CompFox Logo
AboutWorkflowFeaturesPricingCase LawInsights

Updated Daily

Case Law Database

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

Case No. ADJ3133261 (VNO 0400017)
Regular
Aug 17, 2010

FELIPE TOLENTINO vs. CONCO CEMENT, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, XCHANGING INC., FREMONT COMPENSATION

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's petition for reconsideration as premature. The WCAB granted the defendant's petition for reconsideration regarding the temporary disability overpayment issue, deferring it for further proceedings. The Board affirmed the WCJ's findings on injury causation and permanent disability but amended the decision to clarify the overpayment issue. Finally, the WCAB issued a notice of intention to sanction defendant's counsel for attaching and citing unadmitted evidence.

Workers' Compensation Appeals BoardFELIPE TOLENTINOCONCO CEMENTCALIFORNIA INSURANCE GUARANTEE ASSOCIATIONXCHANGING INC.FREMONT COMPENSATIONliquidationADJ3133261VNO 0400017OPINION AND ORDERS DISMISSING PETITION FOR RECONSIDERATION AND GRANTING PETITION FOR RECONSIDERATION
References
Case No. ADJ1923190
Regular
Jul 19, 2010

Richard Martinez vs. SIFLING BROTHERS, ZENITH INSURANCE COMPANY

Lien claimants, Dr. Silver and Dr. Bresler, sought payment for medical services exceeding the Official Medical Fee Schedule (OMFS). They argued their services warranted higher fees due to "extraordinary circumstances" and defendant's alleged improper billing practices. The Workers' Compensation Appeals Board denied their petitions for reconsideration, finding they failed to meet the burden of proof. The board held that lien claimants must demonstrate extraordinary circumstances justifying fees above the OMFS and present evidence of their usual and customary fees.

Workers' Compensation Appeals BoardRichard MartinezSifling BrothersZenith Insurance CompanyDavid BreslerDavid SilverSupplemental Findings and AwardOfficial Medical Fee ScheduleLien ClaimantsReconsideration
References
Case No. ADJ2367528 (SFO 0509283)
Regular
Mar 22, 2011

GUILLERMO BAYLEY vs. YMCA OF THE EAST BAY, TRAVELERS INSURANCE

This case involves a dispute over the payment for a 15-day hospitalization for an industrial injury. Stanford University Medical Center, a lien claimant, sought additional payment beyond the amount calculated under the Official Medical Fee Schedule (OMFS). The Appeals Board granted reconsideration, finding that California Code of Regulations, title 8, section 9792(c) allows for fees exceeding the OMFS if extraordinary circumstances related to the unusual nature of services rendered are proven. The case was returned to the trial level for further development of evidence regarding these extraordinary circumstances and to determine if the claimed fee is reasonable.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationInpatient Hospital Fee ScheduleOfficial Medical Fee Schedule (OMFS)Extraordinary CircumstancesDiagnosis-Related Group (DRG)Reasonable FeeLabor CodeMedical Treatment
References
Case No. ADJ4662216 (MON 0235398) ADJ1137113 (MON 0264731)
Regular
Jul 17, 2017

REBECCA WERTZ vs. HERBALIFE, AIG CLAIMS SERVICES

This case concerns Dr. Silver's lien claim for fees exceeding the Official Medical Fee Schedule (OMFS). The Appeals Board affirmed the WCJ's decision denying the lien claim, finding no statutory or regulatory basis for an "extraordinary circumstances" exception to the OMFS for services rendered after January 1, 2004. The Board also rejected due process claims regarding the exclusion of evidence and the inability to cross-examine the defendant's bill review expert. The Board concluded that lien claimant failed to prove the services were extraordinary or to demonstrate entitlement to equitable relief.

Workers' Compensation Appeals BoardLien ClaimantOfficial Medical Fee ScheduleOMFSExtraordinary CircumstancesAdministrative Director RuleSB 228Labor Code Section 5307.1Equitable ReliefDue Process
References
Case No. ADJ7620210
Regular
Feb 02, 2012

MATTHEW BROWN vs. PENINSULA PONTIAC AUTOMOBILE, AM TRUST NORTH AMERICA, MAJESTIC INSURANCE COMPANY

Defendant insurance company sought removal of an order setting a workers' compensation case for trial, arguing insufficient discovery. The Board denied the petition, finding the defendant waived objections by failing to object to two prior Declarations of Readiness. The Board also noted the defendant's lack of diligence in obtaining requested discovery and the absence of extraordinary circumstances justifying further delay. The order allowing the trial judge discretion for limited medical evidence was upheld.

Petition for RemovalQualified Medical ExaminerDiscoveryMandatory Settlement ConferenceDeclaration of ReadinessObjectionTrialDepositionTemporary Total DisabilityDue Diligence
References
Case No. ADJ3206000 (LAO 0877236)
Regular
Aug 10, 2012

JENNIFER HESTER vs. TECHNICOLOR, Permissibly Self-Insured

The applicant sought reconsideration of a decision limiting the defendant's payment for hip surgery to the Official Medical Fee Schedule, which the applicant's surgeon deemed insufficient. The Appeals Board granted reconsideration due to the complex fee dispute, noting that while extraordinary circumstances existed regarding the surgeon's qualifications, the reasonableness of his requested fee was unproven. To resolve this, the Board ordered the appointment of an agreed physician to investigate the surgeon's usual fee and its reasonableness compared to others with similar expertise.

ReconsiderationFindings of FactAgreed PhysicianMedical TreatmentFee ScheduleExtraordinary CircumstancesUsual FeeHip ArthroscopyOsteoplastyChondroplasty
References
Case No. ADJ7303882
Regular
Sep 11, 2014

ANTONIA HUERTA vs. HUENEME SCHOOL UNIFIED DISTRICT, YORK RISK SERVICES GROUP

This case concerns a hospital's claim for additional payment for an injured worker's lengthy rehabilitation stay following paraplegia after epidural injections. The hospital argued its services were exempt from the Official Medical Fee Schedule due to extraordinary circumstances and the necessity of specialized rehabilitation. The Workers' Compensation Appeals Board adopted the Administrative Law Judge's recommendation, denying the employer's petition for reconsideration. The Board found the ALJ's reasoning regarding reasonable treatment under the fee schedule and the justification for additional payment, including interest, was sound.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeReport and RecommendationStipulationsCustodianUpper ExtremitiesBackHipsLower Extremities
References
Case No. ADJ1422645
Regular
Feb 25, 2014

ROMANITA AYALA vs. COUNTY OF LOS ANGELES/KING DREW MEDICAL CENTER

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the Administrative Law Judge's decision. The Board affirmed that Labor Code section 5814 penalties are only payable to injured employees, not lien claimants. Furthermore, the Board found that the Official Medical Fee Schedule applies to self-procured treatment, and the lien claimant failed to demonstrate extraordinary circumstances to justify fees exceeding these limits. Finally, the Board confirmed that a 7% interest rate applies to governmental entities, not the 10% requested.

Workers' Compensation Appeals BoardLabor Code Section 5814Lien ClaimantOfficial Medical Fee ScheduleSelf-Procured TreatmentReasonable ExpenseExtraordinary CircumstancesSB 228Labor Code Section 4603.2Public Entity Interest Rate
References
Case No. ADJ8742261
Regular
Apr 24, 2015

JOHN MURPHY vs. COUNTY OF FRESNO

The Workers' Compensation Appeals Board granted reconsideration, rescinding the prior order that awarded additional compensation to Cedars-Sinai Medical Center (CSMC). The Board determined that California Administrative Director Rule 9790, as amended, clarifies that regulations allowing payment in excess of the Official Medical Fee Schedule for extraordinary circumstances do not apply to services rendered after January 1, 2004. Therefore, CSMC is not entitled to additional payment beyond the $66,248.58 already paid, as this amount conforms to the 2004 Inpatient Official Medical Fee Schedule for services provided in 2011.

Workers' Compensation Appeals BoardCounty of FresnoCedars-Sinai Medical Center2004 Inpatient Official Medical Fee SchedulePetition for ReconsiderationAdministrative Director Rule 9790Labor Code section 5307.1Senate Bill 228extraordinary circumstanceslien claimant
References
Case No. ADJ2609190
Regular
Jul 19, 2019

DEBORAH ORTIZ vs. KAISER PERMANENTE HOSPITAL/ SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP

The Workers' Compensation Appeals Board granted reconsideration of a lien claimant's petition, rescinding the original order and remanding the case for further proceedings. The Board found that the lien claimant failed to demonstrate "extraordinary circumstances" to justify payment above the Official Medical Fee Schedule, as those provisions were repealed in 2004. Furthermore, the Board clarified that lien claimants now bear the burden of proof for injury arising out of and occurring in the course of employment (AOE/COE), a principle established by recent legislative amendments and case law. The WCJ must now make findings on AOE/COE and other evidentiary issues.

Petition for ReconsiderationLien ClaimantFindings of Fact and OrderOfficial Medical Fee ScheduleExtraordinary CircumstancesLabor Code Section 3202.5Burden of ProofPreponderance of the EvidenceInjury AOE/COECompromise and Release
References
Showing 1-10 of 1,046 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.

CompFox Logo

The AI standard for workers' compensation professionals. Faster research, deeper analysis, better outcomes.

Product

  • Platform
  • Workflow
  • Features
  • Pricing

Solutions

  • Defense Firms
  • Applicants' Attorneys
  • Insurance carriers
  • Medical Providers

Company

  • About
  • Insights
  • Case Law

Legal

  • Privacy
  • Terms
  • Trust
  • Cookies
  • Subscription

© 2026 CompFox Inc. All rights reserved.

Systems Operational