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

Case No. ADJ13096148
Regular
Dec 03, 2020

JUSTINO MONTIEL vs. SOCAL FRAMINGS, INC., REDWOOD FIRE & CASUALTY INSURANCE, BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANIES

The applicant properly selected Dr. Patterson at Casa Colina as his treating physician for his admitted injury, as Casa Colina is listed as a provider within the defendant's Medical Provider Network (MPN). The Board affirmed the WCJ's decision, finding that an acknowledgment of MPN membership is not required for physicians who are shareholders, partners, or employees of a medical group that has elected to participate in the MPN. The defendant failed to provide evidence that Casa Colina's participation was limited to ancillary services. Therefore, the defendant's petition for reconsideration was denied.

Medical Provider NetworkMPNTreating PhysicianLabor Code Section 4600Expedited HearingFindings of FactAncillary ServicesMedical GroupUtilization ReviewPetition for Reconsideration
References
1
Case No. ADJ11314069
Regular
Nov 20, 2018

LUIS TOLENTINO vs. LUKE'S ROOFING, REDWOOD FIRE INSURANCE COMPANY

This case concerns the proper designation of a primary treating physician within a Medical Provider Network (MPN). The applicant selected Dr. Huang, who was employed by Casa Colina. The defendant argued this was improper because Casa Colina was only listed for ancillary services and Dr. Huang was not individually listed in the MPN. The Board affirmed the WCJ's decision, holding that Dr. Huang's designation was proper as long as he acted through Casa Colina, which was included in the MPN without restriction. Regulations permit an entity in the MPN to have its employee physicians considered part of the network, unless specifically excluded.

Workers' Compensation Appeals BoardPetition for ReconsiderationPrimary Treating PhysicianMedical Provider Network (MPN)Ancillary ServicesEmployee PhysicianNon-natural personApplicable RegulationsEntityEmployee
References
0
Case No. ADJ9743742
Regular
Jan 25, 2018

AGUSTIN CASTRO GONZALEZ vs. TRADEMARK CONSTRUCTION COMPANY, INC., ZURICH AMERICAN INSURANCE COMPANY

The applicant sought reconsideration of a Workers' Compensation Appeals Board (WCAB) decision denying 24/7 home custodial care and limiting Casa Colina treatment to four weeks. The WCAB granted reconsideration, amending the decision to defer the issue of 24/7 home health care pending further record development. The WCAB affirmed the original finding that Casa Colina treatment for four weeks was reasonable and necessary, stating that any need for further treatment could be processed normally.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact Award and OrdersWorkers' Compensation Administrative Law JudgeCustodial CareCasa ColinaUtilization ReviewExpedited HearingDeclaration of ReadinessMedical Treatment
References
9
Case No. ADJ9038700
Regular
Sep 06, 2017

RAFAEL GONZALEZ vs. GORDON HAY, INC., ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the employer's petition for reconsideration. The Board affirmed the administrative law judge's order for continued treatment at Casa Colina for the applicant's traumatic brain injury (TBI). This decision was based on a prior Independent Medical Review (IMR) finding that Casa Colina treatment was reasonable and no evidence of changed condition. Furthermore, the employer's failure to conduct timely utilization review for the requested treatment authorized the Board to determine medical necessity based on substantial evidence.

Workers Compensation Appeals BoardTraumatic Brain Injury (TBI)Independent Medical Review (IMR)Utilization Review (UR)Findings and OrderPetition for ReconsiderationSubstantial Medical EvidenceIndustrial InjuryMedical TreatmentCasa Colina
References
2
Case No. ADJ7176285
Regular
May 23, 2011

FRANCISCO CASAS LEYVA vs. WAR MART #2242, AVIZENT FRANK GATES SERVICES

The Workers' Compensation Appeals Board (WCAB) denied reconsideration of a prior decision regarding Francisco Casas Leyva's claim against War Mart \#2242 and Avizent Frank Gates Services. The WCAB adopted the reasoning of the workers' compensation administrative law judge (WCALJ) in its decision. The Board also gave great weight to the WCALJ's credibility findings. Therefore, the petition for reconsideration was formally denied.

Workers' Compensation Appeals BoardFrancisco Casas LeyvaWar MartAvizent Frank Gates ServicesOrder Denying ReconsiderationPetition for Reconsiderationworkers' compensation administrative law judgeWCJGarza v. Workmen's Comp. Appeals Bd.credibility finding
References
1
Case No. ADJ9520089
Regular
Nov 21, 1937

IRMA SOLIS DIAZ vs. JESSE NAVARRO & LUPITA GUTIERREZ dba CASA DEL LAGO, UEBTF

The Workers' Compensation Appeals Board (WCAB) denied Irma Solis Diaz's petition for reconsideration in the case against Jesse Navarro and Lupita Gutierrez dba Casa del Lago. The Board adopted and incorporated the report of the workers' compensation administrative law judge (WCJ). The specific grounds for the denial are not detailed in this opinion but are attributed to the WCJ's report. Therefore, the initial decision, whatever it was, stands.

WORKERS' COMPENSATION APPEALS BOARDPETITION FOR RECONSIDERATIONDENYINGWCJ'S REPORTADOPT AND INCORPORATELOS ANGELES DISTRICT OFFICEAPPLLICANTDEFENDANTSCASE NOOPINION AND ORDER
References
0
Case No. ADJ9219504
Regular
Dec 22, 2016

SANDY CASAS vs. NESTLE HOLDINGS, INC., ACE AMERICAN INSURANCE COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.

The Workers' Compensation Appeals Board affirmed the Administrative Judge's finding that applicant Sandy Casas sustained a left shoulder injury arising out of and in the course of employment. The Board found that Nestle Holdings, Inc. had notice of the injury prior to applicant's termination on October 14, 2013, based on applicant's report to HR on October 9, 2013, and the subsequent HR investigation. Therefore, the post-termination defense under Labor Code section 3600(a)(10) was not applicable. The Board also affirmed the WCJ's finding that the Agreed Medical Evaluator's report was based on substantial evidence.

Workers' Compensation Appeals BoardPost-termination defenseLabor Code section 3600(a)(10)Notice of injuryPre-terminationAgreed Medical EvaluatorSubstantial evidenceHuman ResourcesGrievanceSupervisor misconduct
References
2
Case No. ADJ9671636
Regular
Feb 15, 2017

TERRI SCOTT vs. CITY OF LOS ANGELES

The Workers' Compensation Appeals Board (WCAB) granted the employer's petition for reconsideration, reversing a prior decision. The WCAB found that the employer's utilization review (UR) decisions regarding medical treatment requests were timely. Consequently, the prior award of a cognitive rehabilitation program at Casa Colina to the applicant was rescinded. The WCAB emphasized that timely UR is a prerequisite for awarding such treatment.

Workers Compensation Appeals BoardUtilization ReviewRequest for AuthorizationMedical TreatmentCognitive RehabilitationTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Compensable Consequence InjuryPrimary Treating Physician
References
3
Case No. MISSING
Regular Panel Decision

Casas v. Consolidated Edison Co.

The Supreme Court, New York County, issued an order on October 3, 2011, which declared the defendant's answer stricken due to non-compliance with a conditional preclusion order from October 31, 2006, and limited the trial to the issue of damages. This order was unanimously affirmed on appeal. The defendant failed to provide a reasonable excuse for not complying with discovery requests and did not present a meritorious defense, which was necessary to vacate the preclusion order. The court also clarified that a Workers' Compensation Board panel decision dated August 28, 2009, regarding the plaintiff's accident-related disability, does not have preclusive effect. Additionally, a prior decision and order of this Court, entered on April 9, 2013, was recalled and vacated.

Discovery SanctionsStriking AnswerConditional Preclusion OrderSelf-Executing OrderMeritorious DefenseReasonable ExcuseWorkers' Compensation BoardPreclusive EffectAppellate ReviewRecall and Vacate Order
References
7
Case No. ADJ4615548 (VNO 0497034) ADJ1524834 (VNO 0497035)
Regular
Feb 14, 2011

JULIA DE CASAS vs. GRIMWAY ENTERPRISES

This case involves a lien claimant seeking reconsideration after their $\$8,134.77$ medical treatment lien was disallowed by the WCJ for untimeliness. The lien was filed on February 8, 2010, for treatment rendered between June 2004 and February 2005, well after the August 3, 2006, Order Approving Compromise and Release and exceeding statutory filing deadlines. The claimant argued the lien was enforceable once the defendant was aware of the services and that the defendant had "unclean hands" for failing to disclose pending charges. The Board denied reconsideration, upholding the WCJ's finding that the lien claim was time-barred per Labor Code section 4903.5.

Workers' Compensation Appeals BoardGrimway EnterprisesTristar Risk ManagementEMSI Physicians NetworkTomas RiosAlpha Billing & CollectionsRicardo MuñozPetition for ReconsiderationLien ClaimantRulings Findings of Fact & Order
References
1
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