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

Case No. ADJ10975151
Regular
Jan 06, 2020

RUSSELL CAMARA vs. TESLA, INC., AMERICAN ZURICH INSURANCE COMPANY

In this workers' compensation case, the Applicant sustained an admitted industrial injury to the lumbar spine. The Applicant's primary treating physician (PTP) designated a secondary physician to evaluate permanent and stationary status and impairment, whose report the PTP adopted. The defense challenged the validity of this secondary physician's report, arguing only the Panel Qualified Medical Examiner's (PQME) report was properly obtained. The Workers' Compensation Appeals Board denied the Petition for Reconsideration, affirming that the PTP, or a physician designated by the PTP, is authorized to render opinions on medical issues, provided proper notice and procedural requirements are met. The Board found the designation and subsequent report were compliant with Labor Code and Administrative Director Regulations.

Workers' Compensation Appeals BoardPetition for ReconsiderationPrimary Treating PhysicianQualified Medical ExaminerLabor Code Section 4061.5Permanent and Stationary ReportMedical-Legal EvaluationSecondary PhysicianAdministrative Director Rule 9785Designation of Physician
References
0
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. MISSING
Regular Panel Decision
Apr 07, 1988

De Coste v. Champlain Valley Physicians Hospital

Decedent, Darwin A. De Coste, experienced chest pain and elevated blood pressure, leading him to Champlain Valley Physicians Hospital where he was seen by Dr. William Amsterlaw. Amsterlaw diagnosed reflux esophagitis despite an abnormal electrocardiogram, discharging De Coste, who subsequently suffered a fatal cardiopulmonary arrest 12 hours later. The administrator of De Coste's estate filed a wrongful death action, alleging medical malpractice and that the misdiagnosis was the proximate cause of death. A jury awarded pecuniary damages and funeral expenses, which the defendants appealed. The appellate court affirmed the verdict, finding rational support for the jury's malpractice finding and rejecting the defendants' argument to reduce the award by Social Security benefits due to the effective date of CPLR 4545 (c).

Medical MalpracticeWrongful DeathProximate CauseCollateral Source RuleCPLR 4545Jury VerdictEmergency Room CareMisdiagnosisArteriosclerosisMyocardial Infarction
References
3
Case No. ADJ7484505, ADJ7484506
Regular
Dec 18, 2019

FRANCISCO VILCHIS MONDRAGON vs. PACIFIC FLOOR COVERING, ULLICO CASUALTY COMPANY

The Workers' Compensation Appeals Board granted reconsideration to award a lien claimant reimbursement for psychological treatment services. The Board found that the primary treating physician did refer the applicant to the lien claimant, received and reviewed the lien claimant's reports, and thus complied with reporting requirements. This reversed the trial judge's denial of the lien based on the primary physician's alleged failure to incorporate the secondary physician's reports. The matter was returned for determination of the amount owed.

Workers' Compensation Appeals BoardLien ClaimantPsychological Assessment ServicesPrimary Treating PhysicianSecondary Treating PhysicianRule 9785(e)(4)Reporting RequirementsMedical Treatment ExpensesIndustrial InjuryPsyche
References
3
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
6
Case No. ADJ3748071 (LAO 0785567) ADJ3607480 (LAO 0784668)
Regular
Dec 13, 2010

RALPH OLIVAS vs. SMART & FINAL, Permissibly Self-Insured

This case involves petitions for reconsideration from the applicant and lien claimants Sycamore Pharmacy and Bloch Medical Clinic regarding a WCJ's decision disallowing their liens. The WCJ found no industrial injury to the psyche and disallowed the liens because the primary treating physician, Dr. Schiffman, never adopted or commented on the secondary physicians' reports, failing to comply with Labor Code section 4061.5 and Rule 9785. The Board denied reconsideration, finding the lien claimants failed to meet their burden of proof, the tendered "newly discovered" evidence was not newly discovered, and the defendant did not waive their right to raise the issue of the primary physician's non-adoption.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderIndustrial InjuryPsycheMedical Treatment LiensPrimary Treating Physician (PTP)Qualified Medical Evaluator (QME)Joint Compromise and ReleaseStipulated Award
References
7
Case No. MISSING
Regular Panel Decision

Tesillo v. Emergency Physician Associates, Inc.

Manuel Tesillo sued Emergency Physician Associates, Inc. (EPA) for medical malpractice, alleging vicarious liability for the negligence of Dr. William C. Shepherd, an emergency physician at Schuyler Hospital. EPA moved for summary judgment, arguing Dr. Shepherd was an independent contractor. The court found material issues of fact regarding the extent of EPA's control over Dr. Shepherd and its managerial obligations to the Emergency Department, which could establish an employer-employee relationship despite contractual terms. Consequently, the court denied EPA's motion for summary judgment, indicating that the determination of Dr. Shepherd's employment status requires further discovery and possibly a trial.

Medical MalpracticeVicarious LiabilityRespondeat SuperiorIndependent ContractorAgency by EstoppelSummary JudgmentPhysician NegligenceEmergency DepartmentControl TestMaterial Issues of Fact
References
18
Case No. ADJ7160976
Regular
Sep 25, 2012

ANTONETTA WILLIAMS vs. CLAIRE'S STORES, INC., TRAVELERS INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded the prior award and returned the case for further proceedings because the administrative law judge improperly relied on a secondary treating physician's report. The judge failed to establish that the requested attendant care was authorized or constituted substantial medical evidence. The Board emphasized that the primary treating physician must issue opinions on medical issues and the record needs further development to determine entitlement to attendant care.

Attendant carePrimary treating physicianSecondary treating physicianMedical treatment authorizationUtilization reviewSubstantial medical evidenceWorkers' Compensation Appeals BoardFindings and AwardReconsiderationAgreed Medical Examiner
References
0
Case No. ADJ7469888
Regular
Jul 09, 2013

MARIA RODRIGUEZ vs. MODERN DEVELOPMENT COMPANY, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior award finding applicant sustained industrial injury with 59% permanent disability. The WCAB rescinded the award because the applicant's primary treating physician's final report, which incorporated secondary physician opinions, was improperly excluded from evidence. This exclusion prevented the WCAB from determining compliance with Labor Code section 4061.5 and relevant regulations. The case is returned to the WCJ for further proceedings and a new decision.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact and AwardPrimary Treating PhysicianSecondary Treating PhysiciansLabor Code Section 4061.5Rule 9785Mandatory Settlement Conferencesubstantial evidencecumulative trauma
References
5
Case No. ADJ8323717
Regular
Mar 24, 2014

MARIA GONZALEZ vs. AMERICAN APPAREL, INC.; NEW HAMPSHIRE INSURANCE COMPANY, administered by ATHENS ADMINISTRATORS

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior "take nothing" order. The Board found that the administrative law judge improperly excluded four medical reports from secondary treating physicians, ruling they were admissible evidence even if not reviewed by the primary treating physician. The case is returned to the trial level for further proceedings and decision, with the admitted medical reports to be considered. The Board emphasized that this does not reopen discovery, but allows the WCJ to weigh all evidence to determine industrial causation.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact and OrderIndustrial CausationMedical ReportsAdmissible EvidencePrimary Treating PhysicianSecondary Treating PhysicianValdez v. Workers' Comp. Appeals Bd.Labor Code Section 4061.5
References
2
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