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

Case No. ADJ7781676
Regular
Nov 01, 2017

TERESA HERNANDEZ vs. T K & J, INC., dba LAS PALMAS RESTAURANT, PREFERRED EMPLOYERS INSURANCE COMPANY

This case involves a lien claim by Comprehensive Outpatient Surgery Center for medical treatment provided to applicant Teresa Hernandez. The applicant sustained a complex injury in 2010, and the employer provided some treatment through Dr. Lane, an MPN physician, including surgeries. The lien claimant contended that proper MPN notice was not provided and that the applicant was therefore entitled to seek treatment outside the MPN. However, the Appeals Board denied reconsideration, finding that the lien claimant failed to demonstrate that any lack of notice resulted in a denial of reasonable medical treatment, a burden of proof established by statute. Therefore, the employer was not liable for the applicant's self-procured treatment with non-MPN providers.

MPNLien ClaimantPetition for ReconsiderationFindings and OrderMedical Provider NetworkReasonably Necessary Medical TreatmentSelf-ProcureBurden of ProofLabor CodeSB 863
References
4
Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
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
Case No. MISSING
Regular Panel Decision

Matter of Hill-Chapman v. Earlybird Delivery Systems, LLC

Gerald Chapman, a dispatcher, collapsed and died at work on December 25, 2011, from a pulmonary embolism of unknown cause. His estate filed a claim for death benefits, which the Workers’ Compensation Board established, applying the Workers’ Compensation Law § 21 presumption that unexplained accidents in the course of employment arise out of such employment. The employer appealed, arguing that an independent medical report by Vinay Das could not determine the cause of death and requested cross-examination of the medical examiner and access to decedent’s medical records. The Appellate Division reversed the Board's decision, remitting the matter for the Board to address the employer's contention regarding the denial of access to medical records, while upholding the Board's application of the Section 21 presumption and denial of cross-examination.

Workers' Compensation BenefitsUnexplained DeathPulmonary Embolism CausationPresumption Against EmployerMedical Evidence AdmissibilityRight to Cross-ExamineMedical Record DiscoveryAppellate Division ReviewRemand for Further ProceedingsEmployment-Related Injury
References
8
Case No. ADJ10896105
Regular
Mar 22, 2018

MICHAEL GHATTAS vs. O'REILLY AUTO PARTS, SAFETY NATIONAL CASUALTY COMPANY

This case concerns whether an employer must authorize requested medical treatment for a denied workers' compensation claim. The Appeals Board denied the applicant's petition for reconsideration, upholding its prior decision. The Board concluded that the employer's timely denial of the claim under Labor Code section 5402 terminated their responsibility to authorize medical treatment. Therefore, the employer was not obligated to submit the physician's request for authorization (RFA) to utilization review despite it being pending when the denial was issued.

Workers' Compensation Appeals BoardPetition for ReconsiderationOpinion and Order DenyingDecision After ReconsiderationFindings of Fact Award and OrderRequest for AuthorizationUtilization ReviewLabor Code Section 5402Claim DenialMedical Treatment Authorization
References
0
Case No. ADJ7436407, ADJ1895040 (FRE 0238028)
Regular
Feb 04, 2015

Colleen Newby vs. Fresno Community Medical Center, St. Agnes Medical Center, State Compensation Insurance Fund

The Workers' Compensation Appeals Board denied Colleen Newby's Petition for Removal, upholding the denial of her petition to quash a Qualified Medical Evaluator (QME) request. The Board found that the prior employer, Fresno Community Medical Center, was authorized to file an application for adjudication of claim for Newby's subsequent employment with St. Agnes Medical Center. Crucially, the Board determined that a claim form is not a prerequisite for St. Agnes to request a QME panel in this specific scenario, where a second injury is claimed by a prior employer. Newby's due process claim was rejected as she had an opportunity to present her arguments on removal.

Petition for RemovalPetition to QuashQME RequestQualified Medical EvaluatorClaim FormDue ProcessAgreed Medical EvaluatorApplication for AdjudicationTemporary DisabilityPermanent Disability
References
1
Case No. MISSING
Regular Panel Decision

Claim of Dudas v. Town of Lancaster

The claimant, a laborer, allegedly injured his right ankle on February 28, 2007, after slipping on ice at the employer's Town Hall. Despite ongoing symptoms, the claimant delayed seeking medical treatment and reporting the injury to the employer until June 27, 2007. The employer's workers' compensation carrier initially authorized medical care but later controverted the claim due to conflicting reports regarding the cause of injury. A Workers' Compensation Law Judge disallowed the claim for failure to provide timely notice, a decision affirmed by the Workers' Compensation Board. The appellate court affirmed the Board's decision, concluding that the employer did not waive the defense of timely notice and that the Board did not abuse its discretion in disallowing the claim given the claimant's delay in reporting and treatment.

Workers' CompensationTimely NoticeAnkle InjurySlip and FallEmployer PrejudiceMedical Treatment DelayClaim DisallowanceBoard DiscretionAppellate ReviewWork-Related Injury
References
6
Case No. MISSING
Regular Panel Decision

Equal Employment Opportunity Commission v. Grief Bros.

This employment discrimination case, filed July 1, 2002, involves Michael Sabo (Plaintiff) who alleges constructive discharge based on sexual harassment and claims severe emotional pain and suffering. The Defendant moved for a mental examination of Sabo under Fed.R.Civ.P. 35 and to compel the production of his medical records. Sabo alleged severe humiliation, anxiety, depression, loss of self-esteem, sleeplessness, and weight gain, and admitted to a history of depression, past suicide attempts, and current psychiatric treatment with prescribed medications. The court granted the Defendant's motions, finding that Sabo had placed his mental condition in controversy due to the nature and severity of his claims and his medical history, justifying both the examination and the production of relevant medical records. The court also granted Defendant's request for costs associated with compelling the medical records, but denied the request for costs related to the Rule 35 motion itself, and denied Plaintiff's request for counsel or recording during the examination.

Employment DiscriminationSexual HarassmentConstructive DischargeEmotional DistressMental ExaminationRule 35Medical RecordsDepressionSuicide AttemptsCompensatory Damages
References
11
Case No. MISSING
Regular Panel Decision

Claim of Martin v. New York Telephone

This case concerns an appeal from a Workers' Compensation Board decision regarding the liability for benefits. The claimant sustained a left knee injury in 1987 and a reinjury in 1995. A 1998 Section 32 settlement agreement released the employer from future claims for a lump sum, but required it to cover medical treatment. In 2004, the claimant developed a consequential right knee injury. The Workers' Compensation Board ultimately shifted liability for benefits to the Special Fund for Reopened Cases under Workers' Compensation Law § 25-a, citing the passage of statutory timeframes. The Special Fund appealed, challenging its statutory liability and the employer's ongoing responsibility for medical expenses per the settlement. The appellate court affirmed the Board's decision, upholding the applicability of Section 25-a and noting the employer's statutory obligation for medical treatment.

Workers' Compensation Law § 25-aSpecial Fund for Reopened CasesSection 32 Settlement AgreementConsequential InjuryMedical Treatment LiabilityStatutory LiabilitySchedule Loss of UseAppellate ReviewTimelinessBoard Review
References
4
Case No. ADJ8822318
Regular
Jul 03, 2014

JUAN REZA vs. UNITED PARCEL SERVICE

The Workers' Compensation Appeals Board affirmed the trial judge's decision, finding that the defendant employer's late provision of Medical Provider Network (MPN) notice did not constitute a denial of medical care. Although the employer failed to provide timely MPN notices, the applicant did not prove that this failure directly caused a denial of treatment. The applicant's attorney's correspondence was deemed contradictory regarding the desire to change physicians within the MPN versus self-procuring care outside it. Therefore, the defendant is not liable for the applicant's self-procured treatment outside the MPN.

MPNdenial of careLabor Code section 4616.3(b)self-procured treatmentnotice requirementsphysician changeMTUSsubstantial evidenceKnight v. United Parcel ServiceAppeals Board
References
1
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