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

Case No. ADJ3133261 (VNO 0400017)
Regular
Aug 17, 2010

FELIPE TOLENTINO vs. CONCO CEMENT, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, XCHANGING INC., FREMONT COMPENSATION

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's petition for reconsideration as premature. The WCAB granted the defendant's petition for reconsideration regarding the temporary disability overpayment issue, deferring it for further proceedings. The Board affirmed the WCJ's findings on injury causation and permanent disability but amended the decision to clarify the overpayment issue. Finally, the WCAB issued a notice of intention to sanction defendant's counsel for attaching and citing unadmitted evidence.

Workers' Compensation Appeals BoardFELIPE TOLENTINOCONCO CEMENTCALIFORNIA INSURANCE GUARANTEE ASSOCIATIONXCHANGING INC.FREMONT COMPENSATIONliquidationADJ3133261VNO 0400017OPINION AND ORDERS DISMISSING PETITION FOR RECONSIDERATION AND GRANTING PETITION FOR RECONSIDERATION
References
Case No. ADJ308368 (SAC 0337296)
Regular
Feb 24, 2011

JENNIFER ROBERSON vs. BEYER PONGATZ & ROSEN, STATE COMPENSATION INSURANCE FUND INSURED SACRAMENTO

In this workers' compensation case, the applicant sought reconsideration of a finding that the defendant insurer was not obligated to serve the applicant or her attorney with a request for additional information sent to the applicant's physician. The applicant argued this lack of service prevented her from knowing if timely requests were made. However, the Board dismissed the petition because the underlying issue was moot, as the requested medical treatment had already been authorized. Therefore, the applicant was no longer aggrieved by the service dispute.

Workers' Compensation Appeals BoardPetition for ReconsiderationDismissalMootnessAggrieved PartyWCJTreating PhysicianTreatment RequestAdditional InformationService of Process
References
Case No. ADJ3540065 (SAC 0361552)
Regular
Jan 23, 2017

BRADLEY MAXHAM vs. CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted the defendants' Petition for Removal, rescinding a prior WCJ order. The Board clarified that "information" provided to an Agreed Medical Evaluator (AME) includes treating physician records and relevant medical/non-medical records. A communication becomes "information" if it contains, references, or encloses such records. The case was returned for further proceedings to determine if applicant's letters to the AMEs improperly conveyed "information" without party agreement.

Agreed Medical EvaluatorInformationCommunicationLabor Code Section 4062.3Petition for RemovalEn Banc DecisionWorkers' Compensation Appeals BoardPrejudiceIrreparable HarmSubstantial Evidence
References
Case No. MON 284627
Regular
Aug 11, 2008

BEVERLY DE ROSA vs. STATE OF CALIFORNIA

The Workers' Compensation Appeals Board granted reconsideration to review a sanctions order against the defendant for alleged willful failure to comply with a prior order. The defendant's claims adjuster asserted they had provided the required earnings information within the deadline, which conflicted with the initial finding of non-compliance. The Board rescinded the sanctions and returned the case for further proceedings to determine whether the defendant actually complied with the order.

Workers' Compensation Appeals BoardBeverly De RosaState Compensation Insurance FundLabor Code section 5813willful failure to complySupplemental Findings and Order Imposing Sanctionsapplicant's earningscervical spinepsychestipulated Findings and Award
References
Case No. ADJ3540065
En Banc
Jan 23, 2017

BRADLEY MAXHAM vs. CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION, STATE COMPENSATION INSURANCE FUND

The Appeals Board clarifies the distinction between "information" and "communication" under Labor Code § 4062.3, holding that a communication to a medical evaluator becomes "information" if it contains, references, or encloses medical or nonmedical records relevant to the medical issue, which requires prior agreement between the parties.

Workers' Compensation Appeals BoardPetition for RemovalAgreed Medical Evaluator (AME)Labor Code section 4062.3WCAB Rule 35informationcommunicationprejudiceirreparable harmex parte communication
References
Case No. ADJ9718068
Regular
Dec 01, 2016

ROGER PECORARO vs. PT GAMING, LLC, MATSUI SUMITOMO INSURANCE COMPANY, GALLAGHER BASSET SERVICES

The Workers' Compensation Appeals Board rescinded the Finding & Order and the Order Approving Compromise and Release. This action was taken because the defense counsel improperly sent non-medical records, including a Facebook page printout, to the Qualified Medical Evaluator (PQME) despite applicant's timely objection. Additionally, the Compromise and Release was improperly approved as a walk-through settlement without applicant's attorney present and without proper verification or referral to an Information and Assistance Officer. The case is returned to the trial level for further proceedings.

PQMELabor Code section 4062.3WCAB Rules 35impermissible documentsFacebook postsurveillance videoprocedural irregularitiesOrder Approving Compromise and Releasereconsiderationremoval
References
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
Case No. ADJ7288330
Regular
Oct 03, 2016

GLORIA BENITEZ vs. NEWPORT SUBACUTE HEALTH CARE CENTER, ALASKA NATIONAL INSURANCE COMPANY

The applicant, Gloria Benitez, sought to reopen her workers' compensation claim to include injury to additional body parts beyond her cervical spine and psyche. The original award found injury only to the cervical spine and psyche, with a 19% permanent disability rating for the cervical spine. While the WCJ's initial decision denied injury to additional body parts, the Board granted reconsideration. The Board amended the original findings to defer the issue of injury to the alleged additional body parts, while affirming other aspects of the WCJ's order, including the appointment of a regular physician to evaluate new and further disability.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderNew and Further DisabilityAgreed Medical ExaminerRegular PhysicianLabor Code Section 5410Petition to ReopenIndustrial InjuryCervical Spine
References
Case No. ADJ693974 (OAK 0242212)
Regular
Apr 26, 2019

Glory Shreeve vs. Village Shops/ Ethan Allen Carriage House, Superior National Insurance Company, BROADSPIRE, California Insurance Guarantee Association

In this Workers' Compensation Appeals Board case, applicant Glory Shreeve sought authorization for medical treatment, which was denied by the defendant's Utilization Review (UR) provider. Applicant argued the UR denials were untimely because requests for additional information were not made by a licensed physician, thus invalidating the delays and granting the Board jurisdiction over medical necessity. The Board affirmed the Administrative Law Judge's decision, finding that the UR provider's requests for additional information did not violate Labor Code Section 4610(e) and that the denials were issued within the extended timeframes permitted by DWC Rule 9792.9.1. Consequently, the Board held it lacked jurisdiction to determine the reasonableness and necessity of the requested medical treatment due to the timely UR denials.

Utilization ReviewRequest for AuthorizationLabor Code section 4610(e)DWC Rule 9792.9.1TimelinessJurisdictionMedical NecessityCalifornia Insurance Guarantee Association (CIGA)Petition for ReconsiderationAdministrative Law Judge (WCJ)
References
Case No. ADJ8268219
Regular
Jul 05, 2018

NOHEMI TAINA vs. COUNTY OF SANTA CLARA/VALLEY MEDICAL CENTER

The defendant sought reconsideration of a workers' compensation award for an applicant who sustained industrial injuries to her neck, shoulders, and psyche. The sole issue was whether the applicant's permanent disability percentages for orthopedic and psychiatric conditions should be added or compressed using the Combined Values Chart. The Appeals Board denied reconsideration, finding that the agreed medical evaluators' opinions supporting the additive approach were substantial and adequately explained. The court affirmed the WCJ's decision to add the percentages, noting that this method accurately reflects the additive nature of the applicant's distinct orthopedic and psychiatric impairments.

Permanent Disability Rating ScheduleCombined Values ChartWhole Person ImpairmentAgreed Medical EvaluatorsOrthopedic InjuryPsychiatric InjuryAdditive ApproachSynergistic EffectTrier of FactMedical-Legal Reporting
References
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