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

Case No. ADJ7038469
Regular
Sep 17, 2014

AZIZA SAYED vs. GIORGIO ARMANI, FEDERAL INSURANCE COMPANY

The defendant's petition to appeal an Administrative Director's Independent Bill Review (IBR) determination was dismissed. The Board found the petition premature as it was not first heard by a trial level Workers' Compensation Judge (WCJ). Additionally, the petition failed to comply with numerous procedural requirements, including proper captioning, verification, service, and stating specific grounds for appeal. Consequently, both the petition for reconsideration and the petition appealing the IBR determination were dismissed.

Workers' Compensation Appeals BoardIndependent Bill ReviewPetition for ReconsiderationAdministrative DirectorLabor Code section 4603.6MAXIMUS Federal ServicesInc.Lien claimantOfficial Medical Fee ScheduleWCAB Rules of Practice and Procedure
References
0
Case No. MISSING
Regular Panel Decision

Haddad v. City of Albany

The petitioner appealed a Supreme Court judgment that dismissed their application, which combined a CPLR article 78 proceeding and an action for declaratory judgment. The application challenged the respondent's denial of a request to rescind waste removal violation bills issued by the Department of General Services (DGS) of the City of Albany. The Supreme Court had found that the petitioner failed to exhaust administrative remedies and that claims regarding preemption of local waste ordinances by state penal law were without merit. During the pendency of the appeal, the Board of Zoning Appeals (BZA) administratively reviewed the violations, reversing some charges and upholding others. The appellate court affirmed the Supreme Court's judgment, concluding that a violation of the City of Albany's waste code was not a criminal violation under Penal Law § 55.10, and that the petitioner was indeed required to exhaust administrative remedies for their constitutional claims, as these claims implicated specific aspects of the administrative proceeding rather than the administrative scheme itself.

WasteManagementAdministrativeLawMunicipalCodePenalLawExhaustionOfRemediesDeclaratoryJudgmentAppellateReviewEnvironmentalViolationsPublicHealthPropertyMaintenance
References
10
Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
0
Case No. ADJ9615494
Regular
Oct 08, 2019

CARLOS SOTO TORRES vs. THE CLIFF RESTAURANT, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded an Amended Findings of Fact and Order because essential documentation regarding the timeliness of medical-legal billings and reviews was missing. Specifically, the record lacked proof of service for the provider's invoice, the defendant's initial Explanation of Review (EOR), and the subsequent second bill review. This prevented determination of whether the defendant timely objected to the bill and whether the provider timely requested a second review, necessitating further proceedings at the trial level.

Workers' Compensation Appeals BoardReconsiderationAmended Findings of Fact and OrderQualified Medical EvaluatorQMEDr. Payam MoazzazZenith Insurance CompanyStatute of LimitationsLabor Code section 4903.5Independent Bill Review
References
0
Case No. 2022 NY Slip Op 01011
Regular Panel Decision
Feb 16, 2022

Hamm v. Review Assoc., LLC

The plaintiff, Peter Hamm, an employee, sustained injuries after falling from a ladder while servicing a security system at premises owned by Review Associates, LLC and leased by Fresh Direct, LLC. He initiated a personal injury action alleging common-law negligence and violations of Labor Law §§ 200, 240(1), and 241(6). The Supreme Court initially granted summary judgment to the defendants, dismissing the complaint. On appeal, the Appellate Division modified this order, denying summary judgment for the Labor Law § 240(1) claim against both defendants due to triable issues of fact regarding whether the work constituted "repairs" or "routine maintenance." Additionally, the court denied summary judgment for the common-law negligence and Labor Law § 200 claims against Fresh Direct, LLC, as it failed to establish a lack of notice regarding the defective ladder. The court affirmed the dismissal of the Labor Law § 241(6) claim against both defendants and the common-law negligence and Labor Law § 200 claims against Review Associates, LLC.

Personal InjuryLadder AccidentLabor Law § 240(1)Labor Law § 200Common-law NegligenceSummary JudgmentAppellate DivisionDuty to Maintain Safe PremisesRoutine Maintenance vs. RepairDangerous Condition
References
44
Case No. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
1
Case No. ADJ2834079 (SDO 0293027) ADJ2839895 (SDO 0358837)
Regular
Jun 25, 2009

THUAN CRIM-ROLFE vs. LA COSTA RESORT AND SPA, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for LEGION INSURANCE COMPANY, BROADSPIRE, SAFETY NATIONAL CASUALTY INSURANCE COMPANY

This case involves a clerical error in a prior Workers' Compensation Appeals Board (WCAB) decision. The WCAB previously ordered Safety National Casualty Insurance Company (SNCC) to reimburse the California Insurance Guarantee Association (CIGA) a specific amount for bill review charges. CIGA requested clarification, noting the amount ordered was incorrect. The WCAB affirmed its earlier decision that CIGA is entitled to reimbursement for bill review costs but amended the order nunc pro tunc. The corrected order now states SNCC must reimburse CIGA for bill review charges, with the exact amount to be determined by the parties or the arbitrator.

California Insurance Guarantee AssociationLegion Insurance CompanySafety National Casualty Insurance Companynunc pro tuncclerical errorbill review chargesliquidationcovered claimsreimbursementpetition for reconsideration
References
6
Case No. ADJ11329981
Regular
Jan 14, 2019

JEFFERY DANHAUSER vs. HOWROYD WRIGHT EMPLOYMENT AGENCY, INC., ACE AMERICAN INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC., UNITEDHEALTH GROUP, INC., TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA, SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.

This case involved a petition for reconsideration and removal by a lien claimant disputing medical bill payments. The Appeals Board denied reconsideration and dismissed the removal petition, affirming the WCJ's findings. The Board reiterated that disputes over medical bill amounts after review must proceed to Independent Bill Review (IBR), not through the Appeals Board. A decision directing a party to IBR is a threshold determination, making reconsideration the appropriate remedy, not removal.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalAdministrative Law Judge (WCJ)Independent Bill Review (IBR)Substantive RightLiabilityQuasijurisdictionalThresholdLien Claimant
References
2
Case No. ADJ2652747 (VNO 0344824) ADJ3178119 (VNO 0349849) ADJ4566361 (VNO 0401733)
Regular
Nov 12, 2010

MARK RAINE vs. CITY OF BURBANK

This case involves a lien claimant, Advanced Orthopedics, seeking reconsideration of an administrative order appointing an independent bill reviewer. The Workers' Compensation Appeals Board dismissed the reconsideration petition, finding the order was procedural and not a final decision subject to review. The Board also denied the alternative petition for removal, as the claimant failed to demonstrate significant prejudice or irreparable harm. Therefore, the appointment of the bill reviewer stands, and further development of the record will proceed.

WORKERS' COMPENSATION APPEALS BOARDLIEN CLAIMANTPETITION FOR RECONSIDERATIONPETITION FOR REMOVALORDER FOR APPOINTMENT OF INDEPENDENT BILL REVIEWERWCJOFFICIAL MEDICAL FEE SCHEDULEINTERLOCUTORY ORDERPROCEDURAL ORDERFINAL ORDER
References
5
Case No. ADJ3580938 (LBO 0389610) ADJ2553702 (LBO 0376341)
Regular
Feb 16, 2016

JOSE YANEZ, vs. SPECTER OFF ROAD, INC.; EMPLOYERS COMPENSATION INSURANCE COMPANY; FARMERS INSURANCE COMPANY

The WCAB granted reconsideration of a decision that limited a hospital's lien claim reimbursement and intended to sanction the hospital for bad faith. This rescission and remand for further proceedings occurred because the trial record was incomplete and failed to comply with WCAB Rule 10566 and *Hamilton*. Specifically, minutes of hearing lacked required information, and it was unclear if the hospital agreed to independent bill review. The WCJ must now address the hospital's arguments regarding bill review and the admissibility of the independent reviewer's report.

WCABPetition for ReconsiderationLien ClaimantMonrovia Memorial HospitalAdministrative Law JudgeJoint Findings of FactNotice of Intention to Impose SanctionsIndependent Bill ReviewerGriff StelznerWCAB Rule 10566
References
1
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