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

Case No. ADJ9733920
Regular
Feb 26, 2020

SYLVERIA VILLALOBOS vs. GIUMARRA VINEYARDS, ESIS

The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision disallowing a photocopy lien claim. The Board found the lien claimant failed to prove they actually provided the billed "page capture/conversion and processing" services, as the records were provided on CD-ROM by the defendant. Furthermore, the defendant issued a timely and valid Explanation of Review (EOR) with a reduced payment, which the lien claimant did not object to within the statutory period. Consequently, the Board ruled the defendant was not liable for the denied portion of the lien.

Workers' Compensation Appeals BoardLien claimantReconsiderationFindings of Fact and OrderExplanation of ReviewSection 4903.8(d)Declaration of Custodian of RecordsCD-ROMInvoicePage capture/conversion
References
1
Case No. MISSING
Regular Panel Decision

Great American Insurance v. Canandaigua National Bank & Trust Co.

This case involves an appeal and cross-appeal concerning a dispute over a $300,000 certificate of deposit (CD) held in escrow. Great American Insurance Company (GAIC) provided workers' compensation insurance to Transit Group, Inc., secured by a CD held by Canandaigua National Bank and Trust Company (CNB) as an escrowee. Following Transit's bankruptcy filing, CNB released the CD funds to Transit without notifying GAIC, leading GAIC to sue CNB for breach of fiduciary duty. The Supreme Court granted summary judgment to GAIC. The appellate court affirmed this decision, agreeing that CNB breached its fiduciary duty by improperly releasing the funds. However, the appellate court reversed the Supreme Court's denial of Transit's cross-motion, ruling that CNB was not entitled to common-law indemnification or claims for fraud and negligent misrepresentation against Transit, as CNB's liability stemmed from its own breach of duty and it could not justifiably rely on Transit's attorney's representations.

Escrow AgreementBreach of Fiduciary DutySummary JudgmentWorkers' Compensation InsuranceCommon-Law IndemnificationNegligent MisrepresentationBankruptcy LawAppellate ReviewCertificate of DepositInsurer Liability
References
16
Case No. CV-23-1451
Regular Panel Decision
Nov 07, 2024

Matter of Amato v. Patchogue Supermarkets LLC

Domenico Amato, a claimant, sustained work-related injuries to his bilateral shoulders and biceps in May 2019, leading to two arthroscopic surgeries. Following these, medical evaluations for permanency by two orthopedic specialists, Frank Hudak and Lee Kupersmith, yielded differing schedule loss of use (SLU) percentages for Amato's arms. A Workers' Compensation Law Judge initially found a bilateral 42.5% SLU. However, the Workers' Compensation Board subsequently rejected both physicians' permanency opinions, deeming them unreliable due to inconsistent range of motion (ROM) measurements. Instead, the Board relied on earlier ROM measurements from Dr. Kupersmith, taken before Amato reached maximum medical improvement (MMI), to determine a 20% SLU for each arm. Amato appealed this decision. The Appellate Division, Third Department, modified the Board's decision, finding that it was improper for the Board to determine SLU percentages based on premature medical reports that did not confirm MMI or adhere to proper ROM measurement guidelines. Consequently, the matter was remitted to the Workers' Compensation Board for further consideration.

Workers' CompensationSchedule Loss of UseMaximum Medical ImprovementRange of MotionAppellate DivisionThird DepartmentMedical EvidenceBoard ReviewRemittalOrthopedic Surgery
References
8
Case No. MON 0339411
Regular
Jul 21, 2008

Dionisio Jimenez vs. NUPAC APARTMENTS, STATE COMPENSATION INSURANCE FUND

This case involves a dispute over the proper method used to rate the applicant's permanent disability following a back and leg injury. The defendant contends the Agreed Medical Examiner improperly used the Range of Motion (ROM) method instead of the Diagnosis-Related Estimate (DRE) method per the AMA Guides. The Appeals Board rescinded the prior award and returned the case to the trial level for further development of the record. This development will address why the ROM method was used and clarify the appropriate rating methodology.

Workers' Compensation Appeals BoardDionisio JimenezNupac ApartmentsState Compensation Insurance FundMON 0339411Opinion and Decision After ReconsiderationFindings and AwardIndustrial InjuryBack InjuryRight Leg Injury
References
2
Case No. ADJ10489999
Regular
Feb 01, 2019

Sean Lawson vs. Zenith Insurance Company

This case involves a dispute over the permanent disability rating for applicant Sean Lawson's low back injury. The defendant, Zenith Insurance Company, argues that the Range of Motion (ROM) method used by the Qualified Medical Evaluator (QME) was inappropriate, and the Diagnosis-Related Estimates (DRE) method should have been applied as there was only one level of radiculopathy. The Workers' Compensation Appeals Board (WCAB) affirmed the WCJ's finding that the ROM method was appropriate based on the QME's expert opinion and the AMA Guides' provision for its use with multi-level involvement. However, one Commissioner dissented, believing the DRE method was mandated given the lack of evidence for multi-level radiculopathy.

WCABPetition for ReconsiderationPermanent DisabilityApportionmentNon-industrial factorsDiagnosis-Related Estimates (DRE) methodRange of Motion (ROM) methodQualified Medical Evaluator (QME)AMA GuidesMultilevel radiculopathy
References
1
Case No. ADJ9344211
Regular
Dec 01, 2017

Patricia Preston vs. Los Angeles Unified School District, SEDGWICK CLAIMS MANAGEMENT SERVICES

The applicant sought reconsideration of a workers' compensation award, challenging the permanent disability rating primarily based on the chosen medical evaluation method. The applicant argued the Range-of-Motion (ROM) method, favored by her treating physician, should have been used instead of the Diagnosis-Related Estimates (DRE) method employed by a Qualified Medical Evaluator (QME). Additionally, she contended that her vocational expert's opinion supported a finding of total permanent disability. The Board denied reconsideration, affirming the administrative law judge's decision, finding the QME's DRE rating supported by substantial evidence and the applicant's vocational evidence insufficient to prove total disability. A dissenting opinion argued that findings of multi-level spinal involvement supported the use of the ROM method for a potentially higher rating and questioned the QME's justification for choosing DRE.

Workers' Compensation Appeals BoardPatricia PrestonLos Angeles Unified School DistrictSedgwick Claims Management ServicesADJ9344211Permanent Disability RatingRange-of-Motion MethodDiagnosis-Related Estimates MethodApportionmentDr. Fenton
References
6
Case No. ADJ1 0300458
Regular
Aug 01, 2016

CD MAHEDE HASAN vs. UNIVERSAL CITY NISSAN, INC, INSURANCE COMPANY OF THE WEST WOODLAND HILLS

The Workers' Compensation Appeals Board denied reconsideration of an applicant's claim for benefits. The applicant sustained an arm fracture while arm wrestling with a colleague during a lull at work. The Board adopted the Administrative Law Judge's findings that the injury resulted from horseplay, which was not condoned by the employer. Because injuries from un-condoned horseplay are not considered to arise out of employment, the claim was denied.

WCABPetition for ReconsiderationDeniedHorseplayEmployer CondonationWCJ FindingsCredibility DeterminationSubstantial EvidenceProximate CauseCourse of Employment
References
4
Case No. ADJ9376675
Regular
Oct 20, 2015

JESSICA FIELD vs. INGLEWOOD POLICE DEPARTMENT, ADMINSURE

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The defendant challenged the permanent disability rating, arguing the DRE method, rather than the ROM method, was improperly applied by the QME. The Board adopted the WCJ's report, which found the QME's reliance on the DRE method, specifically Category IV, was supported by substantial medical evidence and properly applied under the AMA Guides, Fifth Edition. The defendant's contention that the rating was invalid under *Blackledge* was also rejected, as the QME report met legal and regulatory requirements.

Workers' Compensation Appeals BoardPetition for ReconsiderationDENIEDINGLEWOOD POLICE DEPARTMENTADMINSUREPermanent DisabilityAMA Guides Fifth EditionDRE MethodLumbar Spine Category IVwhole person impairment
References
2
Case No. ADJ8727749
Regular
Sep 26, 2013

CINDY VARGAS vs. SEARS HOLDINGS CORPORATION, SEDGWICK CMS

This case concerns an employer's petition to remove a WCJ's order compelling them to provide a complete list of their Medical Provider Network (MPN) in specific specialties. The employer argued this was overly burdensome, preferring to limit the list to providers within 30 miles of the applicant's residence. The Appeals Board denied removal, finding the WCJ's order was not burdensome or harassing under Administrative Director Rule 9767.12(f)(3). The Board noted the employer could fulfill the order electronically via CD or website, even if limited to the requested specialties.

Workers' Compensation Appeals BoardPetition for RemovalMedical Provider NetworkMPN listingTitle 8 Cal. Reg. § 9767.12(f)(3)Administrative Director Ruleregional area listingcomplete provider listingelectronic listingCD
References
0
Case No. ADJ8181938; ADJ8702275
Regular
Apr 10, 2023

KAREN MILLER vs. STATE OF CALIFORNIA, VENTURA YOUTH CORRECTIONAL FACILITY, STATE COMPENSATION INSURANCE FUND, STATE CONTRACT SERVICES

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The defendant argued against the statutory 15% increase, the method of evaluating spine impairment, and the inclusion of a sleep disorder. The Board adopted the WCJ's report, finding no error in the application of the 15% increase or the evaluation of the spine impairment using the ROM method as deemed appropriate by the agreed medical examiner. Furthermore, the Board upheld the finding of an industrially caused sleep disorder, noting that formal sleep studies are not always required for diagnosis and that the physician's rating falls within the AMA Guides.

WCABPetition for ReconsiderationDeniedVentura Youth Correctional FacilityAdjudication NumbersOccupational Group 214Cervical SpineLumbar SpineBilateral ShouldersGastrointestinal System
References
1
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