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

Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ4025440 (VNO 0557895)
Regular
Mar 12, 2012

CHARLES B. HANLON vs. WYLE HOLDINGS, INC., AIG adjusted by CHARTIS CLAIMS, INC.

The Workers' Compensation Appeals Board granted reconsideration to clarify an ambiguous award for temporary disability benefits. The applicant sustained a cumulative injury resulting in temporary and permanent disability. The defendant argued the award was unclear regarding the coordination of temporary disability payments with benefits already paid by the Employment Development Department (EDD). The Board clarified that the applicant is to be compensated for temporary disability, less amounts paid by EDD, with adjustments potentially needed to match the agreed-upon temporary disability rate. Furthermore, the Board clarified that EDD's overpayments of unemployment benefits made after the applicant's permanent and stationary date are to be reimbursed from the applicant's permanent disability benefits.

Cumulative industrial injuryTemporary disability indemnityPermanent disability benefitsPetition for ReconsiderationFindings and AwardAmbiguous awardEDD benefitsLabor Code §4904Agreed Medical ExaminerTemporary total disability
References
Case No. ADJ1626199 (SAC 323236)
Regular
Apr 14, 2009

STEVEN WILLIAMS vs. EARTHLINK, INC., FEDERAL INSURANCE COMPANY, CHUBB SERVICES CORPORATION

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior award, finding that defendant was not obligated to pay additional funds to the Employment Development Department (EDD). The Appeals Board determined that the EDD lien had been fully resolved through a prior compromise agreement where the defendant paid $13,500.00. Therefore, the defendant is entitled to credit for the full $18,890.00 EDD paid applicant, with no additional indemnity owed to the applicant or attorney fees awarded.

ReconsiderationEDD lientemporary disability indemnitycompromise agreementcreditsubrogationattorney feescumulative traumaFindings and AwardLabor Code
References
Case No. ADJ3560082 (ANA 0380953)
Regular
Mar 12, 2009

MARGARITA SERRANO vs. 3 DAY BLINDS, STATE COMPENSATION INSURANCE FUND

This case involves a lien claim by Huntington Beach Hospital for medical services rendered to an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration to reverse a prior finding, determining that contractual agreements between the hospital, Blue Cross, and the defendant insurer (SCIF) constitute an "express agreement" under Labor Code section 5304. This express agreement, which includes binding arbitration provisions, divests the WCAB of jurisdiction over the lien dispute. Therefore, the WCAB rescinded its prior award and ordered the parties to arbitrate the dispute according to the terms of their contract.

Workers' Compensation Appeals BoardState Compensation Insurance FundHuntington Beach HospitalComprehensive Contracting Hospital AgreementWorkers' Compensation Managed Care Service AgreementOther PayorLabor Code Section 5304Labor Code Section 4609Express AgreementBinding Arbitration
References
Case No. ADJ2200226
Regular
Apr 08, 2014

RUDY GALLARDO vs. SOUTHERN CALIFORNIA EDISON

The WCAB reversed a prior decision, finding it lacked jurisdiction over a hospital's lien claim for unpaid services. The Appeals Board held that an "express agreement," as required by Labor Code Section 5304 to divest the WCAB of jurisdiction, existed through a chain of contracts between the hospital, a network administrator (Blue Cross), and the self-insured employer. This chain of agreements fixed the payment amounts, thus precluding the WCAB from adjudicating the fee dispute. Any claims of contract breach or non-compliance with other statutes like Section 4609 must be pursued in a different forum.

WCAB jurisdictionLabor Code Section 5304express agreementchain of contractsHuntington HospitalSouthern California EdisonBlue Cross of CaliforniaOfficial Medical Fee Schedulelien claimfee dispute
References
Case No. VNO 541859
Regular
Jan 03, 2008

FAUSTINO SANDOVAL vs. NUTRITION PLUS, INC., PREFERRED EMPLOYERS INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration to amend a Stipulation and Award, allowing defendants credit for EDD payments made to the applicant. The Board affirmed the $\$ 240.00$ temporary disability rate, finding no basis to set aside the stipulation as defendant attempted to rely on a wage statement that was available prior to the agreement. The amendment ensures reimbursement to EDD for benefits paid during the applicant's temporary disability period.

Stipulation and AwardPetition for ReconsiderationAgreed Medical ExaminersMPNTemporary Disability RateCredit for EDD PaymentsWeatherall v. WCABFraudMutual MistakeNewly Discovered Evidence
References
Case No. ADJ253443 (POM 0286361)
Regular
Jan 17, 2014

JUAN MANUEL RESENDIZ vs. DANNY'S TRIMMING & BINDING CORP., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration, rescinding the WCJ's finding that it lacked jurisdiction over a lien dispute between Good Samaritan Hospital and State Fund. The Board found the contracts between State Fund, Blue Cross, and Good Samaritan potentially created an "express agreement" under Labor Code Section 5304, divesting the Board of jurisdiction. However, the Board also noted Good Samaritan failed to meet its initial burden of proof regarding the necessity of its services and that State Fund may not have provided proper notice of its payor status under the contract. The case is returned to the trial level for further evidence development on these issues.

Workers' Compensation Appeals Boardlien claimantPetition for ReconsiderationFindings of FactjurisdictionState Compensation Insurance FundOfficial Medical Fee ScheduleLabor Codeexpress agreementarbitration
References
Case No. SAL 95992 SAL 95993 SAL 97616
Regular
Feb 06, 2008

JOSE G. LIZARRAGA (DECEASED) vs. WATSONVILLE PRODUCE, REPUBLIC INDEMNITY COMPANY OF AMERICA

This case concerns whether a binding compromise and release agreement was formed before the applicant's death. The Appeals Board denied reconsideration, finding that the agreement was not "duly executed" as required by statute because the defendant had not signed it, and a Medicare set aside provision was still pending. The majority concluded that a complete meeting of the minds on all material aspects was lacking, making the WCJ's prior finding of a binding agreement erroneous.

Compromise and ReleaseDuly ExecutedMedicare Set AsideBinding AgreementMeeting of the MindsLabor Code Section 5003Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderIndustrial Injury
References
Case No. ADJ7024559
Regular
Sep 24, 2013

ANTONIA PEDRO vs. KAISER FOUNDATION HOSPITAL, SEDGWICK CLAIMS MANAGEMENT SERVICES

Defendant Kaiser Foundation Hospital sought reconsideration of an award, claiming newly discovered evidence of EDD payments to the applicant during a period of permanent disability advances. The parties subsequently reached an agreement resolving the issue of EDD reimbursement. Consequently, the Appeals Board granted reconsideration, rescinded the original award, and remanded the matter to the WCJ. The WCJ is to issue an amended award based on the parties' revised stipulations.

Workers' Compensation Appeals BoardPetition for ReconsiderationStipulations with Request for AwardAwardNewly Discovered EvidenceEDDPermanent Disability AdvancesPermanent Disability IndemnityAmended AwardReimbursement
References
Case No. ADJ9285089
Regular
Aug 24, 2016

ANA RAMIREZ FARIAS vs. ABLE BUILDING MAINTENANCE, ZURICH NORTH AMERICA

The Appeals Board affirmed an arbitrator's decision that applicant Ana Ramirez Farias must transfer medical care to her employer's exclusive provider network, despite her continued treatment with Dr. Arthur Harris. The majority found that the collective bargaining agreement's provisions on medical treatment, negotiated under Labor Code section 3201.5, take precedence over general Medical Provider Network (MPN) statutes like section 4603.2(a)(2). The dissenting opinion argued that the collective bargaining agreement diminishes the applicant's statutory right to treatment and that section 4603.2(a)(2) should apply due to the agreement's silence on transfer of care disputes.

Labor Code section 3201.7Labor Code section 3201.5(b)Alternative Dispute Resolution (ADR)self-procure treatmentmedical controlexclusive provider networkcarve-out agreementMedical Provider Network (MPN)collective bargaining agreementagreed list of providers
References
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