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

Case No. 2023-06-4955
Regular Panel Decision
Jun 18, 2024

Kean, Carma v. NAVION BKE BELLEVUE, LLC

Navion BKE Bellevue, LLC, filed a motion for partial summary judgment, contending there was no genuine issue of material fact regarding permanent impairment from Ms. Kean’s work-related injury. After a hearing, the Court granted the motion, finding no permanent impairment. However, because the parties agreed the claim was compensable, the Court ordered Navion to provide continuing reasonable and necessary medical treatment. The Court dismissed Ms. Kean's claim for permanent disability benefits with prejudice but affirmed her entitlement to future medical benefits, the need for which must be determined at the time they are requested.

Summary JudgmentPermanent ImpairmentMedical Treatment BenefitsWorkers' Compensation Appeals BoardAdmissibility of EvidenceC-32 FormsMedical Records AdmissibilityWaiver of ObjectionCompensabilityTemporary Disability Benefits
References
6
Case No. 03-14-00726-CV
Regular Panel Decision
Oct 30, 2014

Texas San Marcos Treatment Center, L.P. D/B/A San Marcos Treatment Center v. Veronica Payton

Texas San Marcos Treatment Center appeals the trial court's denial of its motion to dismiss Veronica Payton's health care liability claim. Payton alleged negligence after being assaulted by a patient at the treatment center. The appellant argues that the expert report provided by Dr. William H. Reid is deficient, lacking factual support and specificity concerning the standard of care, its breach, and causation, as required by Chapter 74 of the Texas Civil Practices and Remedies Code. The appellant asserts the trial court abused its discretion by finding the report adequate and requests dismissal of the claims.

Medical MalpracticeExpert ReportMotion to DismissAbuse of DiscretionStandard of CareBreach of DutyCausationHealth Care Liability ClaimPsychiatric FacilityEmployee Assault
References
25
Case No. ADJ1718435 (MON 0341690) ADJ2131482 (MON 0340861)
Regular
May 10, 2017

JEROME MITCHELL vs. COMMUTER EXPRESS, GALLAGHER BASSETT

This case involves a lien claimant, RS Medical, seeking reconsideration after its $6,800.28 lien for medical treatment was disallowed by the WCJ. The WCJ found RS Medical failed to prove the treatment was reasonable and necessary for the admitted industrial injuries. The Appeals Board granted reconsideration, finding the WCJ erred by focusing solely on neck treatment when evidence indicated prescriptions were for multiple body parts, including admitted injuries. The matter is returned to the trial level for the WCJ to re-evaluate the medical evidence and determine the reasonableness and necessity of the treatment.

Lien ClaimReconsiderationWCJUtilization ReviewTENS deviceMedical TreatmentBurden of ProofSubstantial EvidenceReasonableness and NecessityIndustrial Injury
References
5
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. ADJ1208276 (VEN 0109627)
Regular
Sep 02, 2016

DANIEL GARCIA vs. PEPSI COLA CO.; SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board rescinded a prior decision and remanded the case for further proceedings concerning chiropractic treatment for an admitted neck and upper back injury. The original decision allowed 16 visits for 2007, deeming them reasonable and necessary, and found the applicant not subject to the 24-visit cap. However, the Board found the Qualified Medical Evaluator's report, used to support the decision, was stale, having been issued ten years prior to the treatment. The Board directed parties to obtain an updated report from the QME, and noted that the defendant failed to conduct utilization review, a proper avenue for disputing treatment reasonableness.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderAdministrative Law JudgeLien ClaimantChiropractic ServicesLabor Code Section 4603.2(b)(2)PenaltiesSanctionsReasonable and Necessary Treatment
References
7
Case No. No. CIV.A. G-96-441
Regular Panel Decision
Jan 12, 1998

Alcorn v. STERLING CHEM. INC. MED. BENEFITS PLAN

Plaintiffs, including Otis Alcorn (as next friend for Juanita Revels), Meditrust Financial Services, and New Medico Associates, sued Sterling Chemicals Incorporation Medical Benefits Plan for denied medical treatment claims under ERISA. Juanita Revels, after a severe head injury in 1986, received rehabilitation, but the Plan denied coverage for later treatments from 1990, deeming them not "medically necessary." Both parties moved for summary judgment. The court, applying an abuse-of-discretion standard, found that the Plan administrator acted reasonably and did not abuse its discretion in determining that the treatments were not medically necessary. This decision was based on multiple claim reviews and the opinions of several physicians. Consequently, the Court granted the Defendant's motion for summary judgment and dismissed all of the Plaintiffs' claims with prejudice.

ERISAEmployee BenefitsMedical NecessitySummary JudgmentAbuse of DiscretionPlan AdministratorFifth CircuitFactual DeterminationHealth InsuranceBenefit Denial
References
28
Case No. ADJ10033983 ADJ11112700
Regular
Jul 08, 2019

PABLO PEREZ vs. TAYLOR FARMS, ZURICH NORTH AMERICA INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted applicant Pablo Perez's Petition for Removal, rescinding the prior finding that a Functional Capacity Evaluation (FCE) was not a reasonable and necessary medical-legal expense. The WCAB found that an FCE, recommended by Panel Qualified Medical Evaluator Dr. Ali Soozani to assess permanent impairment, provides crucial objective data not fully captured by subjective complaints or a standard physical examination. The Board reasoned that while a physical therapist conducts the FCE, this is permissible under Labor Code section 3209.5 for medical treatment and does not violate Labor Code section 4628 when viewed as a distinct diagnostic tool supporting the QME's overall evaluation. Consequently, the WCAB issued a new Finding of Fact and Order deeming the FCE reasonable and necessary.

Functional Capacity EvaluationMedical-Legal ExpensePanel Qualified Medical EvaluatorPermanent ImpairmentActivities of Daily LivingSubstantial EvidenceAlmaraz/GuzmanLabor Code Section 4628Diagnostic ToolMedical Opinion
References
4
Case No. 2014-06-0070
Regular Panel Decision
May 11, 2015

Campbell, Laura v. Mid-South Waffles, Inc. dba Waffle House

Laura Campbell, an employee of Mid-South Waffles, Inc. d/b/a Waffle House, filed a Request for Expedited Hearing seeking additional medical benefits for a knee injury sustained after slipping on Tabasco sauce at work. Waffle House, through its TPA Brentwood Services, denied the claim, stating the injury did not arise out of or in the course of employment. After reviewing evidence and testimony, the Workers' Compensation Judge found that Ms. Campbell's injury did arise out of and in the course of employment and that Dr. Salyer's recommendation for an MRI was reasonable and necessary. The Court ordered Waffle House to provide medical treatment, including authorizing an MRI and further treatment with Dr. Salyer. Furthermore, the Court referred Brentwood Services for a civil penalty investigation due to its denial of benefits without a reasonable investigation, as their stated reasons for denial were deemed insufficient.

Workers' CompensationMedical BenefitsExpedited HearingKnee InjurySlip and FallCausal ConnectionCourse of EmploymentArising Out of EmploymentMRI RecommendationDenial of Claim
References
7
Case No. ADJ7433042, ADJ7433045, ADJ7433048
Regular
Aug 06, 2013

MARIA GOMEZ vs. HARRIS RANCH BEEF CO., AIMS INSURANCE CO.

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration of a prior decision. The WCJ disallowed the lien claimant's lien for medical treatment, finding that the lien claimant failed to prove the treatment was reasonable and necessary, and its charges were reasonable. The Board affirmed the WCJ's decision, holding that the lien claimant did not meet its evidentiary burden, and denied the petition.

Lien claimantPetition for ReconsiderationJoint Findings of Fact and Ordersubstantial evidencedisallowance of liensCompromise and Releaseuntimely serviceex parte communicationsubstantial medical evidencereasonable and necessary treatment
References
11
Case No. ADJ10555511
Regular
Oct 03, 2018

MARIO GUDINO IBARRA vs. ASHLEY FURNITURE INDUSTRIES, INC., HARTFORD INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC.

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, ruling that Truxtun Pharmacy failed to meet its burden of proof for reimbursement of its lien. The Board found that the pharmacy did not provide substantial medical evidence demonstrating the compound medications were reasonable and necessary under the Medical Treatment Utilization Schedule (MTUS). Specifically, the physician's report lacked necessary citations and the prescribed treatments were not recommended by the MTUS. Therefore, the lien claimant is entitled to no recovery on its lien.

Workers Compensation Appeals BoardAshley Furniture IndustriesHartford Insurance CompanyGallagher Bassett ServicesMario Gudino IbarraTruxtun PharmacyMedical Treatment Utilization ScheduleMTUSOfficial Medical Fee ScheduleOMFS
References
2
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