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

Case No. SAL SJO 252436 (MF); SJO 246192
Regular
Jul 02, 2007

NIHAL HORDAGODA vs. State Compensation Insurance Fund

This case involves an employer's petition for reconsideration of an order authorizing medical treatment and admitting the Qualified Medical Examiner's (QME) reports. The employer argued the QME reports were inadmissible due to an alleged ex parte communication between the applicant and the QME, and that the awarded treatments were improper. The report recommends denying the petition, finding the communication was permissible under LC § 4062.3(h) and that the QME's opinions and awarded treatments for chronic pain were reasonable and not governed by ACOEM guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationQualified Medical EvaluatorLabor Code Section 4062.3Ophthalmological evaluationFunctional capacity evaluationUtilization ReviewACOEM GuidelinesChronic spinal conditionTreating physician
References
0
Case No. ADJ9127012, ADJ9127010
Regular
Aug 10, 2015

ROSA RUIZ vs. BARON HR, LLC, ZURICH AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) dismissed the defendant's Petition for Reconsideration because it sought review of a non-final order. The Board granted removal and rescinded the Finding of Fact, which determined the correct Qualified Medical Evaluator (QME) specialty was chiropractic. The matter was returned to the WCJ for further proceedings to determine the validity of QME panels and reports. This included whether the defendant was properly served and if the selected QME specialty and report were valid.

QME specialty disputePetition for ReconsiderationPetition for Removalnon-final ordersubstantive right or liabilityprocedural non-final ordersprejudicial errorirreparable harmspecific injurycumulative trauma
References
10
Case No. ADJ8529720
Regular
Feb 06, 2017

ALEJANDRA GONZALEZ vs. 3M COMPANY, OLD REPUBLIC INSURANCE

This case concerns whether an untimely supplemental Qualified Medical Evaluator (QME) report warrants a replacement panel. The applicant requested a new panel because the original QME's supplemental report was late. The WCJ denied the defendant's request to keep the original QME, finding the defendant waived objection by striking a name from the new panel. The Appeals Board granted removal, rescinded the WCJ's order, and remanded the case. The Board clarified that striking a name from a new panel does not automatically waive the right to object to its validity.

PQMESupplemental ReportReplacement PanelLabor Code 4062.5DWC Medical UnitDeclaration of ReadinessMSCWaiverAdministrative Director Rule 38Rule 31.5
References
0
Case No. ADJ1384238 (SAC 0366460)
Regular
Oct 09, 2017

ROSA VIRGEN vs. MACY'S WEST, MACY'S CORPORATE SERVICES-RISK MANAGEMENT DEPARTMENT

The Workers' Compensation Appeals Board denied Macy's West's petition for removal, upholding the WCJ's decision not to grant a replacement Qualified Medical Evaluator (QME). The Board found that a late supplemental report alone does not mandate a replacement QME under LC 4062.5 or AD Rule 31.5(a)(12). Granting a replacement QME for untimely supplemental reporting is discretionary and requires a showing of good cause, which Macy's failed to demonstrate. The Appeals Board retains exclusive jurisdiction over the validity of replacement panels.

Workers' Compensation Appeals BoardPetition for RemovalQualified Medical EvaluationPQMEReplacement PanelMedical DirectorTimelinessSupplemental ReportGood CausePrejudice
References
4
Case No. ADJ6470549
Regular
Feb 27, 2012

KATHRYN BENSON vs. CITY OF SAN DIEGO

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior decision, allowing a Qualified Medical Examiner's (QME) report into evidence. The original decision excluded the QME report, finding no ratable permanent disability based on the treating physician's opinion. The Appeals Board found the QME report should have been admitted, as there are no explicit time limits for objecting to a treating physician's report or obtaining a QME evaluation for permanent disability. The case is remanded for further proceedings on permanent disability and attorney's fees with the QME report now part of the record.

Workers Compensation Appeals BoardFindings and AwardPetition for ReconsiderationQualified Medical Examiner (QME)Permanent DisabilityFuture Medical TreatmentTreating PhysicianAgreed Medical Examiner (AME)Labor Code Section 4061Strawn v. Golden Eagle Insurance Co.
References
1
Case No. ADJ8162481
Regular
Aug 29, 2014

JERRY CRADDUCK vs. LOS ANGELES COUNTY OFFICE OF EDUCATION

This case involves the denial of a defendant's Petition for Removal regarding a workers' compensation matter. The defendant sought to have a Qualified Medical Evaluator (QME) report admitted, arguing the applicant's objection was untimely. However, the Board found the QME's report was indeed untimely and the applicant's objection was valid. Removal was denied because the defendant failed to demonstrate substantial prejudice and the WCAB Rules were also violated by the defendant.

Petition for RemovalQualified Medical Evaluator (QME)Untimely ReportOff CalendarStatus ConferenceMedical UnitReplacement PanelTimeliness ObjectionComprehensive Medical-Legal EvaluationMedical Director
References
2
Case No. ADJ7899192, ADJ7902366
Regular
Oct 21, 2019

VALERIE DAILEY vs. SCRIPPS HEALTH

The applicant sought reconsideration of a finding that her psychiatric injury was not a compensable consequence of her industrial neck and elbow injuries. The Board found that the prior QME's report, which applicant sought to admit, should have been considered as it was not properly excluded. The Board also noted that the subsequent QME's report did not review the prior QME's findings, potentially rendering it incomplete. Consequently, the Board rescinded the award and returned the matter for further proceedings to admit the prior QME's report and allow the subsequent QME to review it.

Workers Compensation Appeals BoardPsychiatric InjuryCompensable ConsequenceQualified Medical EvaluatorQME ReportAdmissibility of EvidenceMedical EvaluationFurther ProceedingsFindings and AwardReconsideration
References
9
Case No. ADJ2328508 (FRE 0173522)
Regular
Mar 09, 2009

BETTY DORN vs. HEILIG MANUFACTURING, LUMBERMENS MUTUAL CASUALTY COMPANY

This case involves a lien claimant seeking reconsideration of a WCJ's decision to deny most of its claim for chiropractic services. The WCJ limited the award to treatment rendered before the applicant was notified to seek care within the employer's Medical Provider Network (MPN). The lien claimant argued the WCJ improperly relied on a QME's report and should have considered a second QME's report finding a "serious chronic condition" justifying out-of-MPN treatment. The Appeals Board affirmed the WCJ's decision, finding the first QME's report constituted substantial evidence, the request for a second QME was improperly made by the lien claimant after objections to the first report's timeliness were waived, and the lien claimant failed to prove its MPN membership.

Medical Provider Network (MPN)Qualified Medical Evaluator (QME)Serious Chronic ConditionLien ClaimantPetition for ReconsiderationFindings of Fact and AwardLabor Code Section 4616.2Substantial Medical EvidencePanel QMETimeliness of Report
References
3
Case No. ADJ7294109
Regular
Jun 07, 2013

MANSOUREH AZIMZADEH vs. BURG & BROCK, EMPLOYERS COMPENSATION CO.

This case involves an applicant challenging a Workers' Compensation Judge's decision to disregard the Qualified Medical Examiner's (QME) reports due to flawed apportionment analysis and ordering a new QME panel. The Appeals Board granted removal, rescinded the order for a new QME panel, and returned the matter for further development of the record. The Board agreed that the QME's reports lacked substantial medical evidence due to a misunderstanding of apportionment law and that further development with the same QME would be unhelpful. The Board emphasized that new medical-legal reporting would be necessary to properly weigh evidence.

RemovalReconsiderationPetitionPanel Qualified Medical ExaminerPQMESubstantial Medical EvidenceApportionmentFindings and OrderMedical UnitDiscovery
References
9
Case No. ADJ1934243 (FRE 0221043)
Regular
Apr 25, 2011

MARIA RAYOS vs. WALGREENS, ZURICH INSURANCE COMPANY

This case concerns a dispute over a second Qualified Medical Examiner (QME) for an applicant with a work-related knee, back, and hip injury. The defendant sought removal, arguing that allowing a second QME without striking the first QME's reports violated due process and would taint the new evaluation. The Appeals Board granted removal, amended the prior order, and clarified that a new QME is allowed. However, the admissibility of the first QME's reports is deferred to the trial judge, and those reports, unlike diagnostic study results, are not to be provided to the new evaluator.

Petition for RemovalQualified Medical Evaluator (QME)Admissibility of ReportsDue ProcessWorkers' Compensation Appeals Board (WCAB)Administrative Law Judge (WCJ)Industrial InjuryMedical EvaluationsDiscoveryMandatory Settlement Conference (MSC)
References
0
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