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

Case No. ADJ8035089, ADJ8033530, ADJ8033513
Regular
Jun 27, 2012

Linda Barajas vs. First Group America, Chartis

The Appeals Board overturned a WCJ's denial of reimbursement for a self-procured gym membership. The applicant's claim was in delay status when her physician prescribed the membership, and she notified the adjuster without objection before purchasing it. The Board found the gym membership reasonable and consistent with ACOEM guidelines for shoulder treatment, though limited to six months. Therefore, the applicant is awarded one-half the cost of her 12-month membership as reasonable self-procured medical treatment.

Workers' Compensation Appeals BoardReconsiderationSelf-procured medical treatmentGym membershipTreating physicianDelay statusACOEM guidelinesLabor Code 5402(c)Utilization reviewIndustrial injury
References
0
Case No. ADJ3119223
Regular
Aug 28, 2013

ALEXANDER ALLEN vs. SONOMA VALLEY UNIFIED SCHOOL DIST., permissibly self-insured, administered by REDWOOD EMPIRE SCHOOLS INSURANCE GROUP

The Workers' Compensation Appeals Board rescinded a prior decision, finding that the defendant school district properly served utilization review denial letters for a health club membership. Although the applicant's attorney had changed addresses, the defendant was not notified and sent the letters to the last known address on file with the Board. Despite conflicting medical opinions, the Board found that a gym membership for pool therapy was reasonable and necessary treatment for the applicant's industrial injury.

Workers' Compensation Appeals BoardUtilization ReviewService of ProcessMedical TreatmentHealth Club MembershipPool TherapyQualified Medical EvaluatorSubstantial EvidencePetition for ReconsiderationFindings and Orders
References
8
Case No. 2021 NY Slip Op 01456 [192 AD3d 1287]
Regular Panel Decision
Mar 11, 2021

Matter of Brennan (Village of Johnson City)

In 1995, claimant Kevin Brennan sustained a work-related back and hip injury, leading to a workers' compensation claim. He was later disqualified from future wage-replacement benefits under Workers' Compensation Law § 114-a, with liability transferring to the Special Fund for Reopened Cases. After a left hip replacement in 2011, his treating physician annually requested authorization for a gym membership for rehabilitation, which the Special Fund granted until 2019. The 2019 request was denied based on an independent medical examiner's opinion. A Workers' Compensation Law Judge initially authorized the membership and a lump-sum reimbursement, but the Workers' Compensation Board upheld the authorization while modifying the reimbursement to amounts already paid and requiring proof for future monthly payments. Brennan appealed the Board's decision. However, the Appellate Division dismissed the appeal, finding Brennan was not 'aggrieved' by the Board's decision since he received the primary relief sought, thus lacking jurisdiction.

Workers' Compensation BenefitsGym Membership AuthorizationMedical Necessity DisputeSpecial FundAggrievement DoctrineAppellate JurisdictionReimbursement OrderHip Injury ClaimsStatutory InterpretationWCLJ Decision Review
References
10
Case No. 00-CV-905
Regular Panel Decision

Federal Trade Commission v. First Capital Consumer Membership Services, Inc.

Non-party Electronic Payment Exchange (EPX) sought to intervene as a plaintiff in a case initiated by the Federal Trade Commission (FTC) against First Capital defendants. EPX claimed a significant financial interest due to an outstanding debt from defendant Worldwide Telecom, Inc., and a specific interest in funds held in the "Dakota Financial Group" account seized by the FTC and placed under receivership. EPX moved to intervene as of right and by permission, arguing its interests were not adequately protected by the FTC or the Receiver. The court denied EPX's motion, finding that EPX did not demonstrate that its interests would be impaired or inadequately protected, especially given the FTC's role as parens patriae and the Receiver's obligation to all claimants. The court also noted that EPX had alternative avenues for relief and that allowing intervention would introduce collateral issues and unduly delay the main action.

InterventionFederal Rules of Civil Procedure 24(a)(2)Federal Rules of Civil Procedure 24(b)(2)Asset FreezeReceivershipPromissory NoteCreditor ClaimsAdequacy of RepresentationParens PatriaeCollateral Issues
References
17
Case No. ADJ2940818 (STK 0138641)
Regular
Dec 22, 2009

DAVID KELLER vs. CSAA, TRAVELERS INSURANCE COMPANY

Defendant sought reconsideration of a WCJ's decision awarding applicant permanent disability and medical care, including a gym membership and inversion table. The Appeals Board denied reconsideration, finding the WCJ's decision supported by the record.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardCumulative TraumaIndustrial InjuryPermanent DisabilityMedical CareGym MembershipInversion TableEvidence-Based Medicine
References
1
Case No. ADJ165588 (SAL 0108801)
Regular
Mar 09, 2009

STEVEN G. CARR vs. COUNTY OF SANTA CRUZ, Permissibly Self-Insured, Adjusted By SEDGWICK CLAIMS MANAGEMENT SERVICES

The Board granted reconsideration and amended a prior award, clarifying which expenses are compensable for the applicant's industrial injury. The applicant, a deputy sheriff, was awarded expenses for his gym membership and associated travel, totaling $10,241.76. However, the Board disallowed most pharmaceutical expenses, only allowing those for Celebrex, Nabumetone, and Avapro, along with travel mileage for these prescriptions. The issue of medical mileage reimbursement for treatment of family members was remanded for further adjustment or adjudication.

DeputysheriffIndustrialinjuryHypertensionGymmembershipPharmaceuticalexpensesMileageexpenseMedicaltreatmentPetitionforreconsiderationWCJFindingsofFact
References
1
Case No. ADJ4261717 (FRE 0227914), ADJ2564944 (FRE 0224116)
Regular
Jan 19, 2017

Ann Swengel vs. CAMBRIDGE; AON CORPORATION, AMERICAN CASUALTY COMPANY OF READING, PENNSYLVANIA

The Appeals Board granted the defendant's petition for reconsideration, reversing the prior order that mandated a gym membership. The Board found that because the defendant timely submitted the request for authorization (RFA) to Utilization Review (UR), the UR's denial is not subject to review by the Board, nor is it subject to Independent Medical Review (IMR) if not timely appealed. Consequently, the applicant's petition for reconsideration and for penalties was denied. The Board emphasized that their jurisdiction regarding UR determinations is limited to timeliness.

Utilization ReviewIndependent Medical ReviewPetition for ReconsiderationFindings of Fact and OrderPrimary Treating PhysicianRequest for AuthorizationAdministrative Director's DeterminationMedical Treatment Utilization ScheduleLabor Code Section 5814.5Stipulations with Request for Award
References
5
Case No. MISSING
Regular Panel Decision

Cleary v. Board of Education

The petitioner, a substitute school teacher, sought retroactive membership in the New York State Teachers’ Retirement System after the enactment of Retirement and Social Security Law § 803. Respondent, her employer, denied her application. Petitioner then initiated a CPLR article 78 proceeding, which the Supreme Court granted, annulling the Hearing Officer's determination due to lack of a rational basis. The respondent appealed this decision. The Appellate Court affirmed the Supreme Court's judgment, concluding that the Hearing Officer's finding that the petitioner participated in a procedure requiring a formal decision to join the retirement system lacked a rational basis, as the evidence presented by the respondent, including W-4 forms, personnel notations, and general office practice testimony, was insufficient to meet the burden.

Retroactive membershipTeachers’ Retirement SystemCPLR article 78Rational basis reviewStandard office practiceEvidence sufficiencyConstitutional challengeSubstitute teacherPublic retirement systemNew York law
References
6
Case No. ADJ514225 (SJO 0135271)
Regular
Sep 02, 2009

PIERRE PALENGAT vs. THE TOWN OF HILLSBOROUGH

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration of an award granting further medical treatment, including supervised water therapy and a gym membership, to the applicant. The Board found that the defendant's counsel made false and misleading statements under penalty of perjury in the petition regarding the applicant's failure to object to a prior utilization review denial. Consequently, the Board removed the case for the purpose of imposing a $750 sanction on the defendant's counsel for these bad-faith tactics.

Agreed medical evaluatorUtilization reviewLabor Code section 4062Petition for reconsiderationVerified answerExpedited hearingRemovalAppeals Board Rule 10561Section 5813Bad-faith actions
References
0
Case No. ADJ2772961 (VNO 0505212)
Regular
May 20, 2011

Rodney Elkins vs. DE MOOR'S PAINTING, INC., STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration to clarify that the applicant's treating physician, not the Agreed Medical Evaluator, must direct and manage the decreasing narcotic treatment plan. The Board affirmed the award of a gym membership, exercise sessions, and sleep medication, finding these consistent with the AME's well-reasoned opinion and the treating physician's recommendations. The issue of radiofrequency nerve ablation was deferred as premature pending completion of the current treatment plan. Finally, the Board denied attorney fees under Labor Code section 5814.5, finding no unreasonable delay in compensation due to the defendant's reliance on the AME's medical opinion.

Workers' Compensation Appeals BoardAgreed Medical EvaluatorTreating PhysicianPetition for ReconsiderationFindings of Fact and AwardLabor Code Section 5814.5Medical TreatmentRadiofrequency Nerve AblationNarcotic AnalgesicsGym Membership
References
7
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