MURRAY'S IRON WORKS, COMPWEST INSURANCE COMPANY

This case involves a lien claimant, Frontline Medical Associates, seeking reconsideration of the denial of their lien for medical treatment provided to an applicant, Gabino Daniel Martinez Montes. The lien was denied because the claimant failed to prove membership in the defendant's Medical Provider Network (MPN) or demonstrate the necessity of treatment for denied body parts. The Appeals Board adopted the WCJ's report, which found the lien claimant's evidence inadmissible due to non-disclosure and upheld the denial of reconsideration. The claimant also failed to establish that treatment for denied body parts was medically necessary or that the MPN process was properly bypassed.

Workers' Compensation Appeals BoardPetition for ReconsiderationWorkers' Compensation Administrative Law JudgeFrontline Medical AssociatesLien ClaimantMedical Provider Network (MPN)Pre-Trial Conference StatementAdmissible EvidenceDue ProcessLabor Code Section 4062
References
2
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
5
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