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

Case No. FRE 191206
Regular
Nov 20, 2007

MARY SEPEDA vs. SEPEDA BROTHERS DAIRY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION on behalf of FREMONT INDEMNITY, in liquidation, REPUBLIC INDEMNITY

This case involves an applicant seeking reconsideration of a workers' compensation award concerning a low back injury sustained through July 13, 1995. The applicant, supported by her treating physician, argued for additional disc replacement surgery at the L4-5 level beyond the previously awarded L5-S1 spinal fusion. The Workers' Compensation Appeals Board granted reconsideration and amended the award to include the L4-5 disc replacement surgery, finding it reasonably required to cure or relieve the applicant's injury based on the treating physician's opinion.

CIGAFremont IndemnityRepublic Indemnitylow back injurypermanent disabilityfurther medical treatmentspinal surgeryL5-S1 fusionL4-5 disc replacementtreating physician
References
2
Case No. ADJ9366278
Regular
Nov 18, 2014

JASON ALLEN vs. PROVIDENCE HOLY CROSS HOSPITAL

This case involves a defendant hospital's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The WCAB previously found the hospital's utilization review denial untimely, thus retaining jurisdiction to determine the necessity of the applicant's artificial disc replacement surgery. The WCAB affirmed the finding that the surgery was reasonably necessary, amending the basis for the untimely denial to focus on service notification errors. The defendant argued the administrative rules regarding notification to counsel conflicted with Labor Code section 4610, but the WCAB found no such conflict, upholding its prior decision.

Workers' Compensation Appeals BoardUtilization ReviewTimelinessJurisdictionArtificial Disc ReplacementMedical NecessityPrimary Treating PhysicianAdministrative RulesLabor CodeIndependent Medical Review
References
3
Case No. MISSING
Regular Panel Decision

Claim of Mallette v. Flattery's

A claimant, who had a preexisting lower back condition and had been recommended for artificial disc replacement surgery (ADRE), suffered further lower back injuries in a work accident in 2010. A Workers’ Compensation Law Judge initially apportioned liability for the ADRE equally between the preexisting condition and the work accident. However, the Workers’ Compensation Board modified this, finding the employer's carrier solely liable for the surgery. The carrier appealed, arguing a lack of causal relationship between the accident and the need for ADRE. The Appellate Division affirmed the Board's decision, concluding that substantial evidence supported the finding that the work accident aggravated the claimant's preexisting condition, making the need for ADRE causally related to the accident.

workers' compensationcausal relationshipaggravation of preexisting conditionartificial disc replacement surgerylower back injuryapportionmentmedical authorizationsubstantial evidenceBoard determinationAppellate Division decision
References
5
Case No. MISSING
Regular Panel Decision

Claim of Jacob v. New York City Transit Authority

Claimant sustained work-related injuries in January 2000 and later sought workers’ compensation benefits alleging recurrence. An issue arose regarding the veracity of the medical history provided to the employer’s independent medical examiners, specifically concerning undisclosed prior similar injuries. A workers’ compensation law judge and subsequently the Workers’ Compensation Board found that the claimant violated Workers’ Compensation Law § 114-a, leading to disqualification from wage replacement benefits. However, the Board authorized medical treatment for the January 2000 injuries. On cross appeals, the Board’s determination was affirmed, finding substantial evidence supported the violation and the appropriateness of the penalties imposed.

Workers' Compensation Law Section 114-aMedical MisrepresentationWage Replacement Benefits DisqualificationMedical Treatment AuthorizationPrior Injuries DisclosureSubstantial Evidence ReviewIndependent Medical ExaminationWorkers' Compensation Board DecisionAppellate ReviewAffirmed Decision
References
4
Case No. MISSING
Regular Panel Decision
Jul 27, 2001

Claim of Losurdo v. Asbestos Free, Inc.

The case involves a claimant appealing a Workers’ Compensation Board decision. The Board ruled that the claimant violated Workers’ Compensation Law § 114-a by failing to disclose prior left and right knee injuries to physicians and under oath, leading to disqualification from future wage replacement benefits. Although a Workers’ Compensation Law Judge initially found no fraud, the Board reversed this determination on administrative appeal, concluding the claimant knowingly made false statements. The Appellate Division affirmed the Board's decision, finding it supported by substantial evidence, emphasizing the Board's authority as the sole arbiter of witness credibility. The court rejected the claimant's explanations of forgetting the prior incidents as not credible.

Workers' Compensation FraudMisrepresentation of Medical HistoryFalse Statements Under OathWage Replacement Benefits DisqualificationWorkers' Compensation Law Section 114-aAppellate Review of Board DecisionWitness CredibilitySubstantial EvidencePrior Knee InjuriesAdministrative Appeal
References
11
Case No. SAC 286368
Regular
Jan 25, 2008

DALE OLIVER vs. BRIAN WILLIAMS CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking approval for disc replacement surgery for a work-related back injury. The defendant argued the surgery is experimental per ACOEM guidelines, thus not covered. The Board denied reconsideration, finding the applicant's physician rebutted the presumption of experimental status. The Board determined the surgery is no longer experimental, citing FDA approval, and is reasonably required for the applicant's specific condition, supported by expert medical opinion.

Workers' Compensation Appeals BoardBrian Williams ConstructionState Compensation Insurance Fundindustrial injuryright anklefootelbowshoulderskneesleft lower extremity
References
0
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
6
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. MISSING
Regular Panel Decision

In re Zornow

Carole Zornow petitioned the court to be appointed guardian for her 93-year-old mother, Joan M. Zornow, who suffers from advanced Alzheimer's, primarily for end-of-life decisions. A dispute arose among the seven siblings regarding previously enacted Medical Orders on Life-Sustaining Treatments (MOLSTs), particularly a blanket directive denying artificial feeding and hospitalization. The court temporarily revoked most MOLSTs and appointed Carole and Douglas Zornow as temporary coguardians. Following further submissions and a hearing, the court found insufficient "clear and convincing" evidence for the siblings' claims against artificial feeding and, based on the petitioner's affidavit and nursing home records, determined Joan M. Zornow wished to receive artificial feeding. Consequently, the court permanently revoked the contested MOLSTs (except DNR) and appointed Carole Zornow and Catholic Family Center as coguardians, establishing that end-of-life decisions must align with Mrs. Zornow's Roman Catholic religious beliefs, which generally mandate the continuation of artificially administered food and water.

End-of-life careGuardianshipMental Hygiene LawAlzheimer's diseaseMedical Orders on Life-Sustaining TreatmentArtificial feedingReligious beliefsRoman Catholic ethicsFamily Health Care Decisions ActQuality of life ethic
References
52
Case No. ADJ15951486, ADJ15951487
Regular
Aug 25, 2025

JEFF CRAIL vs. AMTRUST NORTH AMERICA, HARTFORD FIRE INSURANCE COMPANY

The defendant, Amtrust North America and Hartford Fire Insurance Company, filed a Petition for Reconsideration of a Joint Findings of Fact and Orders (F&O) issued on May 20, 2025. The F&O had ordered the replacement of Panel Qualified Medical Examiner (PQME) Dr. Wiseman due to his failure to properly serve his report. The defendant argued that the court improperly interpreted Administrative Director Rule 31.5(a)(12) and that a Declaration of Readiness (DOR) does not constitute both an objection and a request for a replacement panel. The Appeals Board denied the Petition for Reconsideration, affirming the WCJ's decision to replace Dr. Wiseman. The Board's decision cited its en banc ruling in Vazquez v. Inocensio Renteria, reinforcing that a QME's failure to timely issue and serve a report, and engaging in ex parte communication by serving only one party, grants a party the right to seek replacement. The Board also emphasized the informal nature of pleadings in workers' compensation proceedings, as established in Perez v. Chicago Dogs, when addressing the applicant's DOR.

PQMEPetition for ReconsiderationJoint Findings of Fact and OrdersAdministrative Director RuleDeclaration of ReadinessIrreparable HarmMandatory Settlement ConferenceOncology PanelQualified Medical ExaminerProof of Service
References
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