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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

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
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. MISSING
Regular Panel Decision

ABC Medical Management, Inc. v. GEICO General Insurance

The case addresses whether a plaintiff-assignee medical equipment supplier can recover no-fault first-party benefits when a chiropractor, rather than a physician, issued the prescription. Defendant GEICO General Insurance Company moved for summary judgment, arguing that Education Law § 6551 prohibits chiropractors from prescribing such items. The court denied GEICO's motion, ruling that chiropractors are permitted to prescribe TENS units, thermophore devices, and similar medical supplies, as these do not constitute 'drugs or medicines' under the Education Law. Furthermore, the court found that GEICO failed to properly present its medical necessity defense and that the contested issues should be determined by a trier of fact.

No-Fault BenefitsChiropractic PrescriptionMedical EquipmentEducation Law § 6551Summary JudgmentMedical NecessityTENS UnitThermophoreCervical CollarLumbar Support
References
29
Case No. MON 313416 MON 313417
Regular
Jul 30, 2008

TERESA L. GUZMAN vs. THE BOEING COMPANY

The Workers' Compensation Appeals Board granted reconsideration and rescinded a previous award regarding a chiropractor's lien claim. The Board found that the administrative law judge erred in determining the reasonableness of the chiropractor's $7,500 medical-legal report fee, which was reduced to $3,000. The case was returned to the trial level for further proceedings and a new decision, with specific findings of fact and an express order or award required.

Medical-legal evaluationLien claimExcessive billingFee scheduleLabor Code section 5307.6ReconsiderationFindings and AwardIndustrial injuryMedical-legal expensesReasonable and necessary
References
1
Case No. ADJ7692623
Regular
Sep 07, 2012

ANTHONY FAGONE vs. CITY OF FRESNO

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The Board upheld the finding that the applicant sustained industrial injuries and that the defendant lost control of medical treatment due to failing to process the applicant's pre-designated physician form. The defendant's argument that the applicant could not pre-designate a chiropractor was rejected, as the employer's inaction estopped them from benefiting from their processing failure. Therefore, the applicant is entitled to treatment by his chosen chiropractor during the period of the employer's processing error.

Workers' Compensation Appeals BoardIndustrial InjuryNeck InjuryChest Wall InjuryMedical Provider Network (MPN)Pre-designation of Treating PhysicianChiropractorLabor CodeEstoppelFindings and Award
References
1
Case No. ADJ7348056, ADJ8808882
Regular
Feb 17, 2015

DIANA AGUAYO vs. GROSSMONT UNION HIGH SCHOOL DISTRICT, CORVEL CORPORATION

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The defendant argued that the applicant's chiropractor's reports were inadmissible and not the sole basis for an award, and that cervical spine injury lacked substantial medical evidence. The Board found the chiropractor's reports were properly admitted, even if obtained after the statutory visit limit, as the applicant paid for them. Furthermore, evidence from other physicians supported the cervical spine injury finding, meeting the substantial evidence standard. Therefore, the Board upheld the original award.

Workers Compensation Appeals BoardPetition for ReconsiderationJoint Findings Award and OrderPermanent Partial DisabilityApportionmentTreating ChiropractorLabor Code Section 4600(c)Labor Code Section 4064.5(c)(1)Admissibility of EvidenceLabor Code Section 4605
References
1
Case No. ADJ126476
Regular
Aug 16, 2010

DELFINA MORENO vs. HARBORSIDE INNS OF SANTA BARBARA, INSURANCE COMPANY OF THE WEST, EXPLORER INSURANCE

The Workers' Compensation Appeals Board denied reconsideration of a chiropractor's lien claim for $9,671.52. The Board found the lien claimant waived any challenge to the existence of the employer's Medical Provider Network (MPN) by failing to raise it before trial. Furthermore, the lien claimant failed to meet his burden of proving he was part of the defendant's MPN when providing services. Despite repeated notices that he was not authorized and not in the MPN, the chiropractor continued treatment, and the defendant is not obligated to pay for services procured outside the MPN.

Medical Provider NetworkMPNlien claimantreconsiderationwaived issueburden of proofindustrial injurycompromise and releaseworkers' compensationadministrative law judge
References
12
Case No. MISSING
Regular Panel Decision
Aug 27, 1997

Claim of Korczyk v. City of Albany

Claimant, a mechanic's helper, sustained a work-related back injury in May 1992. The employer paid workers' compensation benefits until May 1993, then sought to suspend payments alleging claimant's voluntary withdrawal from the labor market. The Workers’ Compensation Board subsequently ruled that claimant's refusal of a light-duty work offer in April 1993 constituted such a withdrawal. Claimant appealed, asserting her chiropractor advised against the work, but the chiropractor's testimony contradicted this claim. The Board's finding of voluntary withdrawal was ultimately affirmed based on substantial evidence.

Workers' CompensationVoluntary withdrawal from labor marketLight-duty assignment refusalChiropractor testimonyCredibility issueSubstantial evidenceBoard decision affirmedBack injuryMechanic's helperReduced earnings
References
7
Case No. MISSING
Regular Panel Decision

Claim of Paddock v. Barclay Knitwear Co.

Howard T. Mowers, a chiropractor, appealed a Workers' Compensation Board decision that denied him further medical payments for services provided. Mowers had previously been awarded additional fees, interest, and penalties by a Workers' Compensation Law Judge, based on the insurance carrier's failure to timely object to his bills. The Board rescinded this award, stating Mowers failed to provide sufficient evidence to justify bills exceeding the established fee schedule. The Appellate Division affirmed the Board's decision, holding that the Board retains its authority to oversee chiropractor billing practices and demand justification, even if a carrier waives its right to object.

Workers' CompensationChiropractic FeesFee ScheduleBilling PracticesTimely ObjectionsWaiverBoard AuthorityMedical TreatmentAppellate Division
References
0
Case No. MISSING
Regular Panel Decision

Claim of Stewart v. P & C Food Markets, Inc.

A claimant, who worked as a cashier, developed persistent leg and hip pain diagnosed as a slipped femoral epiphysis requiring surgery in August 1990. Following surgery, he allegedly developed chronic low back pain and filed for workers' compensation benefits. While surgeons opined that neither the slipped hip nor back pain were work-related, chiropractors testified otherwise. The Workers’ Compensation Board ruled in the claimant's favor, finding a causal relationship for both conditions. The employer and its insurer appealed, raising an issue about the chiropractors' qualifications which was deemed not properly preserved. The Appellate Division affirmed the Board's decision, finding substantial evidence for the causal relationship.

Workers' CompensationCausal RelationshipSlipped Femoral EpiphysisBack PainChiropractor TestimonyMedical Expert QualificationSubstantial EvidenceAppellate ReviewEmployer AppealInsurance Carrier
References
4
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