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

Case No. ADJ9531226
Regular
Dec 04, 2018

JULICES MARTINEZ vs. SUN VALLEY GROUP, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the administrative law judge's decision. The lien claimant argued that the defendant's explanations of review (EORs) were deficient and did not trigger the lien claimant's obligation to request a second review. However, the Board found that the defendant's EORs substantially complied with statutory requirements and provided sufficient guidance to the lien claimant. Because the lien claimant failed to request a second review within the statutory timeframe, their objections to the billing were deemed waived.

Workers' Compensation Appeals BoardLien ClaimantExplanation of Review (EOR)Labor Code Section 4622Medical-legal ExpensesContested ClaimPetition for ReconsiderationAdministrative Director Rule 9794Second ReviewBill Review
References
7
Case No. ADJ8949526, ADJ8672351
Regular
Nov 05, 2018

ALFREDO ARGUETA vs. LA BREA DINING, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied reconsideration, upholding the administrative law judge's finding that the defendant was not liable for further payment on the lien claimant's invoices. The lien claimant argued the defendant's Explanation of Review (EOR) was deficient and thus they were not obligated to pursue a second bill review. The Board found this argument inconsistent with Labor Code section 4622, which requires timely objection to denied amounts, and adopted the WCJ's report. A dissenting opinion argued that a deficient EOR negates the requirement for a second bill review.

WCABLien claimantPetition for ReconsiderationExplanation of Review (EOR)Labor Code Section 4603.3Labor Code Section 4622Second Bill ReviewWCAB Rule 10451.1Perez v. Colorama Wholesale NurseryMedical-legal billing disputes
References
1
Case No. ADJ9120523
Regular
Jan 25, 2018

Guillermo Reyes Perez vs. Colorama Wholesale Nursery, Zenith Insurance Company

This Workers' Compensation Appeals Board case concerns disputed payments for copying services provided by lien claimant Citywide Scanning Services, Inc. The Board granted reconsideration to amend the original decision based on the WCJ's report. While most of the lien claimant's invoices were deemed satisfied due to failure to request a second review after receiving Explanations of Review (EORs), two invoices were specifically addressed. The Board found the defendant failed to provide valid EORs for services related to Colorama Wholesale Nursery and the California Secretary of State. Therefore, the lien claimant is entitled to full payment for these two invoices, less any amounts already paid by the defendant.

EORLabor Code section 4622WCAB Rule 9794(c)Petition for ReconsiderationLien claimantCopying servicesSecond reviewInvoicesDefendant's answerReport and Recommendation
References
0
Case No. ADJ9615494
Regular
Oct 08, 2019

CARLOS SOTO TORRES vs. THE CLIFF RESTAURANT, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded an Amended Findings of Fact and Order because essential documentation regarding the timeliness of medical-legal billings and reviews was missing. Specifically, the record lacked proof of service for the provider's invoice, the defendant's initial Explanation of Review (EOR), and the subsequent second bill review. This prevented determination of whether the defendant timely objected to the bill and whether the provider timely requested a second review, necessitating further proceedings at the trial level.

Workers' Compensation Appeals BoardReconsiderationAmended Findings of Fact and OrderQualified Medical EvaluatorQMEDr. Payam MoazzazZenith Insurance CompanyStatute of LimitationsLabor Code section 4903.5Independent Bill Review
References
0
Case No. 2022 NY Slip Op 01011
Regular Panel Decision
Feb 16, 2022

Hamm v. Review Assoc., LLC

The plaintiff, Peter Hamm, an employee, sustained injuries after falling from a ladder while servicing a security system at premises owned by Review Associates, LLC and leased by Fresh Direct, LLC. He initiated a personal injury action alleging common-law negligence and violations of Labor Law §§ 200, 240(1), and 241(6). The Supreme Court initially granted summary judgment to the defendants, dismissing the complaint. On appeal, the Appellate Division modified this order, denying summary judgment for the Labor Law § 240(1) claim against both defendants due to triable issues of fact regarding whether the work constituted "repairs" or "routine maintenance." Additionally, the court denied summary judgment for the common-law negligence and Labor Law § 200 claims against Fresh Direct, LLC, as it failed to establish a lack of notice regarding the defective ladder. The court affirmed the dismissal of the Labor Law § 241(6) claim against both defendants and the common-law negligence and Labor Law § 200 claims against Review Associates, LLC.

Personal InjuryLadder AccidentLabor Law § 240(1)Labor Law § 200Common-law NegligenceSummary JudgmentAppellate DivisionDuty to Maintain Safe PremisesRoutine Maintenance vs. RepairDangerous Condition
References
44
Case No. MISSING
Regular Panel Decision

Claim of Backus v. Wesley Health Care Center, Inc.

The Workers’ Compensation Board denied the carrier’s application for review of a February 8, 2002 decision, deeming it untimely as it was filed more than two years after the WCLJ’s initial decision. The carrier had argued that the average weekly wage was miscalculated due to a mistaken assumption about salary payment frequency. The Board also denied the carrier's subsequent application for reconsideration and/or full Board review. The appellate court affirmed the Board’s decisions, finding no abuse of discretion given the carrier’s failure to provide an explanation for the significant delay and the absence of new evidence warranting a rehearing.

Workers' Compensation BenefitsApplication TimelinessAverage Weekly WageAppellate ReviewBoard DiscretionRehearing DenialReconsideration DenialSubstantial EvidenceWorkers' Compensation LawNew York Regulations
References
6
Case No. MISSING
Regular Panel Decision
May 16, 2003

Claim of Isaacs v. Fleet Financial Services

Claimant appealed a Workers’ Compensation Board decision from May 16, 2003, which deemed her application for review untimely. The claimant's initial workers' compensation claim for a compensable back injury was established in 1999, with an average weekly wage set at $258. After the case was reopened in 2000 for further medical treatment and then closed in 2001, claimant sought an explanation for her average weekly wage calculation in March 2003, over three years after the initial decision became final. Her subsequent formal application for Board review of the 1999 administrative decision was denied as untimely because it was filed more than 30 days after the initial decision, as required by 12 NYCRR 313.3 [c] and Workers’ Compensation Law § 23. The court affirmed the Board’s discretionary decision, finding no abuse of discretion given the significant delay and lack of evidence demonstrating erroneous wage computation.

Workers' CompensationAppealTimeliness of ApplicationAdministrative ReviewAverage Weekly WageBoard DiscretionNew York Labor LawJudicial ReviewProcedural IssuesStatutory Interpretation
References
5
Case No. ADJ9838074 ADJ9838134
Regular
Nov 25, 2019

LEON SIMPSON vs. COLLEGE MEDICAL CENTER, NATIONAL CASUALTY INSURANCE, Administered by BROADSPIRE

The Workers' Compensation Appeals Board granted the lien claimant's petition for reconsideration regarding copy service invoices. The Board rescinded the prior decision, finding the administrative law judge's analysis inconsistent with Labor Code section 4622. The case is returned to the WCJ for further proceedings and a new decision consistent with the Board's en banc opinion in *Colamonico*, particularly addressing timely EOR submissions and the proper application of bill review statutes. Specifically, the WCJ must determine if defendants submitted timely explanations of review for all invoices.

Workers' Compensation Appeals BoardLien claimantMedical-legal expenseExplanation of Review (EOR)Labor CodePetition for ReconsiderationRescindFurther proceedingsColamonico v. Secure TransportationReasonable value
References
1
Case No. ADJ9040755
Regular
Apr 26, 2018

JUAN MARTINEZ vs. AREVALO LANDSCAPING SERVICE, CYPRESS INSURANCE COMPANY

This case concerns a lien claimant, Citywide Scanning Service, seeking reconsideration of a Workers' Compensation Appeals Board (WCAB) finding that their services were valued at $\$2,091.61$. The lien claimant argued that the defendant waived objections by failing to submit timely explanations of review (EORs) and that their billing was supported by evidence, entitling them to penalties. The WCAB denied reconsideration, finding that the issue of timely EORs was waived as it was not raised at the initial trial. The only remaining issue for trial was the reasonable value of the services, and the WCAB upheld the administrative law judge's determination.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFinding and OrderExplanation of Review (EOR)Reasonableness and NecessityLachesPhotocopy ServicesCompromise and ReleaseLien Trial
References
1
Case No. ADJ8764706
Regular
Dec 28, 2018

JOSE GARCIA vs. THE SHADY CANYON GOLF CLUB

This case concerns a lien claimant, California Imaging Solutions (CIS), seeking reconsideration of a Workers' Compensation Judge's decision regarding payment for services. The initial decision awarded CIS $1,137.33, of which $814.40 had been paid, leaving a balance of $322.93. CIS argues the defendant waived objections due to non-compliant Explanation of Review (EOR) forms. The Appeals Board granted reconsideration, rescinded the initial order, and returned the matter for further proceedings. The Board found issues with the WCJ's reasoning regarding defendant's objections and the sufficiency of EORs under Labor Code section 4603.3.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and OrderExplanation of Review (EOR)Labor Code Section 4603.3Medical-Legal ExpensesContested ClaimReasonable and Necessary ServicesBill Review Expert
References
9
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