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

Case No. ADJ7249250
Regular
Jun 23, 2011

GUADALUPE MEDINA vs. CLOUGHERTY PACKING dba FARMERS JOHN

The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration to allow them to file a supplemental pleading. This supplemental filing is permitted under California Code of Regulations, Title 8, Section 10848. The defendant must file this pleading within 10 days. The Board granted reconsideration specifically to review the facts and law relevant to the supplemental petition.

Workers' Compensation Appeals BoardPetition for ReconsiderationSupplemental PetitionCalifornia Code of Regulations Title 8 Section 10848WCJPermissibly Self-InsuredClougherty PackingFarmers JohnGuadalupe MedinaJames Scherer
References
0
Case No. ADJ10886261
Regular
Nov 14, 2018

LUIS SANDOVAL vs. PRIME TECH CABINETS, INC, SECURITY NATIONAL INSURANCE COMPANY, AMTRUST

The Workers' Compensation Appeals Board granted the defendant's Petition for Removal, rescinded the WCJ's prior order, and returned the case for further proceedings. The original order found violations of Labor Code section 4062.3(b) and California Code of Regulations, title 8, section 35(c), striking the Qualified Medical Evaluator's report. This reversal was based on a subsequent en banc decision in *Suon v. California Dairies* that clarified the interpretation and remedies for violations of section 4062.3(b). The trial judge will reconsider the section 4062.3(b) issue and potentially other previously raised issues concerning the QME's reporting.

Petition for RemovalFindings and OrderQualified Medical EvaluatorMedical ReportingLabor Code section 4062.3(b)California Code of Regulations section 35(c)En Banc DecisionSuon v. California DairiesRescindedReturned to Trial Level
References
1
Case No. MISSING
Regular Panel Decision

In Re Pursuant to Section 304 of the Bankruptcy Code of Banco Nacional De Obras Y Servicios Publicos, S.N.C.

The International Association of Machinists and Aerospace Workers (IAM) sought relief from a preliminary injunction to pursue an action against Aeronaves de Mexico, S.A. de C.V. (Aeronaves) for declaratory judgment concerning a collective bargaining agreement. Aeronaves, represented by its Mexican bankruptcy trustee Banobras, objected, arguing the claims should be handled in Mexican bankruptcy court. Judge Tina L. Brozman analyzed the request in the context of section 304 of the Bankruptcy Code, emphasizing the specialized nature of American labor law, particularly the Railway Labor Act (RLA). Balancing international comity with the protection of American creditors, the court found that the issues regarding the existence and terms of the collective bargaining agreement required the expertise of an American district court. Therefore, the motion for relief from the stay was granted to permit the IAM action to proceed in the Southern District of New York.

Bankruptcy LawInternational ComitySection 304 StayRailway Labor Act (RLA)Collective Bargaining AgreementForeign BankruptcyAncillary ProceedingsDeclaratory ReliefLabor DisputeCreditor Claims
References
32
Case No. SRO 112972
Regular
Jun 12, 2008

STELLA JUAREZ vs. ARTERIAL VASCULAR ENGINEERING, NELSON STAFFING, CENTRE INSURANCE COMPANY by REM, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION by BROADSPIRE for CALIFORNIA COMPENSATION INSURANCE COMPANY, in liquidation

The California Insurance Guarantee Association (CIGA) has the right to seek contribution from Centre Insurance Company for workers' compensation benefits paid to an applicant with a cumulative trauma injury. CIGA's claim is not barred by the one-year limitation period for employer contribution claims under Labor Code section 5500.5(e), as CIGA is not an employer and Centre is considered "other insurance" under Insurance Code section 1063.1(c)(9). Therefore, the Appeals Board granted CIGA's petition for reconsideration and reversed the arbitrator's decision, awarding CIGA contribution from Centre.

CIGAContributionReconsiderationFindings Award and OrderLabor Code section 5500.5Insurance Code section 1063.1(c)(9)Cumulative TraumaGeneral EmployerSpecial EmployerOther Insurance
References
8
Case No. SRO 0107686
En Banc
Jul 27, 2004

Jose L. Martinez vs. Jack Neal & Son, Inc., Fremont Compensation Insurance Company, In Liquidation, California Insurance Guarantee Association, Cambridge Integrated Services, Inc.

The Appeals Board held that under Insurance Code section 1063.1(c)(8), as amended effective January 1, 2004, the California Insurance Guarantee Association (CIGA) is not liable for Labor Code section 5814 penalties awarded on or after that date for an insolvent insurer's unreasonable delay of benefits.

CIGAinsolvent insurercovered claimsLabor Code section 5814Insurance Code section 1063.1(c)(8)unreasonable delaymedical benefitsen banc decisionprospective applicationstatutory exclusion
References
20
Case No. 2016-119 K C
Regular Panel Decision
Jul 06, 2018

Jing Luo Acupuncture, P.C. v. NY City Tr. Auth.

This case involves an appeal from an order and judgment concerning a claim for first-party no-fault benefits for acupuncture services. The plaintiff, Jing Luo Acupuncture, P.C., as assignee of Sarah Adams, sought to recover unpaid balances from the NY City Transit Authority. The Civil Court initially granted the plaintiff's motion for summary judgment and denied the defendant's cross-motion. On appeal, the Appellate Term reversed the judgment, finding that the plaintiff failed to establish prima facie entitlement to summary judgment. The court also held that the defendant was not precluded from interposing its fee schedule defense, as it had fully paid for services billed under CPT codes 97811, 97813, and 97814 according to the workers' compensation fee schedule. Consequently, the plaintiff's motion for summary judgment was denied, and the defendant's cross-motion was granted in part for those specific CPT codes, while denied for CPT code 99262 and the seventh cause of action.

Acupuncture ServicesNo-Fault BenefitsSummary JudgmentFee Schedule DefenseWorkers' Compensation Fee ScheduleCPT CodesAppellate ReviewInsurance LawTimely DenialFirst-Party Benefits
References
14
Case No. 2016-329 S C
Regular Panel Decision
Apr 27, 2017

Spineisland for Chiropractic, P.C. v. 21st Century Advantage Ins. Co.

This case involves an appeal by Spineisland For Chiropractic, P.C., acting as an assignee, against 21st Century Advantage Insurance Company concerning first-party no-fault benefits. The plaintiff sought to recover for services billed under CPT code 95831. The District Court of Suffolk County had previously granted the defendant's motion for summary judgment, asserting that the defendant had appropriately paid the plaintiff based on the workers' compensation fee schedule. On appeal, the Appellate Term affirmed the lower court's decision. The Appellate Term found that the defendant had adequately demonstrated the proper application of CPT code 95833 for the services billed under CPT code 95831, and the plaintiff failed to present a triable issue of fact.

No-fault benefitsSummary judgmentCPT codeWorkers' compensation fee scheduleAppellate TermSuffolk CountyAssigneeInsurance disputeChiropractic servicesMedical billing
References
1
Case No. 2015-976 K C
Regular Panel Decision
Dec 22, 2017

Acuhealth Acupuncture, P.C. v. Hereford Ins. Co.

This case concerns an appeal from an order of the Civil Court regarding a dispute between Acuhealth Acupuncture, P.C. (applicant) and Hereford Ins. Co. (defendant) over first-party no-fault benefits. The applicant sought recovery for services billed under CPT code 97039, which has a 'By Report' designation in the workers' compensation fee schedule requiring additional documentation. The Civil Court initially granted the defendant's motion for summary judgment and denied the applicant's cross-motion. On appeal, the Appellate Term modified the order, denying the branch of the defendant's motion seeking summary judgment on the CPT code 97039 claims, as the defendant failed to demonstrate it requested the required additional verification. However, the applicant's cross-motion for summary judgment was still denied as it failed to establish its prima facie entitlement to judgment.

No-fault insuranceSummary judgment motionCPT codeWorkers' compensation fee scheduleVerification of claimAppellate reviewMedical billing disputeInsurance benefitsAssignee claimCivil procedure
References
5
Case No. MISSING
Regular Panel Decision
Jul 10, 2013

Christopher C. v. Bonnie C.

This divorce action between Christopher C. and Bonnie C. addresses equitable distribution, spousal maintenance, and counsel fees. The defendant, Bonnie C., who has a court-appointed guardian due to mental and emotional difficulties, had separated from the plaintiff in 2003 and informally divided marital assets. The court ratified this prior asset division, noting the defendant had dissipated her share. Finding the defendant unable to work and self-support, and the plaintiff capable of employment despite his claims of disability, the court awarded the defendant non-durational permanent maintenance of $2,500 per month and substantial attorney's fees. The plaintiff's motion to suspend or refund temporary maintenance was denied.

DivorceSpousal MaintenanceEquitable DistributionGuardianshipMental Health IssuesAsset DissipationAttorney's FeesFinancial CapacityPermanent MaintenanceMarital Property
References
12
Case No. 2015-608 Q C
Regular Panel Decision
Dec 19, 2017

Adelaida Physical Therapy, P.C. v. 21st Century Ins. Co.

In this case, Adelaida Physical Therapy, P.C., acting as an assignee, appealed an order from the Civil Court of the City of New York, Queens County. The original order had granted 21st Century Insurance Company's motion for summary judgment, dismissing parts of a complaint seeking first-party no-fault benefits for services billed under specific CPT codes (97010, 97110, and 97124). The Appellate Term, Second Department, reversed the lower court's decision. The appellate court found that 21st Century Insurance Company failed to demonstrate that it had used the correct conversion factor to calculate the reimbursement rate, thus not establishing its defense that the charged fees exceeded the workers' compensation fee schedule. As a result, the branches of the defendant's motion for summary judgment related to those CPT codes were denied.

No-Fault BenefitsCPT CodesSummary JudgmentWorkers' Compensation Fee ScheduleReimbursement RateAppellate ReviewInsurance DisputeCivil ProcedureConversion FactorMedical Billing
References
2
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