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

Case No. ADJ8217279
Regular
May 05, 2017

PETER BOURASSA vs. DOLLAR TREE, SEDGWICK

The Appeals Board affirmed the WCJ's decision regarding applicant Peter Bourassa's workers' compensation claim. The lien claimant, Monrovia Memorial Hospital, sought payment exceeding $\$58,272.00$ for services rendered. The Board clarified that facility fees for long-term care hospitals exempt from the Official Medical Fee Schedule (OMFS) must be paid on a "reasonable cost basis." The lien claimant failed to meet its burden of proving the reasonableness of its charges under relevant case law.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien ClaimantReasonable Cost BasisOMFSKunz studyAffirmAffirmAffirm
References
Case No. ADJ2536831
Regular
Jan 12, 2017

BRENDA DUSON SEARCY vs. HAWTHORNE CONVALESCENT HOSPITAL, STATE COMPENSATION INSURANCE FUND

Lien claimant Washington Chiropractic sought reconsideration of a prior award limiting chiropractic treatment reimbursement. The Workers' Compensation Appeals Board denied reconsideration, affirming the administrative law judge's findings. The Board found the lien claimant failed to meet its burden of proving the treatment was reasonable and necessary for the industrial injury. This ruling upholds the principle that lien claimants must affirmatively establish the medical necessity of their services.

Lien claimantPetition for ReconsiderationFindings and Awardchiropractic manipulationQualified Medical Evaluatorreasonable and necessary treatmentburden of proofaffirmative burdencompensable injuryOfficial Medical Fee Schedule
References
Case No. ADJ1927786
Regular
Dec 21, 2012

LUIS CISNEROS vs. GCL CORPORATION, INC., LIBERTY MUTUAL INSURANCE COMPANY

This case involves a lien claimant, Joyce Altman Interpreters, Inc., seeking reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The applicant sustained an industrial injury to his left knee and back, and his claim was settled via compromise and release. The WCAB denied reconsideration, affirming the administrative law judge's award for the lien claimant's services. While the lien claimant argued the awarded rate was too low and excluded preparation, travel, and waiting time, the WCAB found their submitted evidence insufficient to prove a higher reasonable market rate. The WCAB concluded the awarded rate was reasonable and the lien claimant failed to meet their burden of proof.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFindings Award and OrderCompromise and ReleaseInterpreting ServicesReasonable Market RateBurden of ProofPreponderance of the EvidenceClear and Convincing Evidence
References
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. ADJ7130808, ADJ8334379
Regular
Dec 23, 2016

MARIA CONTRERAS vs. PRODUCTS ENGINEERING CORPORATION, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration to review a WCJ's decision that denied certain medication charges claimed by lien claimant Dr. Charles Schwarz, while upholding other treatment charges. The lien claimant argued that denials were untimely or that prescriptions were not submitted to utilization review. However, the Board affirmed the WCJ's decision, reiterating that the lien claimant bears the burden of proving the reasonableness and necessity of the treatment. Crucially, the lien claimant failed to establish the amount owed on its lien or provide payment documentation, thus failing to meet its evidentiary burden.

Workers' Compensation Appeals BoardReconsiderationJoint Findings and AwardMedication ChargesUtilization ReviewLien ClaimantBurden of ProofPreponderance of the EvidenceReasonableness and NecessityUnpaid Dates of Service
References
Case No. ADJ2623740
Regular
Dec 13, 2010

MARTHA HERNANDEZ vs. MARRIOTT INTERNATIONAL, INC.

The Appeals Board rescinded its Notice of Intention to Impose Sanctions against CMS Network, Inc. and its representatives, Dominic D. Arguello and Randal Hollien. Initially, sanctions were considered due to repeated misstatements of law concerning a lien claimant's burden of proof in petitions for reconsideration. Although zealous advocacy is not an excuse for legal misstatements, the Board found no intent to mislead and acknowledged the respondents' understanding of correct legal precedent. The matter is returned to the trial level, with the Board emphasizing that lien claimants bear the burden of proving the reasonableness of their fees, citing precedent like *Kunz* and *Tapia*.

WCABRemovalSanctionsLien claimant burden of proofPetition for reconsiderationHearing representativesZealous advocacyMisstatements of lawEn banc decisionsBinding precedent
References
Case No. ADJ9226212
Regular
Jan 31, 2018

MARGARITA GARCIA vs. REYNOLDS PACKING COMPANY, UNITED STATES FIRE INSURANCE COMPANY

This case concerns a worker's claim for a psychiatric injury stemming from her industrial orthopedic injuries. The defendant argued the psychiatric claim was barred by the statute of limitations and the six-month employment rule. The Appeals Board denied reconsideration, affirming the original award. They found the psychiatric claim related back to the timely filed orthopedic claim, thus not time-barred. Furthermore, the Board held the defendant bore the burden of proving the six-month employment requirement for psychiatric injuries and failed to meet this burden.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardCompensable Consequence InjuryStatute of LimitationsSix Month RuleLabor Code Section 3208.3Panel Qualified Medical EvaluatorBurden of ProofAffirmative Defense
References
Case No. ADJ 7511877, ADJ 7396932
Regular
May 03, 2017

MARIA MORALES vs. MONTEBELLO UNIFIED SCHOOL DISTRICT, YORK RISK SERVICES GROUP, INC.

The Appeals Board affirmed the WCJ's decision disallowing further payment on Monrovia Memorial Hospital's lien. The court found that Monrovia failed to provide sufficient evidence to establish that its requested charges were reasonable and consistent with a "reasonable cost basis" as required for long-term care hospitals exempt from the Official Medical Fee Schedule. Lien claimants bear the affirmative burden of proving the reasonableness of their liens by a preponderance of the evidence. The Board also noted that discovery was properly closed at the lien conference, precluding Monrovia's delayed introduction of evidence.

Workers' Compensation Appeals BoardJoint Findings and OrderIndustrial InjuryCervical SpineLumbar SpineRight HipBilateral KneesPsycheLien ClaimantMonrovia Memorial Hospital
References
Case No. ADJ9719810
Regular
Nov 07, 2016

CORETHA KEITH vs. DOLLAR TREE, INC., ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Dollar Tree's petition for reconsideration. The Board affirmed the administrative law judge's finding that the applicant sustained a right knee injury and was not terminated for cause. The employer failed to meet its burden of proof by a preponderance of the evidence that the applicant violated policy or that an investigation occurred. Therefore, temporary disability benefits were appropriately awarded.

WCABPetition for ReconsiderationFindings of FactTemporary DisabilityIndustrial InjuryRight KneeQuality Control PersonTermination for CauseBurden of ProofAffirmative Defense
References
Case No. VNO 0458244
Regular
Nov 07, 2007

MARIA TORRES vs. WELMARK TEXTILE, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board affirmed a prior order denying a lien claimant's claim for reimbursement under Labor Code section 5402(c). The Board found the lien claimant waived the issue by not raising it at trial, and further failed to meet their burden of proof by not demonstrating a claim form was filed or the claim was accepted. Consequently, the lien claimant was ordered to take nothing.

Workers' Compensation Appeals BoardLien ClaimantCumulative TraumaCompromise and ReleaseDeferred IssueLien ConferenceBurden of ProofLabor Code Section 5402(c)SB 899Prospective Application
References
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