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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

Pizzo v. Barnhart

Plaintiff Kathleen Pizzo appealed the Commissioner of the Social Security Administration's final determination denying her disability insurance benefits. The District Court reviewed the ALJ's decision, which had assigned no weight to the treating physician's opinion and significant weight to a consulting physician's report. The court found that the ALJ erred by failing to give appropriate weight to the treating physician's opinion, not adequately developing the administrative record to obtain missing medical notes, and giving undue weight to the consulting physician's report which did not explicitly support the capacity for sedentary work. Consequently, the Commissioner's determination was remanded for further administrative proceedings consistent with the District Court's decision, granting the plaintiff's motion for judgment on the pleadings to the extent of the remand and denying the Commissioner's cross-motion.

Social Security ActDisability Insurance BenefitsAdministrative Law JudgeTreating Physician RuleResidual Functional CapacitySedentary WorkMedical EvidenceRemandSubstantial EvidenceRecord Development
References
23
Case No. 2022 NY Slip Op 01758 [203 AD3d 531]
Regular Panel Decision
Mar 15, 2022

Valentine v. 2147 Second Ave. LLC

Michael Valentine, a project safety coordinator for Homeland Safety Consultants, sued 2147 Second Avenue LLC and other defendants for injuries sustained at a demolition and construction site. The Supreme Court, Bronx County, granted summary judgment to defendants Gary Silver Architects, P.C. and Sunshine Quality Construction, Inc., dismissing the complaint against them, and denied Valentine's motion for partial summary judgment on his Labor Law § 240 (1) claim. The Appellate Division, First Department, affirmed this decision, finding no evidence of affirmative negligence by GSA and concluding that Sunshine was not on site as a general contractor until after the accident. The court also upheld the denial of Valentine's Labor Law claim, noting it was never properly pleaded in his complaints.

Demolition ProjectConstruction AccidentProject Safety CoordinatorSummary JudgmentLabor Law § 240 (1)Affirmative NegligenceGeneral Contractor LiabilityPleading AmendmentsAppellate ReviewPremises Liability
References
4
Case No. ADJ6575307
Regular
Jan 21, 2011

NANCY ANDREWS vs. LAW OFFICES OF KENNETH REYNOLDS, OAK RIVER INSURANCE COMPANY

This case involves a workers' compensation applicant who sustained industrial injuries to her back and upper extremities. The defendant sought reconsideration of a prior award, arguing they were not obligated to conduct utilization review or obtain a second opinion regarding a spinal surgery recommendation from Dr. Anderson. The Appeals Board denied the petition, finding the defendant failed to timely object or initiate the required processes after Dr. Anderson recommended the same surgery previously suggested by a second-opinion physician. The Board clarified that utilization review and second opinion obligations extend to any physician's treatment recommendations, not solely the primary treating physician.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryBack InjuryUpper ExtremitiesPrimary Treating PhysicianUtilization Review (UR)Second Opinion ProcessLabor Code Section 4062
References
1
Case No. ADJ11328275
Regular
Dec 10, 2018

DENISE DOYLE vs. TECH MAHINDRA (AMERICAS) INC., ALLMERICA FINANCIAL BENEFIT INSURANCE COMPANY, HANOVER INSURANCE GROUP

The defendant sought reconsideration of an order allowing the applicant to consult a second physician within the employer's Medical Provider Network (MPN). The defendant argued that the MPN physician's release from care was not a dispute over diagnosis or treatment, and Labor Code sections 4061 and 4062, requiring medical-legal evaluations, applied instead. The Appeals Board dismissed the petition, finding it was not taken from a final order as it did not determine substantive rights or liabilities. The Board also noted that even if considered on its merits, the petition would be denied because Labor Code Section 4616.3 and Administrative Director Rule 9785(b)(3) allow an employee to seek a second opinion within the MPN when disputing a release from care.

Workers' Compensation Appeals BoardPetition for ReconsiderationMedical Provider NetworkMPNLabor Code Section 4616.3Second Physician ConsultMedical-Legal EvaluationFinal OrderSubstantive Right or LiabilityThreshold Issue
References
4
Case No. MISSING
Regular Panel Decision
Aug 29, 1991

Ass'n of Surrogates & Supreme Court Reporters Within the City of New York v. New York

This case involves a motion by Defendant Matthew T. Crosson for an order entering judgment following a remand from the Second Circuit. The Second Circuit had declared New York's lag-payroll law unconstitutional, enjoining its effects and directing restitution of lagged wages for affected nonjudicial employees of the Unified Court System. The key issue in this district court opinion is whether the restitution should be paid from the 1990-1991 Judiciary Budget, which was set to lapse, and whether prejudgment interest should be awarded. The court granted Defendant Crosson's motion, ordering the immediate payment of lagged wages totaling $9.2 million from the 1990-1991 appropriation to avoid further layoffs and ensure timely restitution. Additionally, the court awarded prejudgment interest at a rate of nine percent, calculated from March 13, 1991, to fully compensate the plaintiffs for the delayed payment of their rightfully earned wages.

Lag Payroll LawConstitutional LawContract ClauseEquitable RemediesRestitutionPrejudgment InterestState Finance LawJudiciary BudgetSecond CircuitDistrict Court Decision
References
18
Case No. ADJ9667092
Regular
Jan 12, 2016

Virginia Fernandez vs. KMART, ACE AMERICAN INSURANCE COMPANY

Applicant Virginia Fernandez injured her knee and wrist, but her MPN physician's report was contradictory and failed to address all complaints, leading to a dispute. The defendant denied her request for a second opinion within the MPN, insisting she use the panel QME process. The Appeals Board found the applicant was entitled to a second opinion within the MPN to resolve the dispute over her treatment. However, the Board reversed the lower judge's order, ruling the defendant's refusal did not constitute a denial of medical treatment allowing her to seek care outside the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNSecond Opinion PhysicianQualified Medical EvaluatorQMEDenial of Medical TreatmentLabor Code section 4616.3Labor Code section 4616.4Independent Medical Review
References
3
Case No. ADJ1124701 (OAK 0304697)
Regular
Jan 25, 2010

GENE THOMAS vs. SLEEP TRAIN MATTRESS CENTER, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision favoring the applicant's spinal surgery, finding that proper procedural steps were not followed. The employer's utilization review (UR) had denied the surgery, but neither party followed the required second-opinion process under Labor Code section 4062(b). The WCAB returned the case to the trial level, allowing the employer ten days from receipt of the decision to object to the surgery and initiate the second-opinion process. This decision aligns with the WCAB's en banc ruling in *Cervantes*, which clarified the procedures for handling spinal surgery disputes after UR denials.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code section 4062(b)Spinal SurgerySecond OpinionCervantes v. El Aguila Food ProductsACOEM GuidelinesExperimental TreatmentEn Banc DecisionAdministrative Director Rules
References
4
Case No. ADJ3262542 (GRO 27301) ADJ437058 (GRO 28637)
Regular
Jan 25, 2010

Herman Dennler vs. TIMEC CO., INC., ST. PAUL TRAVELERS, OPEN WAVES SYSTEMS, LUMBERMAN'S MUTUAL CASUALTY COMPANY, BROADSPIRE

The Workers' Compensation Appeals Board denied St. Paul Travelers' petition for reconsideration regarding a Findings and Award. The WCJ found the applicant needed surgery as recommended by Dr. Khoo and that Travelers unreasonably delayed its authorization. The Board affirmed the WCJ's findings, citing Labor Code § 4062(b) which mandates employer authorization of surgery when a second opinion evaluator recommends it. Travelers' failure to authorize the recommended revision surgery, despite a second opinion report, constituted an unreasonable delay warranting increased compensation and attorney fees.

Labor Code § 4062(b)Petition for ReconsiderationFindings and AwardPetition for ReconsiderationOpinion and OrderWCJLabor Code § 5814Labor Code § 5814.5Industrial InjuryLumbar Spine
References
1
Case No. ADJ19947925
Regular
May 19, 2025

Andres De Jesus Garcia vs. Slater's 50/50, Security National Insurance Company

Applicant, Andres De Jesus Garcia, sought reconsideration of a March 12, 2025 Findings and Award (F&A) which denied his request for a new primary treating physician (PTP) or a second opinion. The workers' compensation administrative law judge (WCJ) had found that the applicant reached maximum medical improvement (MMI) based on reports from his PTP and a panel qualified medical evaluator (PQME). Applicant contended he is entitled to a change of PTP or a second opinion within the medical provider network (MPN) under various Labor Code sections and WCAB Rules. The Appeals Board granted the Petition for Reconsideration, deferring a final decision after reconsideration to allow for further review of the factual and legal issues.

Petition for ReconsiderationMedical Provider Network (MPN)Primary Treating Physician (PTP)Maximum Medical Improvement (MMI)Qualified Medical Evaluator (PQME)Labor Code sections 4616.3 and 4616.4WCAB Rules 9767.6(e) and 9767.7Tenet/Centinela Hospital Medical Center v. Workers' Comp. Appeals Bd. (Rushing)Labor Code section 5909Electronic Adjudication Management System (EAMS)
References
12
Case No. ADJ7908543
Regular
Nov 13, 2012

JOSE RIVAS vs. CALIFORNIA CARPET, LLC, ICW GROUP

In Rivas v. California Carpet, LLC, the Appeals Board granted the defendant's Petition for Removal, rescinding a prior award of spinal surgery. The WCJ had improperly excluded the second opinion physician's report as untimely. The Board found the applicant waived his objection to the report's untimeliness by not raising it until after the examination. The case was returned to the trial level for reconsideration of the surgery's necessity, including the second opinion report.

Petition for RemovalFindings and AwardSpinal SurgeryPrimary Treating PhysicianSecond Opinion PhysicianLabor Code Section 4062(b)Timeliness ObjectionWaiverExpedited HearingMedical Unit
References
1
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