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Case Law Database

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

Case No. ADJ6833713
Significant
Mar 28, 2013

Luis Enriquez (deceased) vs. Couto Dairy, Zenith Insurance Company

The Appeals Board holds that the federal Airline Deregulation Act (ADA) preempts California's fee schedule for air ambulance services (AD Rule 9789.70) if the provider qualifies as an 'air carrier' under the ADA. The matter is returned to the trial level to determine the provider's legal status.

Airline Deregulation ActAD Rule 9789.70preemptionair carrierair transportationOfficial Medical Fee ScheduleOMFSFederal Aviation AdministrationFAAinterstate air transportation
References
Case No. ADJ7303543
Regular
Apr 08, 2013

JUAN RAMOS vs. SCI TEK STAFFING, CHARTIS

This case involves a workers' compensation claim where the Appeals Board granted reconsideration. The prior WCJ decision was found inconsistent with *Enriquez v. Couto Dairy*, which established that the Appeals Board can find preemption of Administrative Director (AD) Rule 9789.70, specifically the Official Medical Fee Schedule for air ambulance services. The Board clarified that the Airline Deregulation Act may preempt this rule if the air ambulance provider qualifies as an "air carrier" and has the burden of proving this status. Therefore, the matter was returned to the trial level for further proceedings and a new decision consistent with *Enriquez*.

Workers' Compensation Appeals BoardEnriquez v. Couto DairyArticle III section 3.5 California ConstitutionLabor Code section 5307.1preemptionAdministrative Director Rule 9789.70Official Medical Fee ScheduleOMFSair ambulance servicesAirline Deregulation Act
References
Case No. ADJ1480264 (FRE 0200339) MF
Regular
Dec 29, 2015

JOSE ACOSTA vs. PETERSON FAMILY, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision concerning the retroactive application of a 2012 statutory fee reduction for ambulatory surgical centers. This decision was made after the defendant, State Compensation Insurance Fund (SCIF), and lien claimant Sierra Pacific Surgical Center (SPSC) reached a settlement agreement. The WCAB returned the case to the trial level for approval of this settlement, allowing the WCJ to reissue the rescinded decision if the settlement is not approved. The original decision had found that the fee reduction did not apply retroactively to services provided before January 1, 2004.

Workers' Compensation Appeals BoardState Compensation Insurance FundSierra Pacific Surgical Centerambulatory surgical centeroutpatient surgical centerMedicare reimbursementSenate Bill 863Labor Code section 5307.1(c)(1)retroactive applicationsettlement agreement
References
Case No. ADJ710353 (VNO 0479290)
Regular
Jun 04, 2012

DIMAS POSADA vs. PARKWOOD LANDSCAPE & MAINTENANCE, EVEREST NATIONAL INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) dismissed a lien claimant's petition for reconsideration because it was filed untimely. The WCAB determined that the petition was submitted 36 days after the Order Dismissing Lien Claim was served, exceeding the statutory 20-day period plus an additional five days for mail service. As a result, the WCAB lacked jurisdiction to review the merits of the lien claimant's arguments. The lien claimant had argued the dismissal was due to a missed hearing caused by a file transfer and timely responded to a notice.

WCABADJ710353VNO 0479290Dimas PosadaParkwood Landscape & MaintenanceEverest National Insurance CompanyBel Air Surgical InstituteExpert Medical ReviewOrder Dismissing Lien ClaimNotice of Intention to Dismiss Lien
References
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
Case No. ADJ6461309
Regular
Jul 19, 2012

JOSEPH MARTIN vs. City of Ukiah, Permissibly Self-Insured, administered by REDWOOD EMPIRE MUNICIPAL FUND

The Workers' Compensation Appeals Board denied reconsideration, upholding the WCJ's decision regarding air ambulance service fees. The board found that California Administrative Rule 9789.70, which dictates reasonable fees for ambulance services, is preempted by the federal Airline Deregulation Act. This preemption applies because the rule attempts to regulate the prices and services of air carriers, which is exclusively within federal purview. Therefore, the board concluded that the specific fee limitations in Rule 9789.70 do not apply to air ambulance services.

Workers Compensation Appeals BoardAD Rule 9789.70Air Ambulance ServicesAirline Deregulation ActADA Preemption49 U.S.C. § 41713(b)(1)Morales v. Trans World AirlinesState Regulation of Air CarriersWCABPetition for Reconsideration
References
Case No. ADJ4525685
Regular
Apr 08, 2011

MAGDALENA CASTILLEJA vs. COUNTY OF TULARE, AMERICAN HOME ASSURANCE COMPANY

This case involves a lien claimant, Summit Surgical Center (formerly Sierra Pacific Surgical Center), seeking reconsideration of a decision denying their lien for $11,799.50. The Workers' Compensation Appeals Board denied reconsideration because the lien claimant failed to provide any legal or factual support for their petition. The Board also issued a Notice of Intention to Impose Sanctions of $500 against the lien claimant and their representative for filing a frivolous and unsubstantiated petition. The lien claimant argued the carrier should be liable for treatment costs without the provider having to prove compensability.

WCABPetition for ReconsiderationLien ClaimantIndustrial InjuryAOE/COEMedical TreatmentMedical Legal ServicesSanctionsLabor Code § 5813Bad Faith
References
Case No. ADJ473373 (ANA 0406381)
Regular
Feb 10, 2012

FERNANDO GUTIERREZ vs. SOCAL FRAMING aka BMHC; ACE AMERICAN INSURANCE, administered by ESIS, INC.

This case concerns applicant's claim for extended temporary disability (TD) benefits beyond 104 weeks due to a left eye injury. The Appeals Board affirmed the WCJ's denial of the "amputation" exception, ruling that the surgical removal of an eye does not fit the statutory definition. However, the Board remanded the case for further development of the record on the "high-velocity eye injury" exception, as the velocity and force of the object that struck the applicant's eye were unclear. The applicant's Petition for Removal was dismissed as reconsideration was the appropriate remedy.

Workers' Compensation Appeals BoardFernando GutierrezSoCal FramingBMHCACE American InsuranceESISInc.ADJ473373ANA 0406381Opinion and Decision
References
Case No. ADJ9178345
Regular
Aug 14, 2015

LISA BROWN vs. STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS & REHABILITATION/CALIFORNIA INSTITUTE FOR WOMEN

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The Board affirmed the finding that the applicant was an employee, not a volunteer, entitled to workers' compensation benefits. The applicant's claim was not time-barred because the defendant failed to notify her of her right to file a claim. The Board also cautioned the defendant's attorneys for citing an overruled case.

Workers' Compensation Appeals BoardDepartment of Corrections and RehabilitationCalifornia Institute for WomenCalifornia Institute for MenForestry and Fire Unitincarcerated applicantvolunteer exclusionLabor Code 3352(i)Labor Code 3365statute of limitations
References
Case No. ADJ8777230
Regular
Jun 29, 2015

TIMETHY BLAKELEY vs. AIR RESOURCES BOARD, STATE COMPENSATION INSURANCE FUND

This case concerns a petition for reconsideration filed by the defendants, Air Resources Board and State Compensation Insurance Fund, following a Workers' Compensation Appeals Board (WCAB) decision that awarded benefits to Timothy Blakeley. The defendants argued the administrative law judge erred in determining Blakeley's psychiatric injury was not primarily caused by lawful personnel actions and that the causation threshold was misapplied. The WCAB denied the petition, adopting the WCJ's report which found the defendants failed to demonstrate the personnel actions were in good faith and that the applicant's injury was predominantly work-related. The WCAB gave significant weight to the WCJ's credibility determination of the applicant's testimony.

Workers' Compensation Appeals BoardPetition for ReconsiderationWCJ credibility determinationLabor Code §3208.3(h)substantial causegood faith personnel actionpsychiatric injuryAir Resources BoardSCIFAME Dr. Donald Feldman
References
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