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

Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ3560082 (ANA 0380953)
Regular
Mar 12, 2009

MARGARITA SERRANO vs. 3 DAY BLINDS, STATE COMPENSATION INSURANCE FUND

This case involves a lien claim by Huntington Beach Hospital for medical services rendered to an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration to reverse a prior finding, determining that contractual agreements between the hospital, Blue Cross, and the defendant insurer (SCIF) constitute an "express agreement" under Labor Code section 5304. This express agreement, which includes binding arbitration provisions, divests the WCAB of jurisdiction over the lien dispute. Therefore, the WCAB rescinded its prior award and ordered the parties to arbitrate the dispute according to the terms of their contract.

Workers' Compensation Appeals BoardState Compensation Insurance FundHuntington Beach HospitalComprehensive Contracting Hospital AgreementWorkers' Compensation Managed Care Service AgreementOther PayorLabor Code Section 5304Labor Code Section 4609Express AgreementBinding Arbitration
References
Case No. ADJ2200226
Regular
Apr 08, 2014

RUDY GALLARDO vs. SOUTHERN CALIFORNIA EDISON

The WCAB reversed a prior decision, finding it lacked jurisdiction over a hospital's lien claim for unpaid services. The Appeals Board held that an "express agreement," as required by Labor Code Section 5304 to divest the WCAB of jurisdiction, existed through a chain of contracts between the hospital, a network administrator (Blue Cross), and the self-insured employer. This chain of agreements fixed the payment amounts, thus precluding the WCAB from adjudicating the fee dispute. Any claims of contract breach or non-compliance with other statutes like Section 4609 must be pursued in a different forum.

WCAB jurisdictionLabor Code Section 5304express agreementchain of contractsHuntington HospitalSouthern California EdisonBlue Cross of CaliforniaOfficial Medical Fee Schedulelien claimfee dispute
References
Case No. ADJ10084051
Regular
Oct 14, 2019

LIDIO LEONEL TORRES vs. KML SERVICES INC., STATE COMPENSATION INSURANCE FUND

CareMeridian, LLC, a healthcare provider, sought to set aside an approved Workers' Compensation Appeals Board (WCAB) compromise and release (C&R) agreement that resolved the applicant's future medical care. CareMeridian argued it was an aggrieved party and was denied due process regarding payment for its services. The WCAB denied the petition, finding CareMeridian was not a party to the C&R and therefore not entitled to notice or a hearing at the time of its approval. Furthermore, the Board determined that CareMeridian lacked standing to challenge the C&R's adequacy, as the applicant and insurer had the statutory right to compromise their liabilities.

Compromise and ReleasePetition for ReconsiderationAggrieved PartyStandingDue ProcessMedical Provider LienSkeleton PetitionNon-PartyNoticeOpportunity to Be Heard
References
Case No. ADJ7987503; ADJ7516174
Regular
May 29, 2012

ELOY MORENO-HERNANDEZ vs. SYSCO FOODS/FRESH POINT, ZURICH AMERICAN INSURANCE, GALLAGHER BASSETT SERVICES

The Appeals Board granted the applicant's Petition for Removal and rescinded the prior order compelling a second QME evaluation. The Board found that the Presiding Workers' Compensation Judge erred in deciding the QME issue at a Mandatory Settlement Conference (MSC) without a clear agreement from both parties to submit the issue for decision. Additionally, there was no proper evidentiary record upon which the judge could base the decision. The matter is returned to the trial level for further proceedings, including another MSC and potential trial, to properly address the QME selection dispute.

Petition for RemovalQualified Medical Evaluator (QME)Mandatory Settlement Conference (MSC)Due ProcessPanel QMEAdministrative Law Judge (WCJ)Labor Code Section 5502(e)(2)WCAB Rule 10353(a)Agreement of the PartiesSubstantial Evidence
References
Case No. ADJ253443 (POM 0286361)
Regular
Jan 17, 2014

JUAN MANUEL RESENDIZ vs. DANNY'S TRIMMING & BINDING CORP., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration, rescinding the WCJ's finding that it lacked jurisdiction over a lien dispute between Good Samaritan Hospital and State Fund. The Board found the contracts between State Fund, Blue Cross, and Good Samaritan potentially created an "express agreement" under Labor Code Section 5304, divesting the Board of jurisdiction. However, the Board also noted Good Samaritan failed to meet its initial burden of proof regarding the necessity of its services and that State Fund may not have provided proper notice of its payor status under the contract. The case is returned to the trial level for further evidence development on these issues.

Workers' Compensation Appeals Boardlien claimantPetition for ReconsiderationFindings of FactjurisdictionState Compensation Insurance FundOfficial Medical Fee ScheduleLabor Codeexpress agreementarbitration
References
Case No. ADJ1973537 (SRO 0141664)
Regular
Jun 24, 2019

KENT WARD vs. TIMEC COMPANY, INC., ZURICH AMERICAN INSURANCE COMPANY

The applicant sought reconsideration of an arbitration decision that found his employer, Timec, 25% comparatively negligent for his injury, reducing Timec's credit from a third-party settlement. The applicant argued for a higher employer negligence percentage to increase his potential workers' compensation benefits. The Board denied reconsideration, adopting the Arbitrator's findings and reasoning. The Board found the applicant failed to present evidence to overcome the Arbitrator's negligence determination.

Third-party creditComparative negligenceArbitrator's findingsPetition for reconsiderationLabor Code section 3861Employer's liabilityThird-party claim valueNet settlement amountCredit against workers' compensationEmployer's breach of duty
References
Case No. SAL 95992 SAL 95993 SAL 97616
Regular
Feb 06, 2008

JOSE G. LIZARRAGA (DECEASED) vs. WATSONVILLE PRODUCE, REPUBLIC INDEMNITY COMPANY OF AMERICA

This case concerns whether a binding compromise and release agreement was formed before the applicant's death. The Appeals Board denied reconsideration, finding that the agreement was not "duly executed" as required by statute because the defendant had not signed it, and a Medicare set aside provision was still pending. The majority concluded that a complete meeting of the minds on all material aspects was lacking, making the WCJ's prior finding of a binding agreement erroneous.

Compromise and ReleaseDuly ExecutedMedicare Set AsideBinding AgreementMeeting of the MindsLabor Code Section 5003Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderIndustrial Injury
References
Case No. ADJ91 04682
Regular
Mar 15, 2016

NOEL CERVANTES vs. UCLA MEDICAL CENTER, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and awarded lien claimant Liberty Life Assurance reimbursement for $3,940.85 in short-term disability payments. The WCAB found that the lien claimant provided sufficient notice of its payments to UCLA Medical Center before UCLA paid overlapping temporary disability benefits. Legibility of a reimbursement agreement was deemed irrelevant when the parties stipulated to the payments made. Therefore, UCLA Medical Center was ordered to reimburse Liberty Life Assurance for these benefits under Labor Code section 4903.1.

Labor Code section 4903.1(a)Lien claimantPetition for ReconsiderationGroup disability policyReimbursement AgreementOverlapping disability paymentsNotice of lienTemporary disability benefitsShort-term disability paymentsCompromise and Release Agreement
References
Case No. ADJ599176 (SAC 0333692) ADJ2396484 (RDG 0122019) ADJ7950339
Regular
Mar 21, 2017

Fernando Muniz Villalpando vs. Doherty Brothers, Martin Dusters, State Compensation Insurance Fund

This case involves an applicant seeking to self-administer his Medical Set-Aside Account (MSA) after previously agreeing to third-party administration by Bridge Pointe/NuQuest. The Appeals Board granted reconsideration, rescinded the prior order, and returned the matter to the trial level. The Board found that the trial judge needs to review the original agreement to determine if it allows for a change of administration or if applicant has contractual rights to pursue this. Further proceedings will assess applicant's competency for self-administration and any opposition from the defendant.

Medical Set-Aside AccountMSAPetition for ReconsiderationJoint Findings and OrderMedical Set-Aside Account administrationself-administrationBridge PointeNuQuestState Compensation Insurance FundCompromise and Release Agreement
References
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