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

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. 02-22-00072-CV
Regular Panel Decision
Jul 27, 2023

BioTE Medical, LLC v. John Carrozzella, MD, JCMD Medical Services, Inc., Dan Deneui, and Terri Deneui

This case addresses whether a contractual "residual benefit" clause, requiring a post-termination fee for using a competing treatment method, constitutes a covenant not to compete under Texas law. Appellant BioTE Medical, LLC, licensed a pellet-based bioidentical hormone replacement therapy (BHRT) method. Appellee JCMD Medical Services, Inc., a former customer, terminated its agreement and began using a competitor's BHRT without paying the residual-benefit fee. BioTE Medical sued JCMD for breach of contract. The trial court granted summary judgment to JCMD, finding the clause unenforceable either as a noncompete or a violation of public policy. The appellate court reversed, holding that the residual-benefit clause is not a covenant not to compete as it does not restrict JCMD from competing with BioTE Medical, but rather from using a competitor's product. The court also declined to invalidate the clause on uncodified public policy grounds, deferring to the Legislature's policy determinations.

Contract lawCovenants Not to Compete ActResidual benefit clausePublic policyBioidentical hormone replacement therapy (BHRT)Breach of contractSummary judgmentAppellate reviewTexas lawBusiness and Commerce Code
References
33
Case No. 13-09-00350-CV
Regular Panel Decision
Jan 21, 2010

Gulf Coast Medical Center, LLC, Tony Todd, Crna, Dan Madsen, M.D. and South Texas Medical Clinics, P.A. v. Jacqueline Temple and Marcus Banks, Individually and as Representatives of the Estate of Markasia Banks, a Minor Child

Appellants, Gulf Coast Medical Center, LLC, Tony Todd, CRNA, Dan Madsen, M.D., and South Texas Medical Clinics, P.A., appealed the trial court's denial of their motions to dismiss. The underlying suit was filed by appellees Jacqueline Temple and Marcus Banks, alleging negligence in the care and treatment of their deceased minor child, Markasia Banks. The core issue on appeal was the appellees' failure to timely serve an expert medical report as required by the Texas Civil Practice and Remedies Code. The Court of Appeals determined that the appellees' claims were 'health care liability claims' and that the expert report was indeed untimely, and that an abatement due to a failure to provide medical authorization did not extend the deadline. The court also affirmed the constitutionality of the expert report requirement. Consequently, the appellate court reversed the trial court's judgment, granted the appellants' motions to dismiss, and remanded the case for the award of attorney's fees and costs to the appellants.

Health Care Liability ClaimExpert Medical ReportMotion to DismissTimeliness of ReportAbatementMedical MalpracticeNegligenceDue ProcessTexas ConstitutionAppellate Review
References
32
Case No. 2016-01-0716
Regular Panel Decision
Mar 27, 2017

Lane, Thomas v. Cleveland Utilites

This Expedited Hearing Order addresses Thomas Lane's claim for medical benefits related to a November 20, 2015 spinal injury at Cleveland Utilities. Mr. Lane, who also had a 2007 spinal injury at the same employer, sought treatment for his condition. The Court considered medical opinions from Drs. Folsom and Broadstone regarding the causation of his current spinal issues. Finding that the 2015 work injury aggravated a pre-existing condition, the Court concluded that Mr. Lane is likely to prevail at trial. Consequently, Cleveland Utilities and its carrier are ordered to process medical charges and authorize ongoing treatment by Dr. Paul Broadstone for the 2015 work injury.

Workers' CompensationSpinal InjuryMedical BenefitsAggravation of Pre-existing ConditionCausationExpedited HearingOrthopedic CareSciaticaRadiculopathyTennessee Law
References
9
Case No. 2016-08-1486
Regular Panel Decision
Nov 30, 2018

Nance, Amy v. JCSD Emergency Medical Group d/b/a Medic One Response

Ms. Nance, an emergency medical technician, injured her left upper extremity while moving a patient. After conservative treatment, she was diagnosed with cubital tunnel syndrome and later recommended for a cervical spine evaluation by Dr. Cole. Medic One denied the requested benefits, claiming misrepresentation and non-work-related activity. The Court found Ms. Nance likely to prevail for medical benefits, ordering Medic One to authorize a cervical spine evaluation and allow her to select a specialist. However, Ms. Nance was not found eligible for temporary disability benefits due to insufficient medical proof of disability.

Workers' CompensationMedical BenefitsTemporary Disability BenefitsCubital Tunnel SyndromeCervical Spine EvaluationMedical MisrepresentationCausal ConnectionExpedited HearingPermanent ImpairmentTreating Physician
References
3
Case No. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. ADJ6975049
Regular
Jun 05, 2018

CONSUELO VIEYRA vs. COUNTY OF LOS ANGELES

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision and returned the case for further proceedings, finding that the defendant's utilization review denials were not timely communicated to the physician. While the initial WCJ found the UR timely, the WCAB disagreed, asserting jurisdiction to determine medical necessity. Crucially, the WCAB found that the 2009 Medical Treatment Utilization Schedule (MTUS) guideline used for the denial was an invalid regulation. The matter was returned for further development of the record regarding medical necessity, considering the proper legal framework for treatment requests.

Workers' Compensation Appeals BoardConsuelo VieyraCounty of Los AngelesUtilization ReviewRequest for AuthorizationHome Health CareReasonable and Necessary TreatmentMedical TreatmentIndependent Medical ReviewMTUS Chronic Pain Medical Treatment Guidelines
References
17
Case No. MISSING
Regular Panel Decision

Yklik Medical Supply, Inc. v. Allstate Insurance

Plaintiff Yklik Medical Supply, Inc., a medical supply provider, sued Allstate Insurance Company to recover $317 in unpaid medical bills for equipment supplied to its assignor, Tammy Agosto. Yklik moved for summary judgment, asserting proper bill submission and Allstate's failure to timely pay or deny the claim. Allstate argued that the charges exceeded the Workers' Compensation fee schedule and that a partial payment had been made. The court found that Yklik established a prima facie case. The central issue was whether Allstate's fee schedule defense was precluded due to its failure to issue a timely denial within 30 days as mandated by Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The court ruled that since Allstate waited 56 days to send its denial, it was precluded from raising the fee schedule defense, and therefore, summary judgment was granted to the plaintiff.

No-fault insurancesummary judgmenttimely denialfee schedulepreclusion ruleinsurance lawmedical supplybilling practicespersonal injury protectionassignor
References
19
Case No. 2018-08-1537
Regular Panel Decision
Apr 30, 2019

Gammel, Loretta v. Bratton & O'Neal, P.C.

Loretta Gammel, a legal assistant for Bratton & O’Neal, P.C., sustained a compensable left-knee injury on February 6, 2018, while at work. Her authorized treating orthopedist, Dr. Timothy Micek, recommended surgery for an acute medial meniscus tear after conservative treatment failed, causally relating the injury to her work. Despite Dr. Micek's recommendations, utilization review denied the surgery. Ms. Gammel then sought an Expedited Hearing to compel approval of the surgery. The Court ruled in favor of Ms. Gammel, finding that she is likely to prevail at trial, as Dr. Micek's treatment recommendations are presumed medically necessary and the employer presented no rebutting medical evidence. Consequently, the Court ordered Bratton & O’Neal, P.C. to provide the necessary medical treatment, including the meniscus surgery.

Workers' CompensationMedical BenefitsKnee InjuryMeniscus TearExpedited HearingUtilization Review DenialTreating PhysicianCausationOrthopedicsPresumption of Medical Necessity
References
0
Case No. MISSING
Regular Panel Decision

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
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