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

Case No. ADJ 11017618
Regular
Oct 29, 2020

Robert Shelven vs. RALPHS GROCERY COMPANY, SEDGWICK CMS, INC.

In this workers' compensation case, the applicant sought reconsideration of a decision denying their petition. The core issue was whether a February 2020 request for a cervical spine epidural injection constituted the "same treatment recommendation" as a previously denied September 2019 request, thereby preventing mandatory utilization review under LC § 4610(k). The Board denied reconsideration, adopting the WCJ's reasoning that the February 2020 request, while for one level instead of two, was for the "same treatment" at C5-C6 which had been denied within the prior 12 months. The Board further agreed that no documented change in facts material to the basis of the prior denial was presented, thus the Court lacked jurisdiction to determine the medical necessity of the treatment.

Utilization ReviewRequest for AuthorizationCervical Spine Epidural InjectionLC § 4610(k)Medical Treatment Utilization ScheduleInternational Medical Reviewtimelinessjurisdictionreasonable and necessaryFindings and Order
References
2
Case No. ADJ1776695 (STK 0194100)
Regular
Dec 28, 2015

LINDA PACKARD vs. SAN JOAQUIN COUNTY MENTAL HEALTH

This case concerns applicant Linda Packard's request for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision denying specific dental treatment, extraction of tooth 18 and a cantilever bridge. The WCAB denied reconsideration, upholding the administrative law judge's finding that the requested treatment was not medically necessary due to the industrial injury. The dissenting commissioner argued that the jaw condition was encompassed within the initial finding of "head" injury and that the WCAB retained jurisdiction to enforce the prior award of further medical treatment. The dissent proposed granting reconsideration to find liability for jaw treatment and allow for utilization review of the specific procedure.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderWCJindustrial injurytooth extractioncantilever bridgetemporomandibular jointLabor Code section 4610utilization review
References
10
Case No. MISSING
Regular Panel Decision

Bland v. Gellman

A claimant had two workers' compensation claims, one managed by the Special Fund for Reopened Cases and the other by Travelers Insurance Company, with liability equally apportioned. The claimant's treating physician requested a variance for aquatic therapy, which both carriers denied. Although a Workers' Compensation Law Judge approved the treatment, the Workers' Compensation Board reversed, asserting that the variance request form (MG-2) was not properly served on the Board and that the review request was untimely. The Appellate Division reversed the Board's decision, finding substantial evidence that the MG-2 form was timely filed with the Board, referencing both claim numbers, and that the request for review of the denial was also timely. The court concluded that the Board's determination lacked substantial evidence and remitted the matter for further proceedings.

Variance RequestAquatic TherapyClaim DenialMG-2 FormTimely FilingAdministrative LawAppellate ReviewSpecial Fund for Reopened CasesTravelers Insurance CompanySubstantial Evidence
References
3
Case No. ADJ10084576
Regular
Oct 06, 2016

ROSE SMITH vs. MEGGITT SENSING SYSTEMS PLC, THE HARTFORD

This case involves Rose Smith's workers' compensation claim where the defendant, Meggit Sensing Systems and its insurer, The Hartford, seek reconsideration of an order allowing Smith to obtain medical treatment outside their Medical Provider Network (MPN). The Appeals Board denied the petition, affirming the WCJ's finding that the defendant's failure to authorize a requested third medical opinion constituted a denial of care. This denial entitled the applicant to seek treatment outside the MPN at the defendant's expense. The defendant argued the request was procedurally deficient and not a request for treatment, but the Board found the failure to respond to the RFA for a third opinion, in context, was a failure to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Request for Authorization (RFA)Petition for ReconsiderationDenial of Medical TreatmentThird Medical OpinionUtilization Review (UR)Primary Treating PhysicianCumulative TraumaLoss of Control
References
3
Case No. ADJ8917716
Regular
May 03, 2016

INGA CZECH vs. BANK OF AMERICA, ACE AMERICAN INSURANCE COMPANY

Defendant Bank of America sought reconsideration of an award for medical treatment, arguing the Request for Authorization (RFA) was improperly served on their attorney, not the adjuster, thus not triggering utilization review timelines. The Workers' Compensation Appeals Board denied reconsideration, affirming that the applicant's physician's requested treatment was reasonable. The Board held that when an attorney receives an RFA and the defense has objected to its receipt, the attorney has a duty to transmit it to the claims administrator to fulfill the duty of good faith investigation. Therefore, the defendant's failure to process the treatment request after receiving it through their attorney resulted in liability for the awarded medical care.

Workers Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Request for Authorization (RFA)Declaration of Readiness to Proceed (DOR)Expedited HearingAdministrative Law Judge (WCJ)Agency LawAttorney NegligenceGood Faith Investigation
References
7
Case No. ADJ10896105
Regular
Mar 22, 2018

MICHAEL GHATTAS vs. O'REILLY AUTO PARTS, SAFETY NATIONAL CASUALTY COMPANY

This case concerns whether an employer must authorize requested medical treatment for a denied workers' compensation claim. The Appeals Board denied the applicant's petition for reconsideration, upholding its prior decision. The Board concluded that the employer's timely denial of the claim under Labor Code section 5402 terminated their responsibility to authorize medical treatment. Therefore, the employer was not obligated to submit the physician's request for authorization (RFA) to utilization review despite it being pending when the denial was issued.

Workers' Compensation Appeals BoardPetition for ReconsiderationOpinion and Order DenyingDecision After ReconsiderationFindings of Fact Award and OrderRequest for AuthorizationUtilization ReviewLabor Code Section 5402Claim DenialMedical Treatment Authorization
References
0
Case No. ADJ3273415 (AHM 0131697) ADJ1190217 (AHM 0131698) ADJ4181066 (AHM 0131699)
Regular
Jan 29, 2010

GINA MENDOZA vs. COUNTY OF LOS ANGELES DEPARTMENT OF CHILDREN AND FAMILY SERVICES, TPA AIMS

This case concerns a lien claimant's petition for reconsideration of a disallowed medical treatment lien. The Workers' Compensation Appeals Board (WCAB) denied the petition, affirming the administrative law judge's finding that the lien lacked evidence of reasonableness. The WCAB found the lien claimant's initial request for authorization deficient under California regulations and its subsequent request, though potentially compliant, was timely denied via utilization review. Furthermore, an agreed medical evaluator had previously opined against the necessity of the treatments in question.

Workers' Compensation Appeals BoardLien claimantPetition for reconsiderationJoint Findings and OrderMedical treatment lienIndustrial injuryStipulated AwardsIntermediate typist clerkPermanent disabilityUtilization review
References
0
Case No. ADJ7144283
Regular
Feb 04, 2015

RALPH LOYNACHAN vs. COUNTY OF LOS ANGELES

This case involved an applicant's petition for removal, seeking to address penalties for delayed treatment, which the WCJ denied due to a pending lien conference. The Appeals Board denied the applicant's petition, finding it failed to meet the extraordinary standards for removal, especially since a status conference request was inappropriate with a scheduled hearing. The defendant's subsequent notice, construed as a removal or disqualification petition, was dismissed as untimely. The Board found the defendant's notice to be without merit, admonishing counsel against future similar filings.

Petition for RemovalAppeals BoardWCJ GutierrezPenalties and SanctionsDelay of TreatmentCatastrophically Injured WorkerPetition for DisqualificationUntimely PetitionLabor Code Section 5311WCAB Rule 10452
References
2
Case No. ADJ1871643 (SDO 0291759)
Regular
Oct 23, 2017

JOSE GOMEZ vs. DEPARTMENT OF CORRECTIONS, REHABILITATION PAROLE & COMMUNITY SERVICES, Legally Uninsured, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, affirming the WCJ's award of medical treatment. The defendant's Utilization Review denial was deemed untimely because their Request for Information was served more than five business days after the initial request, excluding the day after Thanksgiving. The Board clarified that the day after Thanksgiving is considered a normal business day for UR purposes under Labor Code section 4600.4. Therefore, the defendant's untimely RFI did not extend the UR deadline, and the requested medical treatment was properly authorized.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationRequest for InformationTimelinessBusiness DayLabor Code Section 4600.4Petition for ReconsiderationFindings and AwardPrimary Treating Physician
References
0
Case No. 03-92677
Regular Panel Decision

Enron Corp. v. J.P. Morgan Securities Inc.

Enron filed a motion for reargument under Bankruptcy Rule 9023, seeking reconsideration of a May 2, 2006 opinion that denied its motion to amend its complaint to add Lehman Brothers Japan, Inc. as a defendant. Enron argued that the court overlooked Lehman's misrepresentation regarding named defendants, which constituted concealment under Rule 15(c)(3). The court found that Enron had sufficient information to name Lehman Japan and that its reliance on Lehman's statement was not reasonable. The court also denied considering new arguments raised by Enron as they were not timely. Ultimately, the court denied Enron's request for relief under Rule 9023, concluding that no material facts were overlooked, new arguments were untimely, and no manifest injustice occurred.

Bankruptcy Rule 9023Federal Rules of Civil Procedure 15(c)(3)Relation-Back DoctrineAmendment of ComplaintMistake in IdentityConcealmentMisrepresentationReasonable RelianceEquitable TollingFraudulent Concealment
References
19
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