What the panel ordered
Findings and Order of August 27, 2020 rescinded; case returned to WCJ for further proceedings and new decision.
Petition for Reconsideration granted to further study factual and legal issues; prior Findings and Order rescinded and matter returned to WCJ for further proceedings.
What was disputed, and how it came out
Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.
Dr. Shaw's medical opinions were found not to be substantial evidence because they were based on an inadequate medical history and lack of review of treating physicians' records, leading to rescission of the prior Findings and Order and remand for further proceedings.
From the decision · page 1Applicant seeks reconsideration of the Findings and Order (F&O) issued by the workers' compensation administrative law judge (WCJ) on August 27, 2020, wherein the WCJ found in pertinent part that based on the reports of pain medicine qualified medical examiner (QME) James B. Shaw, M.D., applicant did not sustain injury arising out of and in the course of employment (AOE/COE), to her head, back, neck, and shoulder; and the WCJ ordered that applicant take nothing by way of her injury claim.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Dr. Shaw stated he needed treating physicians' medical records to accurately understand the work injury claim but was not provided those records.
Favours Applicant prevailed
Without review of these records, Dr. Shaw's opinions were based on inadequate medical history and thus not substantial evidence.
From the decision · page 4As quoted above, in his October 7, 2019 report, Dr. Shaw stated, "I will require the records of the treating physicians to accurately understand her alleged work injuries versus whether she is simply being treated for prior injuries." (Joint Exh. 101, October 7, 2019, p. 29.) In his December 26, 2019 supplemental report, Dr. Shaw makes no reference to any "records of the treating physicians" nor is there any evidence that he was provided such reports for his review. Dr. Shaw clearly stated that he needed to review the treating physicians' medical records in order to "accurate understand" applicant's work injury claim. Therefore, absent his review of those records, his opinions are based on an inadequate medical history, and in turn are not substantial evidence. (Place v. Workmen's Comp. Appeals Bd, supra; Hegglin v. Workmen'sComp. Appeals Bd, supra.)
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Dr. Shaw opined applicant did not sustain injury AOE/COE to head, back, neck, and shoulder, but his opinions were based on inadequate medical history and lack of treating physicians' records, thus not substantial evidence.
Dr. Shaw stated he needed treating physicians' records to accurately understand the work injury claim but did not have them, making his opinions inadequate and not substantial evidence.
From the decision · page 1Applicant seeks reconsideration of the Findings and Order (F&O) issued by the workers' compensation administrative law judge (WCJ) on August 27, 2020, wherein the WCJ found in pertinent part that based on the reports of pain medicine qualified medical examiner (QME) James B. Shaw, M.D., applicant did not sustain injury arising out of and in the course of employment (AOE/COE), to her head, back, neck, and shoulder; and the WCJ ordered that applicant take nothing by way of her injury claim.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Place v. Workmen's Comp. Appeals Bd. (1970) 3 Cal.3d 372; Hegglin v. Workmen's Comp. Appeals Bd. (1971) 4 Cal.3d 162; Zemke v. Workmen's Comp. Appeals Bd. (1968) 68 Cal.2d 794
An opinion based on inadequate medical history or incorrect legal theory is not substantial evidence.
Dr. Shaw's opinions were rejected as not substantial evidence because they were based on inadequate medical history and lack of treating physicians' records.
From the decision · page 4DISCUSSION It has long been established that a medical opinion does not constitute substantial evidence if it is based on inadequate medical histories or examinations, or on surmise, speculation, conjecture, or guess. (Place v. Workmen's Comp. Appeals Bd. (1970) 3 Cal.3d 372 [35 Cal.Comp.Cases 525]; Hegglin v. Workmen's Comp. Appeals Bd. (1971) 4 Cal.3d 162 [36 Cal.Comp.Cases 93].) Also, a physician's opinion that is predicated upon an incorrect legal theory is not substantial evidence. (Zemke v. Workmen's Comp. Appeals Bd. (1968) 68 Cal.2d 794 [33 Cal.Comp.Cases 358, 363].) Labor Code section 3208.1 defines injury as follows:
Labor Code 3208.1
Definition of injury under Labor Code section 3208.1.
The issue involved injury arising out of and in the course of employment.
From the decision · page 4An injury may be either: (a) "specific," occurring as the result of one incident or exposure which causes disability or need for medical treatment; or (b) "cumulative," occurring as repetitive mentally or physically traumatic activities extending over a period of time, the combined effect of which causes any disability or need for medical treatment. The date of a cumulative injury shall be the date determined under Section 5412. (Lab. Code § 3208.1)
What proof carried it
The evidence the panel weighed, by kind.
Dr. Shaw's opinions were based on inadequate medical history and lack of review of treating physicians' records.
From the decision · page 4As quoted above, in his October 7, 2019 report, Dr. Shaw stated, "I will require the records of the treating physicians to accurately understand her alleged work injuries versus whether she is simply being treated for prior injuries." (Joint Exh. 101, October 7, 2019, p. 29.) In his December 26, 2019 supplemental report, Dr. Shaw makes no reference to any "records of the treating physicians" nor is there any evidence that he was provided such reports for his review. Dr. Shaw clearly stated that he needed to review the treating physicians' medical records in order to "accurate understand" applicant's work injury claim. Therefore, absent his review of those records, his opinions are based on an inadequate medical history, and in turn are not substantial evidence. (Place v. Workmen's Comp. Appeals Bd, supra; Hegglin v. Workmen'sComp. Appeals Bd, supra.)
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
- Issues, outcomes and weights were extracted by AI and released only where the source passage checked. Read the official decision before relying on anything here. Not legal advice.
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