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

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. ADJ3196569 (POM 0282676)
Regular
Aug 28, 2009

JEANETTE DOMINGUEZ, vs. RICH PRODUCTS; ZURICH NORTH AMERICA INSURANCE

Lien claimants sought reconsideration of a WCJ's award of minimal amounts for pharmacy services, arguing they should have been paid their full billed amounts. The Workers' Compensation Appeals Board denied the petition, agreeing with the WCJ's findings that the billed amounts were not reasonable or necessary. The Board also noted the petition was procedurally deficient for lack of verification and for failing to clearly state contentions or reference the record. Therefore, the lien claimants' petition for reconsideration was denied on both substantive and procedural grounds.

Workers' Compensation Appeals BoardLien claimantsPetition for ReconsiderationFindings and AwardCompromise and ReleaseCumulative injuryProduction workerIndustrial injuryAdministrative law judgeWCJ Report
References
2
Case No. MISSING
Regular Panel Decision

Emspak v. Conroy

The defendants moved for a further bill of particulars regarding item 30 and requested the entire bill be verified by a union officer. The plaintiff's attorney acknowledged the omission for item 30 was an oversight and agreed to provide it. He argued his self-verification was proper under subdivision 3 of rule 99 of the Rules of Civil Practice, citing the plaintiff's absence from the county, and claimed defendants waived objection by not returning the bill within 24 hours. The court clarified that Rules 10 and 11 do not apply to verification. While an attorney can verify a bill of particulars under rule 117, the court ruled that merely stating the party is out of county is insufficient; the attorney must also detail the basis of their knowledge, especially given a prior order requiring an oath for inability to furnish particulars. The motion for a further bill was granted.

Bill of particularsVerificationAttorney verificationRules of Civil PracticeWaiverMotionCourt procedurePleadingSufficiency of verification
References
3
Case No. ADJ7308922
Regular
Apr 22, 2013

ARTURO CARO vs. JAX MARKET 3, FIREMAN'S FUND

The Workers' Compensation Appeals Board granted reconsideration of an order dismissing a lien claim, finding that the lien claimant's representative misrepresented facts regarding payment of a lien activation fee. Despite the claimant's verified petition claiming payment was made and evidence presented, the Board's own search and the WCJ's report confirmed non-payment. Consequently, the Board issued a notice of intention to impose sanctions up to $2,500 against Qualified Billing & Collections and Diego Plasencia for bad-faith actions and false statements.

Lien Activation FeeLabor Code Section 4903.06WCJ Order Dismissing LienPetition for ReconsiderationVerified PetitionMisrepresentation of FactsBad Faith ActionsWCAB Rule 10561Labor Code Section 5813Sanctions
References
0
Case No. ADJ4243140 (OXN 0130418)
Regular
Sep 23, 2009

ALMALILIA MARTINEZ vs. TRACEY VILLA, NATIONAL FIRE INSURANCE OF HARTFORD, CNA CLAIMS PLUS

The Workers' Compensation Appeals Board granted reconsideration to amend a prior award concerning a lien claimant's fees for medical interpreting services. The amended award clarifies that certain specific medical sessions are valued at the greater of the stipulated market rate or the billed amount. Other medical interpreting services are awarded at one-half of the greater of the market rate or billed amount, with the total value of the lien affirmed as previously decided.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationJoint Findings and AwardWorkers' Compensation JudgeMedical Interpreting ServicesMarket RateAdministrative Director RulesReasonable ValueWCAB Appearances
References
1
Case No. LBO 0355987
Regular
Jul 14, 2008

EDELMA D'TRINIDAD vs. LONG BEACH UNIFIED SCHOOL DISTRICT, Permissibly Self-Insured, Adjusted by SOUTHERN CALIFORNIA RISK MANAGEMENT ASSOCIATES (SCRMA)

This case involves a lien claim for surgical services where the applicant's insurer sought to reduce the billed amount. The Workers' Compensation Appeals Board denied reconsideration, upholding the administrative law judge's finding that only $3,100.00 was a reasonable charge for the services. This decision was based on credible testimony and evidence from a defense witness who presented a "Kunz study" demonstrating that the billed amount far exceeded usual and accepted fees in the area.

Workers Compensation Appeals BoardLien ClaimantReconsiderationFindings and OrderReasonable ValueSurgery CenterIndustrial InjuryLabor Code Section 3202.5Burden of ProofKunz Study
References
4
Case No. ADJ4070560
Regular
Mar 11, 2010

Lawrence Ware vs. Abrazo Del Sol, Inc., Zenith Insurance Company

The WCAB affirmed the judge's award of $2,625.00 to lien claimant Dr. Gabriel for a medical-legal report, reducing his billed amount by $875.00. The Board found that the doctor's report did not qualify as a Qualified Medical Evaluation and that the lien claimant failed to meet his burden of proving the reasonableness of the full billed amount, particularly regarding the time spent on report preparation. While defendants did not strictly follow objection procedures, their challenge to the report's reasonableness was considered, and the WCJ's discretionary reduction was upheld. Consequently, the lien claimant's petition for reconsideration was denied.

Medical-legal expensesLien claimantReconsiderationWCJOfficial Medical Fee ScheduleLabor Code Section 4622(a)Compromise and ReleaseConsequential injuryDental reportingQualified Medical Evaluator
References
7
Case No. MISSING
Regular Panel Decision

Hojnowski v. Buffalo Bills, Inc.

David Hojnowski, a former equipment manager for the Buffalo Bills, sued his former employer alleging age discrimination under the Age Discrimination in Employment Act, New York State Human Rights Law, and violations of the Employee Retirement Income Security Act. The Buffalo Bills moved to dismiss the claims and compel arbitration, citing an arbitration clause in Hojnowski's employment contract. Hojnowski contended that the arbitration agreement was unenforceable due to the absence of arbitration rules and unconscionability. The court determined that the arbitration rules were sufficiently incorporated into the agreement and that the contract was not unconscionable. Consequently, the court granted the Bills' motion, compelling Hojnowski to arbitration and dismissing his complaint.

Arbitration AgreementEmployment LawAge DiscriminationERISANew York State Human Rights LawMotion to DismissContract EnforceabilityUnconscionability DefenseFederal Arbitration ActNFL Commissioner
References
25
Case No. MISSING
Regular Panel Decision

Munson v. Seneca County

This case involves an appeal from a Workers’ Compensation Board decision regarding an employer’s obligation to pay interest on medical bills in a controverted claim. The self-insured employer controverted the claimant’s injury but paid hospital bills after compensability was established. The hospital, as medical provider, sought interest on bills submitted prior to the compensability finding, arguing the employer failed to timely object to the bill amounts. The Workers’ Compensation Board denied the request for interest, concluding the employer was not obligated to pay until compensability was determined. The appellate court affirmed the Board’s decision, finding its interpretation of Workers’ Compensation Law § 13-g and its regulations to have a rational basis, as the statute defers payment obligations until the employer’s liability is finally determined.

Workers' CompensationMedical BillsInterest PaymentEmployer LiabilityStatutory InterpretationTimely ObjectionCompensabilityBoard DecisionAppealNew York Law
References
0
Case No. MISSING
Regular Panel Decision
Mar 09, 2001

Convenient Medical Care, P.C. v. Medical Business Associates, Inc.

Plaintiff, a professional medical corporation, entered into a billing services contract with defendant, a medical billing service provider, in early 1997. The agreement was terminated by plaintiff in 1998 due to alleged failures by the defendant in timely billing worker's compensation patients and delays in returning billing records. Defendant subsequently moved for summary judgment on its counterclaims for breach of contract and an account stated, which the Supreme Court denied. On appeal, the appellate court modified the lower court's order, reversing the denial of summary judgment for defendant's breach of contract counterclaim and granting summary judgment to the defendant on the issue of liability. The court found plaintiff's arguments and evidence insufficient to defeat the defendant's prima facie showing for summary judgment, but denied summary judgment for an account stated due to discrepancies in claimed amounts.

Breach of ContractSummary JudgmentMedical Billing ServicesNegligenceCounterclaimsAppellate ReviewContract TerminationWorker's Compensation PatientsEvidentiary ProofMerger Clause
References
10
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