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

Case No. ADJ7267845
Regular
Feb 21, 2012

JOSE ACEVEDO vs. TREND PERSONNEL, CHARTIS INSURANCE, GALLAGHER BASSETT SERVICES

This case concerns whether medical liens for treatment rendered after December 18, 2008, are valid. The primary treating physician, Dr. Hoegel, released the applicant from care on that date, and the applicant failed to object to this determination under Labor Code sections 4061 and 4062. Therefore, the applicant could not designate a new primary treating physician and any subsequent treatment liens are barred. The Appeals Board granted reconsideration to clarify that the applicant's failure to follow statutory objection procedures invalidates post-release medical liens.

Workers' Compensation Appeals BoardReconsiderationDecision After ReconsiderationFindings of Facts Re: LiensTenet/Centinela Hospital Medical Center v. Workers' Comp. Appeals Bd. (Rushing)Primary Physician's Permanent and Stationary ReportCompromise and ReleaseLien ClaimantsLabor Code section 4061(b)Labor Code section 4062(a)
References
1
Case No. MISSING
Regular Panel Decision
Jun 24, 1991

Marziliano v. Sullivan

Plaintiff Josephine Marziliano sought review of a determination by the Secretary of the United States Department of Health and Human Services that denied her request to waive recovery of an overpayment of Supplemental Security Income benefits. The Magistrate Judge recommended that the matter be referred to the Secretary for a new hearing, emphasizing the importance of giving required deference to the treating physician’s opinions in such overpayment waiver proceedings. The defendant objected to the application of the treating physician rule in these proceedings. District Judge Goettel adopted the Magistrate Judge's report and recommendation, affirming that the treating physician rule applies with full force when determining whether a claimant was 'at fault' in accepting an overpayment and ordered the case remanded for a new hearing.

Supplemental Security Income (SSI)Overpayment WaiverTreating Physician RuleMental ImpairmentAdministrative Law Judge (ALJ)RemandSocial Security Administration (SSA)Disability BenefitsResource LimitationsReporting Requirements
References
8
Case No. ADJ1505960 (RDG 0127227)
Regular
Jan 05, 2010

JOSEPH RHOADS vs. WESTERN READY MIX, INC., TRAVELERS PROPERTY \& CASUALTY

The Workers' Compensation Appeals Board rescinded a prior award of spinal surgery, remanding the case for further proceedings. The Board found that the defendant's objection to the treating physician's spinal surgery recommendation failed to follow proper utilization review procedures as outlined in *Cervantes v. El Aguila Food Products, Inc.* The defendant must now adhere to the prescribed utilization review and objection timelines, starting with a new report from the treating physician. The Board expressed no final opinion on the applicant's entitlement to surgery or the attorney's fee pending the WCJ's new decision.

Workers' Compensation Appeals BoardRemovalReconsiderationFindings and AwardWorkers' Compensation JudgeIndustrial InjurySpinal SurgeryTreating PhysicianSecond Opinion PhysicianAmerican College of Occupational and Environmental Medicine Guidelines
References
3
Case No. 2021 NY Slip Op 01469
Regular Panel Decision
Mar 11, 2021

Matter of Mayewski v. Superior Plus Energy Servs.

Claimant David Mayewski suffered work-related second and third-degree burns in 2013, leading to scarring and skin grafts. Following a permanency evaluation, his treating physician and an independent medical examiner offered reports concerning a schedule loss of use for his right arm and leg, and the treating physician also found a nonschedule permanent impairment for his torso/skin. The Workers' Compensation Law Judge and the Workers' Compensation Board both concluded that the injuries were amenable to a nonschedule classification. Mayewski appealed this decision, arguing it was limited to his torso and did not account for limited range of motion in his extremities. The Appellate Division, Third Department, affirmed the Board's decision, finding it supported by substantial evidence from the treating physician's report detailing objective skin disorder findings, thermal regulation issues, skin irritation, and intermittent pain.

Workers' CompensationSchedule Loss of UseNonschedule ClassificationPermanent Partial DisabilityBurnsSkin ImpairmentAppellate ReviewMedical EvidenceImpairment Guidelines
References
5
Case No. ADJ9725603
Regular
Nov 23, 2020

LUZ LOZA vs. GOLDBLATT GOLDBLATT/BAY AREA RESTAURANT MANAGEMENT, ARCH INSURANCE COMPANY, administered by YORK RISK SERVICES GROUP, INC.

The Workers' Compensation Appeals Board granted reconsideration of an administrative law judge's order finding the applicant entitled to pre-authorization for their treating physician to issue a PR-4 report at the medical-legal billing rate. While affirming the applicant's right to obtain the report, the Board clarified that the defendant retains the right to object to or raise defenses regarding the physician's billing. The Board reasoned that treating physicians are permitted to provide comprehensive medical-legal evaluations, and such reports are governed by specific medical-legal fee schedules, not the Official Medical Fee Schedule.

PR-4 reportmedical-legal billing ratepre-authorizationprimary treating physician (PTP)Qualified Medical Evaluator (QME)comprehensive medical evaluationOfficial Medical Fee SchedulePetition for ReconsiderationFindings of Fact and Order (F&O)Labor Code
References
3
Case No. CV-23-0056
Regular Panel Decision
Dec 14, 2023

In the Matter of the Claim of Daniel Villagil

Claimant Daniel Villagil appealed two decisions from the Workers' Compensation Board. He sustained lower back and left leg injuries from a pot of boiling water in October 2019, leading his treating physician to suggest a 20% schedule loss of use (SLU) award for his left leg. The employer and carrier objected, arguing the scars weren't a basis for SLU. A Workers' Compensation Law Judge denied the award due to the physician's report lacking explanation for the percentage and failing to document permanent physical/functional impairments. The Board affirmed this, finding no credible medical evidence of permanency or functional impairment. Claimant's subsequent application for reconsideration was also denied, prompting these appeals. The Appellate Division affirmed the Board's decision, citing the lack of credible medical proof and the conclusory nature of the treating physician's report, and found no abuse of discretion in denying reconsideration.

Schedule Loss of UsePermanent ImpairmentMedical EvidenceTreating Physician ReportMaximum Medical ImprovementWorkers' Compensation BoardAppellate DivisionReconsideration ApplicationFunctional ImpairmentScars
References
7
Case No. MISSING
Regular Panel Decision

Bennett v. Secretary of United States Depatment of Health & Human Services

Charles Bennett ("plaintiff") is appealing a final decision by the Secretary of the United States Department of Health and Human Services, which denied his application for disability insurance and supplemental security income benefits. Bennett, a 41-year-old with a history of heart issues and a December 1986 back injury, claims disability, which was initially denied by an Administrative Law Judge and upheld by the Appeals Council. The court's review examines whether the Secretary's decision is supported by substantial evidence, specifically evaluating the "treating physician rule" concerning the opinions of Dr. Blum and Dr. Gold versus consulting physicians like Dr. Massoff. While objective tests confirm a bulging disc and treating physicians noted decreased range of motion, the court found their cursory "total disability" conclusion for Workers' Compensation purposes insufficient under the Act. Consequently, the court remands the case to the Secretary, requiring further information on Bennett's current residual functional capacity for sedentary or light work.

Social Security ActDisability Insurance BenefitsSupplemental Security IncomeResidual Functional CapacityLumbosacral Spine StrainBulging DiscTreating Physician RuleRemandAdministrative Law JudgeAppeals Council
References
11
Case No. 533089
Regular Panel Decision
Oct 07, 2021

Matter of Barden v. General Physicians PC

Claimant, a patient services representative, sought to amend her workers' compensation claim to include left shoulder aggravation after a work-related injury to her right shoulder. The Workers' Compensation Board disallowed this request, finding that claimant failed to provide sufficient credible medical evidence to establish a causal relationship between her employment and the left shoulder condition. The Appellate Division, Third Department, affirmed the Board's decision. The court noted that the claimant's treating physician opined the left shoulder pathology was largely preexisting and unrelated to the work injury, and other medical opinions either lacked sufficient weight or were based on inaccurate information, providing no basis to disturb the Board's finding.

Workers' CompensationShoulder InjuryCausationMedical EvidencePreexisting ConditionAppellate ReviewBoard DecisionClaim AmendmentPatient Services Representative
References
10
Case No. ADJ8717299
Regular
Mar 14, 2017

JOSEPH LOBB vs. JEFFREY D. HADDEN, JEFFREY D. HADDEN AND DOROTHY M. HADDEN DBA NAT PEST CONTROL AND FIREWOOK AKA NPC, DOROTHY M. HADDEN, NATURAL PEST CONTROLS FIREWOOD

This case involves an employer's objection, treated as a petition for reconsideration, to a Workers' Compensation Appeals Board (WCAB) decision that awarded benefits to an employee. The employers claim they never received notice of the original WCJ's decision or subsequent Board actions, including the September 2, 2016 decision. The WCAB found that the employers were indeed deprived of due process due to improper service. Consequently, the WCAB granted reconsideration to allow the employers to file an answer and ensure a just decision.

Petition for ReconsiderationDue ProcessImproper NoticeOfficial Address RecordProof of ServiceDeclaration of ServiceToll StatuteActual NoticeWCJ DecisionAppeals Board
References
0
Case No. ADJ8611746
Regular
Feb 27, 2017

VILMA AGUILAR vs. SLATKIN RESIDENCE, STATE FARM INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The defendant argued the administrative law judge erred in awarding 17% permanent disability by relying on the applicant's treating physician over a qualified medical evaluator. The Board found the treating physician's opinion was well-supported by objective clinical findings and consistent with the diagnosis of lumbar radiculopathy. Therefore, the Board gave significant weight to the administrative law judge's findings and denied the petition.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardPermanent DisabilityPrimary Treating PhysicianQualified Medical EvaluatorMedical OpinionCredibility DeterminationsSubstantial EvidenceLumbar Radiculopathy
References
8
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