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

Case No. SAL SJO 252436 (MF); SJO 246192
Regular
Jul 02, 2007

NIHAL HORDAGODA vs. State Compensation Insurance Fund

This case involves an employer's petition for reconsideration of an order authorizing medical treatment and admitting the Qualified Medical Examiner's (QME) reports. The employer argued the QME reports were inadmissible due to an alleged ex parte communication between the applicant and the QME, and that the awarded treatments were improper. The report recommends denying the petition, finding the communication was permissible under LC § 4062.3(h) and that the QME's opinions and awarded treatments for chronic pain were reasonable and not governed by ACOEM guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationQualified Medical EvaluatorLabor Code Section 4062.3Ophthalmological evaluationFunctional capacity evaluationUtilization ReviewACOEM GuidelinesChronic spinal conditionTreating physician
References
0
Case No. ADJ7643460
Regular
May 01, 2017

Tracy Lee vs. XCHANGING, GRANITE STATES INSURANCE COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.

This case concerns Defendant's Petition for Removal seeking a new Qualified Medical Evaluator (QME) panel due to a QME's untimely supplemental report. The Appeals Board denied the petition, finding Defendant failed to demonstrate substantial prejudice or irreparable harm. While the QME's report was late, Labor Code Section 4062.5 and Rule 31.5(a)(12) do not mandate replacement for untimely supplemental reports, making the decision discretionary. The WCJ's decision not to order a replacement was reasonable given the QME's extensive involvement and the lack of a mandatory replacement provision.

Workers' Compensation Appeals BoardPetition for RemovalQualified Medical EvaluatorQME panelsupplemental reportuntimelysubstantial prejudiceirreparable harmLabor Code section 4062.5Rule 31.5(a)(12)
References
5
Case No. ADJ10885080
Regular
Aug 21, 2019

ALMA PADRON vs. MODESTO CITY SCHOOLS

The Workers' Compensation Appeals Board affirmed a judge's finding that the applicant's Qualified Medical Evaluator (QME) report was not untimely. The applicant argued the report was late because she did not receive it until after her objection date, but the Board found her objection was filed after the QME's proof of service date. The Board also determined that the timeliness of the QME report was an interlocutory issue not subject to reconsideration and that the applicant failed to demonstrate irreparable harm. Therefore, the Board denied the applicant's petition for reconsideration.

AOE/COEQME panelreplacement QMEPetition for ReconsiderationPetition for RemovalWCJMedical Unitproof of serviceEvidence Code § 641presumption of receipt
References
14
Case No. ADJ11280224
Regular
Oct 25, 2019

APRIL WILLIAMS vs. KERN COUNTY SUPERINTENDENT OF SCHOOLS

The Workers' Compensation Appeals Board granted reconsideration and amended a prior order, finding the applicant is not entitled to a replacement Qualified Medical Evaluator (QME) panel. The Board determined that the QME's supplemental report was timely because the initial request for the report was not received by the QME's office, and the subsequent fax request was within the statutory timeframe. Additionally, the Board revised a finding to reflect injury AOE/COE solely to the applicant's low back, deferring the issue of injury to other body parts. The Board noted that even if the report had been late, a replacement panel is not automatically mandated and requires a showing of good cause.

Workers' Compensation Appeals BoardPetition for ReconsiderationQualified Medical EvaluatorReplacement QME PanelFindings of FactOrder and Opinion on DecisionDue ProcessMedical UnitSupplemental ReportMailing Presumption
References
8
Case No. ADJ8529720
Regular
Feb 06, 2017

ALEJANDRA GONZALEZ vs. 3M COMPANY, OLD REPUBLIC INSURANCE

This case concerns whether an untimely supplemental Qualified Medical Evaluator (QME) report warrants a replacement panel. The applicant requested a new panel because the original QME's supplemental report was late. The WCJ denied the defendant's request to keep the original QME, finding the defendant waived objection by striking a name from the new panel. The Appeals Board granted removal, rescinded the WCJ's order, and remanded the case. The Board clarified that striking a name from a new panel does not automatically waive the right to object to its validity.

PQMESupplemental ReportReplacement PanelLabor Code 4062.5DWC Medical UnitDeclaration of ReadinessMSCWaiverAdministrative Director Rule 38Rule 31.5
References
0
Case No. ADJ1384238 (SAC 0366460)
Regular
Oct 09, 2017

ROSA VIRGEN vs. MACY'S WEST, MACY'S CORPORATE SERVICES-RISK MANAGEMENT DEPARTMENT

The Workers' Compensation Appeals Board denied Macy's West's petition for removal, upholding the WCJ's decision not to grant a replacement Qualified Medical Evaluator (QME). The Board found that a late supplemental report alone does not mandate a replacement QME under LC 4062.5 or AD Rule 31.5(a)(12). Granting a replacement QME for untimely supplemental reporting is discretionary and requires a showing of good cause, which Macy's failed to demonstrate. The Appeals Board retains exclusive jurisdiction over the validity of replacement panels.

Workers' Compensation Appeals BoardPetition for RemovalQualified Medical EvaluationPQMEReplacement PanelMedical DirectorTimelinessSupplemental ReportGood CausePrejudice
References
4
Case No. ADJ8975338
Regular
Jun 21, 2017

Kevin Livingstone vs. ATI, American Insurance Company, ESIS

This case involves a defendant's attempt to strike a Qualified Medical Evaluator's (QME) report and obtain a replacement due to a 7-day delay in a supplemental report. The Appeals Board vacated its prior order granting reconsideration because the initial WCJ's order denying the strike was not a final order subject to reconsideration. The Board further denied the defendant's petition for removal, finding no irreparable harm. The ruling clarifies that only an untimely initial QME evaluation mandates replacement, whereas a late supplemental report is within the WCJ's discretion to address based on good cause.

WCABPetition for ReconsiderationPetition for RemovalQualified Medical EvaluatorQMESupplemental ReportTimelinessFinal OrderInterlocutory OrderAdministrative Director
References
14
Case No. ADJ9150447; ADJ9150446
Regular
Jun 24, 2016

PAUL CORRADO vs. AQUAFINE CORPORATION, ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) dismissed the defendant's petition for reconsideration because the order sought to be reconsidered was interlocutory, not a final determination. The WCAB granted the defendant's petition for removal, rescinded the judge's order for a new Qualified Medical Evaluator (QME) panel, and returned the case for further proceedings. This decision clarifies that while a QME's untimely supplemental report may be grounds for replacement, it does not automatically mandate it under Labor Code § 4062.5, requiring the judge to exercise discretion based on specific factors. The WCAB emphasized the importance of timely dispute resolution and that a late supplemental report alone is insufficient to order a new QME without considering other elements of prejudice and good cause.

WCABRemovalReconsiderationQME PanelSupplemental ReportLabor Code Section 4062.5Administrative Director Rule 38TimelinessInterlocutory OrderSubstantial Justice
References
10
Case No. ADJ6470549
Regular
Feb 27, 2012

KATHRYN BENSON vs. CITY OF SAN DIEGO

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior decision, allowing a Qualified Medical Examiner's (QME) report into evidence. The original decision excluded the QME report, finding no ratable permanent disability based on the treating physician's opinion. The Appeals Board found the QME report should have been admitted, as there are no explicit time limits for objecting to a treating physician's report or obtaining a QME evaluation for permanent disability. The case is remanded for further proceedings on permanent disability and attorney's fees with the QME report now part of the record.

Workers Compensation Appeals BoardFindings and AwardPetition for ReconsiderationQualified Medical Examiner (QME)Permanent DisabilityFuture Medical TreatmentTreating PhysicianAgreed Medical Examiner (AME)Labor Code Section 4061Strawn v. Golden Eagle Insurance Co.
References
1
Case No. ADJ3851886 (LBO 0381289)
Regular
Feb 07, 2011

MARY WEISSMAN vs. LONG BEACH UNIFIED SCHOOL DISTRICT, Permissibly Self-Insured, Adjusted By TRISTAR RISK MANAGEMENT

The Appeals Board granted removal and dismissed the employer's petition for reconsideration. They found the employer was prejudiced by the late admission of the applicant's QME report, violating due process. The Board affirmed the WCJ's order for further medical development by the AME, instructing him to base his opinion on the applicant's deposition testimony. Finally, the May 14, 2010 QME report was struck from the record.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationAgreed Medical EvaluatorQualified Medical EvaluatorIndustrial InjuryCumulative InjuryViral CardiomyopathySubstantial EvidenceDue Process
References
15
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