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Case Law Database

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

Case No. MISSING
Regular Panel Decision

Long Island Neurological Assocs., P.C. v. Highmark Blue Shield & Reed Smith LLP

Plaintiff Long Island Neurological Associates, P.C. sued Highmark Blue Shield and Reed Smith LLP for under-reimbursement of surgical services under ERISA. The case involved a 4-year-old patient who received complex out-of-network surgery from Dr. Schneider due to the unavailability of in-network providers. Highmark significantly under-reimbursed the billed amount and denied multiple appeals, failing to provide requested documentation. The patient's parents assigned their rights to the Plaintiff, leading Defendants to move for dismissal, asserting an anti-assignment provision in their Administrative Service Agreement (ASA). The Court denied the motion, ruling that the ASA is not an ERISA plan document and thus its anti-assignment clause is not binding on plan participants, confirming Plaintiff's standing. The Rule 12(b)(6) motion was also denied as abandoned.

ERISAMotion to DismissAnti-assignment clauseAdministrative Service Agreement (ASA)Plan DocumentSubject Matter JurisdictionStandingUnder-reimbursementOut-of-network providerHealth Insurance
References
27
Case No. 2016-03-0413
Regular Panel Decision
Oct 05, 2017

Dodson, Deborah v. LHC Group

Deborah Dodson, an employee of LHC Group, injured her left ankle and right knee in May 2015. She underwent knee surgery and was placed at maximum medical improvement by Dr. Johnson. She later developed small fiber neuropathy, and despite a referral, faced difficulties obtaining a neurologic impairment evaluation. The Court granted Ms. Dodson's request for a neurologic impairment evaluation, either by Dr. Butler or another neurologist, referring Dr. Butler to the Penalty Program for failure to provide an impairment opinion. However, the Court denied her claim for additional temporary total disability benefits, finding she reached MMI on March 23, 2017, when Dr. Butler ceased active treatment.

Workers' CompensationNeurologic Impairment EvaluationTemporary Total Disability BenefitsMaximum Medical ImprovementSmall Fiber NeuropathyPain ManagementExpedited HearingMedical TreatmentImpairment RatingPenalty Program
References
3
Case No. MISSING
Regular Panel Decision

In re Anonymous

This case concerns an adoption proceeding in Nassau County for a neurologically handicapped child. The petitioners, an approved adoptive family, sought to finalize the adoption. Former foster parents, the intervenors, challenged this, claiming a statutory preference for adoption due to their long-term care of the child. The court found that the intervenors had previously declined to adopt the child and failed to take affirmative steps to gain statutory preference while the child was in their care. The decision emphasized that intervention rights apply to current foster parents in custody disputes, and ultimately, the court prioritized the child's best interests by granting the petitioners' adoption application.

AdoptionFoster CareChild WelfareNeurological HandicapBest Interests of ChildInterventionStatutory PreferenceSocial Services LawAgency Discretion
References
3
Case No. MISSING
Regular Panel Decision
May 20, 2007

Guzman v. 4030 Bronx Boulevard Associates L.L.C.

This appeal concerns the preclusion of expert testimony from a neuropsychologist, Dr. Elkhonon Goldberg, regarding the causation of infant plaintiff Tyrone Guzman's neurological deficits. The plaintiff has a history of multiple head traumas, and the lawsuit stems from alleged injuries sustained during a bathroom ceiling collapse. The trial court precluded Dr. Goldberg's testimony due to a lack of objective medical foundation to establish that the June 2001 incident was the proximate cause, subsequently dismissing the complaint. The appellate court agreed with the preclusion of testimony on causation but found an abuse of discretion in denying a continuance to allow plaintiffs to secure another medical expert. The matter was reversed and remanded for further proceedings.

Expert TestimonyNeuropsychologyTraumatic Brain InjuryCausationMotion in LimineContinuanceAppellate ProcedureEvidentiary StandardPersonal InjuryHead Trauma
References
22
Case No. MISSING
Regular Panel Decision

Stephens v. Colvin

Plaintiff Duane Stephens sought judicial review of the Commissioner of Social Security's denial of his application for Disability Insurance Benefits and Supplemental Security Income. The U.S. Magistrate Judge found that the Administrative Law Judge (ALJ) erred at step three by not finding plaintiff's intellectual disability met Listing 12.05(c) and that the ALJ's Residual Functional Capacity (RFC) determination was not supported by substantial evidence, particularly regarding plaintiff's attention and concentration limitations. The court granted the plaintiff's motion for judgment on the pleadings and remanded the case to the Commissioner for reconsideration, emphasizing the need to re-evaluate adaptive functioning deficits and potentially consult a vocational expert.

Disability Insurance BenefitsSupplemental Security IncomeSocial Security ActAdministrative Law Judge (ALJ) ReviewAppeals Council ReviewResidual Functional Capacity (RFC)Listing of Impairments (Appendix 1)Intellectual DisabilityAdaptive Functioning DeficitsChronic Obstructive Pulmonary Disease (COPD)
References
41
Case No. 2021-08-0423
Regular Panel Decision
Dec 20, 2021

Stansbury, Pamela v. Federal Exprress Corp.

Ms. Pamela Stansbury suffered a compensable head injury while working at FedEx. She sought additional medical and temporary disability benefits, expressing dissatisfaction with her treating physician, Dr. Alan Nadel, and requesting payment for past emergency room treatment. FedEx contended it had provided all entitled benefits, as Dr. Nadel released Ms. Stansbury with no work restrictions after concluding there were no residual neurological issues. The Court denied Ms. Stansbury's claims, finding she did not meet her burden to prove entitlement to additional medical benefits or a change in physician, nor did she provide sufficient evidence for unauthorized past medical expenses. Furthermore, she failed to present medical evidence supporting further temporary disability benefits beyond what FedEx had already paid.

Workers' Compensation ClaimsExpedited HearingMedical Benefits DenialTemporary Disability BenefitsHead InjuryPhysician PanelEmployer ResponsibilityBurden of ProofMedical Treatment AuthorizationPosttraumatic Headache
References
2
Case No. 2018-05-1079
Regular Panel Decision
Apr 05, 2019

Kassmieh, Michael v. NEIS, Inc.

Michael Kassmieh, an auditor, sought workers' compensation benefits for facial pain, headaches, and tinnitus following a head injury in July 2017 while working for NElS, Inc. Despite NElS accepting the initial claim and providing authorized medical treatment, multiple physicians, including neurologists Dr. Strickland and Dr. Graham, found no objective neurological deficits or concluded that Mr. Kassmieh's subjective complaints were disproportionate to the minor injury. The Court denied Mr. Kassmieh's request for specific medical treatment and disability benefits, ruling he was unlikely to establish medical causation for his current complaints, as required by Tenn. Code Ann. § 50-6-102. NElS, however, was ordered to continue providing reasonable and necessary treatment for any conditions directly arising from the work injury.

Workers' CompensationHead InjuryFacial PainHeadachesTinnitusMedical CausationExpedited HearingNeurologyOphthalmologyENT Specialist
References
1
Case No. MISSING
Regular Panel Decision

Smith v. Apfel

The plaintiff applied for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefits, alleging disability since August 1993 due to bipolar disorder, attention deficit hyperactivity disorder (ADHD), and phobias. The Administrative Law Judge (ALJ) denied the claim, a decision upheld by the Appeals Council. The plaintiff subsequently brought this matter to the District Court, contending that the ALJ misapplied legal standards by failing to properly weigh his treating physician's opinion, incorrectly concluding his impairments did not meet a listed impairment, and inadequately describing his work capabilities. The court found that the ALJ failed to apply the proper legal standard to the treating physician's opinion and improperly discredited the plaintiff's subjective complaints by mischaracterizing evidence in the record. As a result, the court reversed the ALJ's decision and remanded the case, ordering reconsideration of the treating physician's opinion, the plaintiff's functional limitations, and further development of the record concerning the plaintiff's residual functional capacity.

Disability BenefitsSocial Security ActSSISSDIBipolar DisorderADHDPhobiasTreating Physician RuleALJ ErrorRemand
References
24
Case No. MISSING
Regular Panel Decision

Vay v. Comm'r of Soc. Sec.

Plaintiff Emily R. Vay sought judicial review of the Commissioner of Social Security's final decision denying her application for Supplemental Security Income (SSI) under Title XVI of the Social Security Act. Plaintiff alleged disability due to anxiety, attention deficit hyperactivity disorder, pervasive development disorder, Asperger's syndrome, and learning disability since January 16, 2014. Her application was initially denied, and after a hearing before Administrative Law Judge William M. Manico, an unfavorable decision was issued on January 21, 2016, which became the Commissioner's final decision after the Appeals Council denied review on May 26, 2017. Before the District Court, both parties filed cross-motions for judgment on the pleadings. Plaintiff argued that the ALJ failed to develop the record regarding recent treatment, improperly assessed her credibility, and mischaracterized her impairments, leading to an unsupported Residual Functional Capacity (RFC) finding. The Court, presided over by Judge Elizabeth A. Wolford, granted the Commissioner's motion and denied Plaintiff's motion, finding that the Commissioner's determination was supported by substantial evidence and free from legal error. The Court concluded that the ALJ adequately developed the record, made a reasonable credibility assessment based on conflicting evidence, and properly assessed Plaintiff's impairments and RFC.

Supplemental Security IncomeSocial Security ActDisability BenefitsALJ Decision ReviewResidual Functional CapacityCredibility AssessmentRecord DevelopmentAttention Deficit Hyperactivity DisorderAnxiety DisorderAutism Spectrum Disorder
References
27
Case No. ADJ9379623
Regular
May 18, 2018

ETHERY AMARI vs. CHILDREN'S HOSPITAL OF LOS ANGELES

The Workers' Compensation Appeals Board granted the applicant's petition for removal, rescinding a prior order that denied her request for an additional neurology Qualified Medical Evaluator (QME). The applicant sustained admitted injuries including to her spine and shoulder, and also claimed headaches. Her treating physician recommended a neurology consult twice, and the applicant testified about worsening headaches post-injury. The Board found that these factors constituted good cause and demonstrated significant prejudice, warranting the appointment of a neurology QME panel.

Petition for RemovalPanel Qualified Medical EvaluatorNeurology QMEWCABFindings and OrderIndustrial InjuryCervical SpineLumbar SpineHeadachesPrimary Treating Physician
References
1
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