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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
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
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
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
Case No. ADJ1543782
Regular
Aug 18, 2009

Richard E. Knudsen vs. CITY OF BEVERLY HILLS

In this workers' compensation case, the Board denied the defendant City of Beverly Hills' reconsideration of its prior decision. The Board had overturned a judge's finding that a police officer's shoulder injury sustained while exercising in the station gym during off-duty hours was not industrial. The Board determined the injury was compensable because it was a reasonable expectancy of employment under the specific circumstances. This decision reinforces the finding that the officer's workout was a reasonable part of his employment, even during off-duty hours.

Workers Compensation Appeals BoardCity of Beverly Hillspolice officerleft shoulder injuryindustrial injuryreasonable expectancyoff-duty hoursgymcompensablereconsideration
References
Case No. ADJ1543782 (VNO 0540728)
Regular
May 27, 2009

Richard E. Knudsen vs. CITY OF BEVERLY HILLS

The Workers' Compensation Appeals Board granted reconsideration, reversing a previous decision that denied benefits for a police officer's shoulder injury. The Board found the injury sustained in the on-duty gym was industrial because the applicant's belief that working out was expected was objectively reasonable, given the employer provided gym facilities and allowed officers to stay overnight for safety and duty readiness. The injury is now considered a compensable industrial injury.

Workers' Compensation Appeals BoardCity of Beverly Hillspolice officeroff-duty injuryindustrial injuryreasonable expectancypersonal comfort doctrineexertional injurygym workoutpremises
References
Case No. ADJ6737653
Regular
May 17, 2010

ABHIJIT BASU vs. ACTIFY, INC., HARTFORD INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration while granting the applicant's. The Board affirmed the original findings regarding industrial injury and the need for future medical treatment, but amended the decision to defer the issue of temporary disability. The record was found deficient regarding temporary disability, particularly concerning the applicant's job duties and medical opinions on incapacity, necessitating further development at the trial level. The Board's reasoning for deferring temporary disability relies on the lack of prior payments, medical opinions, or stipulations on this issue.

Workers' Compensation Appeals BoardIndustrial InjuryProduct ManagerLow Back InjuryNeck InjuryUpper Extremity InjuryTrapezius AreaFurther Medical TreatmentVAX-DGym Membership
References
Case No. ADJ3344826
Regular
Nov 09, 2010

RONALD FRYER vs. CORNUCOPIA COMMUNITY MARKET, TRAVELERS INSURANCE

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration regarding an order to authorize medical treatment and pay bills, as well as dismissing the applicant's untimely petition for reconsideration. The defendant argued the WCJ erred in ordering reimbursement for bills not following Utilization Review, while the applicant claimed further wrongdoing and sought an award of benefits. The Board adopted the WCJ's report, denying the defendant's petition, and dismissed the applicant's petition as untimely.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderMedical Treatment AuthorizationPrimary Treating PhysicianMedical Provider NetworkGym MembershipIndustrial InjuryUtilization ReviewApplicant
References
Case No. ADJ2373559 (OAK 0280633)
Regular
Dec 29, 2008

LYNN JONES vs. INTERNEWS NETWORK, STATE COMPENSATION INSURANCE FUND

The WCAB granted reconsideration, rescinded the prior award, and returned the case to the trial level to allow parties to complete the dispute resolution process regarding medical treatment denials. The Board found that after utilization review denied treatment, the parties failed to follow the required procedures under Labor Code sections 4610 and 4062 to resolve the dispute. Therefore, a new decision is to be made after the proper dispute resolution process is completed.

Workers' Compensation Appeals BoardUtilization ReviewMedical Treatment DisputeLabor Code Section 4610Labor Code Section 4062Qualified Medical ExaminerGym MembershipPhysical TherapyIndustrial InjuryTreating Physician
References
Case No. SJO 0246192 SJO 0252436
Regular
Jul 30, 2007

Notal HORDAGODA vs. JAMES S. NEIL, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration of the Administrative Law Judge's decision, upholding the award of medical treatment and admitting the Panel Qualified Medical Evaluator's reports. While the Board clarified that ACOEM guidelines are not exclusive to acute spinal conditions, they affirmed the awarded treatment was supported by substantial evidence. The Board found no violation of Labor Code section 4062.3 regarding applicant's communication with the QME, as it was in the course of examination.

Workers' Compensation Appeals BoardReconsideration DeniedACOEM GuidelinesLabor Code Section 4600Panel Qualified Medical EvaluatorQME reports admissibilityLabor Code Section 4062.3ophthalmological evaluationfunctional capacity evaluationUtilization Review
References
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