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

Case No. ADJ367320 (VNO 0476303) ADJ566883 (LAO 0740861)
Regular
Jun 16, 2015

CRISTINA UGARTE vs. FLINKMAN REALTY, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board (Appeals Board) reconsidered a prior decision that denied separate reimbursement for implanted hardware for lien claimant Pacific Hospital of Long Beach. The Appeals Board found that the WCJ misinterpreted regulations regarding hospital billing and reimbursement. Specifically, the Appeals Board determined that implanted hardware is separately reimbursable under section 9789.22(g) regardless of whether the inpatient services qualify as a cost outlier. Therefore, the Board rescinded the WCJ's decision and returned the case for further proceedings to calculate the correct payment for the implanted hardware.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien claimantReimbursementImplanted hardwareOutlier feesRegulationsCost outlierInpatient hospital services
References
0
Case No. MISSING
Regular Panel Decision

Agriculture Ins. Co., Inc. v. Ace Hardware Corp.

Plaintiff Agricultural Insurance Company, Inc., as assignee of injured worker Robert T. Treadway, Jr., moved for partial summary judgment on liability under N.Y. Labor Law § 240(1) against defendants Ace Hardware Corporation and Butler Construction Company. Treadway was severely injured when he fell from an elevated height at a construction site after the steel beam he was standing on collapsed. Although provided with a safety harness and line, these were attached to the very beam that failed, rendering them inadequate. The court granted the plaintiff's motion, concluding that the defendants violated § 240(1) by failing to provide proper protection and that this failure was the proximate cause of Treadway's injuries. The court rejected arguments regarding the admissibility of an accident report, a superceding cause (wind), and Treadway's contributory negligence.

N.Y. Labor LawSummary JudgmentLiabilityConstruction AccidentElevated WorkSafety DevicesProximate CauseContributory NegligenceHearsay ExceptionParty Admission
References
31
Case No. MISSING
Regular Panel Decision

Claim of Flynn v. Ace Hardware Corp.

A claimant, a forklift operator for Ace Hardware Corporation, suffered a neck injury and stopped working in April 2004, filing for workers' compensation benefits in June 2004. Initially, a Workers’ Compensation Law Judge established the claim, but the Workers’ Compensation Board reversed this, finding the claimant failed to provide timely notice to the employer within 30 days as required by Workers’ Compensation Law § 18. The appellate court affirmed the Board's decision, noting that the employer was not informed of a work-related injury until June 30, 2004, and the claimant did not demonstrate that the delay was not prejudicial to the employer. The court found substantial evidence supported the Board's determination.

Timely NoticeWorkers' Compensation LawEmployer PrejudiceWork-Related InjuryAppealBoard Decision30-Day Notice PeriodFamily Medical Leave ActDisability BenefitsSubstantial Evidence
References
3
Case No. ADJ7170139, ADJ7176930
Regular
Mar 22, 2017

ROBERT GAONA vs. CAPITAL BUILDERS HARDWARE, SOUTHERN INSURANCE COMPANY, ENDURANCE REINSURANCE CORPORATION OF AMERICA

This case involves Robert Gaona's workers' compensation claims against Capital Builders Hardware and their insurers. The Court of Appeal previously annulled its writ of review and remanded the case to the Workers' Compensation Appeals Board (WCAB). The WCAB has now affirmed its prior decision from March 24, 2016, which dismissed the defendants' Petition for Reconsideration and denied their Petition for Removal. Therefore, the original Joint Findings and Orders issued by the WCJ on June 5, 2015, stand affirmed.

Workers' Compensation Appeals BoardRemittiturCourt of AppealPetition for ReconsiderationPetition for RemovalJoint Findings and OrdersAdministrative Law JudgeAnnulledAffirmedSubstitution of Commissioner
References
1
Case No. MISSING
Regular Panel Decision

Rechenberger v. Nassau County Medical Center

Edward Rechenberger suffered hip fractures and underwent two operations at Nassau County Medical Center in May 1982. Following a re-injury and later diagnosis, he learned the surgical hardware was improperly implanted, leading to further operations. Mr. Rechenberger sought leave to serve a late notice of claim against the medical center. The Supreme Court initially denied the motion, but the Appellate Division reversed this decision, finding that the hospital had actual knowledge of the essential facts of the claim within the statutory 90-day period through its own medical records. The court concluded that the delay in serving the notice of claim was not substantially prejudicial to the hospital, and thus, granted the petitioners leave to serve the late notice of claim.

Medical MalpracticeLate Notice of ClaimNassau CountyHip FractureSurgical ErrorContinuous Treatment DoctrineActual NoticePrejudiceAppellate ReviewMunicipal Corporation
References
11
Case No. MISSING
Regular Panel Decision

Niedermaier v. Southern Tier Building Trades Benefit Plan

Plaintiff Karl Niedermaier, a natural gas pipeline superintendent, sought health benefits coverage from the Southern Tier Building Trades Plan for his bilateral hearing loss and cochlear implant received in 2011. The Plan, through the Joint Board of Trustees, denied his requests for coverage, citing "artificial implant" and "hearing aid" exclusions. After two internal appeals were denied, Plaintiff commenced an action under ERISA to recover benefits. Both parties moved for summary judgment. The court found that while a cochlear implant is not a hearing aid, it reasonably falls under the "artificial implant" exclusion of the Plan. Therefore, the court granted the Defendants' motion for summary judgment and denied the Plaintiff's motion.

ERISAhealth benefitscochlear implanthearing lossartificial implant exclusionhearing aid exclusionsummary judgmentplan interpretationbenefits denialprocedural irregularities
References
24
Case No. ADJ5827846
Regular
May 29, 2013

TSHEA PARTNER vs. SOUTHERN CALIFORNIA EDISON

This Workers' Compensation Appeals Board case denied reconsideration of a lien claim by Pinnacle Lien Services on behalf of Access Mediquip. The applicant received spinal stimulator implants, and the lien claimant sought payment for implantable devices. The Appeals Board adopted the judge's report, which found that the charges for the implantable devices were included in the payments made to the surgery center. The court determined that the lien claimant failed to provide sufficient evidence to prove the defendant's liability for these separately itemized devices.

Petition for ReconsiderationWorkers' Compensation Appeals BoardSouthern California EdisonPinnacle Lien ServicesAccess MediquipSpinal stimulatorImplantable devicesCPT codesAmbulatory Surgery CenterDe Anza Ambulatory Surgery Center
References
1
Case No. ADJ3897698 (ANA 0370975)
Regular
Feb 03, 2010

CARLOS URREA vs. MLB INVESTMENTS dba B&E FEED & SUPPLY, TRUCK INSURANCE EXCHANGE

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior decision finding the defendant not liable for an applicant's back surgery and subsequent hardware removal. The WCAB ruled that while the initial surgery by Dr. Fonseca was deemed unreasonable and unnecessary, the defendant remains liable for the removal of hardware resulting from that surgery as a compensable consequence of the industrial injury. The WCAB rescinded the previous order and returned the case for further proceedings on the issue of credit for the applicant's civil malpractice settlement.

Workers' Compensation Appeals BoardIndustrial InjuryLow Back InjurySelf-Procured SurgeryCompensable ConsequenceMedical MalpracticeAgreed Medical EvaluatorReasonable and NecessarySurgical HardwareProximate Cause
References
3
Case No. ADJ3491952
Regular
Sep 04, 2012

ELISEO CHACON vs. PICO RIVERA PALLETS INCORPORATED, CALIFORNIA INSURANCE COMPANY

This case involves a lien claimant, Access Mediquip, seeking payment for surgical implants. The Workers' Compensation Judge disallowed the lien, finding the claimant not credible regarding the actual costs of the implants, despite acknowledging their provision. Access Mediquip filed a petition for reconsideration, but the Appeals Board dismissed it. The dismissal was based on the petition being untimely filed 26 days after the judge's decision was mailed, exceeding the statutory 20-day period extended by 5 days for mail service.

Workers' Compensation Appeals BoardLien claimantPetition for reconsiderationTimelinessDismissalWCJ decisionLumbar fusion surgeryAccess MediquipPico Rivera PalletsCalifornia Insurance Company
References
4
Case No. MISSING
Regular Panel Decision

Ferlazzo v. 18th Avenue Hardware, Inc.

Plaintiff Marie Ferlazzo moved to extinguish liens and subrogation rights asserted by Oxford Health Plan and The Rawlings Company, LLC against her personal injury settlement proceeds. Oxford, administering a Medicare Advantage plan, sought reimbursement for medical expenses. Ferlazzo contended that General Obligations Law § 5-335 (a) barred such claims as Oxford lacked a statutory right of reimbursement. The court examined the Medicare Secondary Payer Act and the Medicare Advantage Program, concluding that unlike Medicare, private Medicare Advantage insurers only have contractual, not statutory, rights to reimbursement. Citing federal precedents, the court ruled that Oxford's claim was subject to state law and not entitled to recovery from the settlement. Consequently, the court granted Ferlazzo's motion to extinguish the liens and subrogation rights.

Personal InjurySubrogationMedicare AdvantageHealth Insurance LienSettlement ProceedsGeneral Obligations LawStatutory InterpretationContractual RightsFederal PreemptionPrivate Insurer
References
4
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