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

Case No. ADJ11027267
Regular
Feb 03, 2023

LUIS ROSALES vs. IRELAND TILE AND STONE INC., SEDGWICK 14779 SAN DIEGO

This case involves an injured tile setter, Luis Rosales, who claimed lumbar radiculopathy stemming from an admitted industrial lumbar contusion. The Workers' Compensation Appeals Board denied reconsideration of a prior order, upholding a finding of 0% permanent disability. This decision was based on the Qualified Medical Examiner's (QME) reports, which the Board found to be substantial evidence. The Board specifically rejected the applicant's argument that the QME's opinions were inconsistent, clarifying that the QME found the sacral cyst unrelated to the lumbar contusion, not that the symptoms were unrelated to the cyst.

Petition for ReconsiderationQualified Medical ExaminerPQMEDr. Sonusupplemental reportsubstantial evidencelumbar contusionsacral cystradiculopathypermanent disability
References
2
Case No. MISSING
Regular Panel Decision

Claim of Washington v. New York City Department of Buildings

The case involves an appeal concerning a claimant's right knee injury, initially sustained in a 1999 fall while working for the New York City Department of Buildings. After an initial workers' compensation claim, the claimant filed a second claim in 2001 for a pseudo-meniscal cyst in the same knee. While a Workers’ Compensation Law Judge deemed it a new injury, the Workers’ Compensation Board reversed, finding the cyst causally related to the 1999 incident. This court affirmed the Board's amended decision, relying on an impartial orthopedic surgeon's testimony that the cyst developed from either synovial fluid leakage post-1999 surgeries or a degenerating meniscus tear, not a secondary injury.

Knee injuryWorkers' CompensationCausationMedical evidenceSynovial cystMeniscus tearBoard decisionAppealOrthopedic surgeonPrior injury
References
6
Case No. MISSING
Regular Panel Decision

Claim of Nickens v. Randstad

Claimant, employed by a temporary agency, suffered severe lumbar and sacral vertebrae fractures on October 7, 2003, when caught in a garbage truck's hydraulic lift. The employer and carrier argued he was gathering cans for personal use, a prohibited act. However, the Workers’ Compensation Law Judge (WCLJ) found the injury work-related, established an average weekly wage, and awarded temporary disability benefits. The carrier sought review from the Workers’ Compensation Board, contending they were denied cross-examination of claimant’s physicians, an opportunity to present a witness regarding the prohibited act, and cross-examination of claimant about his labor market attachment. The Board affirmed the WCLJ’s decision. The Appellate Division affirmed the Board's decision, finding no reversible error.

Workers' CompensationAccidental InjuryHydraulic Lift AccidentVertebrae FracturesTemporary EmploymentProhibited Act DefenseCross-Examination DenialLabor Market AttachmentWorkers' Compensation BoardAppellate Review
References
2
Case No. MISSING
Regular Panel Decision

Gonzalez v. Secretary of United States Department of Health & Human Services

Lydia Gonzalez, 72, sought Medicare reimbursement for her hospital stay from July 28 to August 19, 1981, following surgeries at Nassau Hospital for a sacral ulcer. The hospital's Utilization Review Committee and Physicians Review Organization determined she only required "custodial care," which is not covered by Medicare. Her discharge was delayed due to insanitary home conditions. After appeals to the New York Statewide Professional Standard Review Council and an Administrative Law Judge affirmed the denial, Gonzalez pursued legal action. The District Court granted the defendant's motion, affirming the Secretary's decision, finding that while the ALJ's reasoning was unclear, substantial evidence supported the conclusion that Gonzalez's extended hospital stay was due to non-medical "disposition problems" rather than a medical necessity for skilled nursing care.

Medicare benefitscustodial careskilled nursing careSocial Security Acthospital dischargemedical necessityadministrative reviewdenial of benefitsUtilization Review CommitteeAppeals Council
References
8
Case No. MISSING
Regular Panel Decision

Claim of Lamia v. New York City Transit Authority

The claimant, a 62-year-old painter, suffered a work-related back injury in 1979. After receiving initial benefits, he returned to light duty but stopped due to pain and retired on pension in July 1980, moving to Florida. The case was reopened in 1981 based on a medical report from Dr. Jack Lund, who diagnosed chronic lumbo sacral myositis and total disability. An administrative law judge rejected the employer's argument that the claimant voluntarily left the labor market and awarded reduced compensation. The Workers’ Compensation Board affirmed this decision. The appellate court further affirmed the board's decision, ruling that the determination of disability versus voluntary withdrawal from the labor market was a factual question supported by substantial evidence. The court also upheld the rejection of the employer's untimely medical reports.

Workers' CompensationLabor Market WithdrawalPermanent DisabilityBack InjuryMedical EvidenceAppellate ReviewSubstantial EvidenceTreating PhysicianEmployer AppealTimely Medical Report Filing
References
2
Case No. MISSING
Regular Panel Decision

Claim of Avila v. St. Francis Hospital

In this Workers' Compensation case, the claimant, an orderly, sustained a low back injury in 1965 while employed by St. Francis Hospital. Initially diagnosed with a lumbo-sacral strain and an unstable back, a lump-sum settlement was approved in 1969 based on a mild causally related partial disability. Nearly a decade later, in 1978, the claimant applied to reopen the settlement due to severe leg pain and a confirmed extruded disc at L5-S1, requiring a laminectomy. The Workers’ Compensation Board reversed a Law Judge's finding, determining that there was a change in condition and degree of disability not contemplated at the time of the original settlement. The Special Fund for Reopened Cases appealed this decision, arguing against the reopening. The Appellate Division affirmed the Board's decision, citing that the definitive change from a mild disability to a herniated disc requiring surgery was an uncontemplated medical condition change, justifying the reopening under Workers’ Compensation Law § 15 (5-b).

Reopened CaseLump-Sum SettlementPermanent Partial DisabilityHerniated Lumbar DiscLaminectomyChange of ConditionUncontemplated Medical ConditionWorkers' Compensation Board DecisionAppellate ReviewMedical Evidence
References
2
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