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Case Law Database

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

Case No. ADJ2172104 (SAC 0326562)
Regular
Jan 15, 2015

THOMAS MEEKER vs. OREGON PACIFIC BUILDING PRODUCTS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT COMPENSATION INSURANCE COMPANY

This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in *Dubon II*, the Appeals Board reversed this finding. The Board ruled that under *Dubon II*, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.

Utilization ReviewRequest for AuthorizationProvigilDubon IIIndustrial InjuryPermanent DisabilityFuture Medical TreatmentPetition for ReconsiderationAdministrative Law JudgeWorkers' Compensation Appeals Board
References
14
Case No. ADJ2585403
Regular
Jan 12, 2012

ALEX ORTEGA vs. AWHS, INC., VIRGINIA SURETY COMPANY, APPLIED RISK SERVICES (Claims Administrator)

This case involves a dispute over Trazamine medication for an industrial injury. The Appeals Board affirmed the Workers' Compensation Judge's award of Trazamine, finding the defendant's utilization review denials were legally invalid. The Board determined that Labor Code section 4062 procedures were not triggered by the invalid denials and dismissed the defendant's ex-parte communication claim as inapplicable to pre-2005 injuries. Consequently, the applicant is entitled to Trazamine as prescribed by his treating physician.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardInjuryLeft upper extremityLeft footPsycheErectile dysfunctionSleep disorderTrazamine
References
0
Case No. ADJ14953769
Regular
Feb 28, 2023

MANUEL DE JESUS CHAVAC vs. 99 CENTS ONLY STORES, LLC, ATHENS ADMINISTRATORS

The applicant sought reconsideration of a WCJ's finding that QME Panel No. 7480460 was valid. The applicant argued the panel was invalid because the defendant failed to serve the denial letter on the applicant's attorney, thus violating due process and Labor Code section 4062.2. The Appeals Board granted reconsideration, finding the defendant's denial letter was improperly served, preventing the applicant's attorney from objecting. Consequently, QME Panel No. 7480460 was deemed invalid, and the parties were ordered to proceed with Panel No. 7483530.

Workers' Compensation Appeals BoardQualified Medical EvaluatorQME PanelLabor Code section 4060Administrative Director Rule 30(b)Petition for ReconsiderationFindings of Fact and OrderInjury AOE/COEDenial of LiabilityService of Process
References
8
Case No. ADJ3685938 (WCK 0066506)
Regular
Dec 02, 2014

EMMETT BOONE vs. DREYER'S GRAND ICE CREAM, FIREMAN'S FUND INSURANCE COMPANY

In this workers' compensation case, the Appeals Board affirmed a prior award finding defendant's utilization review (UR) denials for prescription refills invalid. The Board agreed with the WCJ that the UR denials were untimely because the defendant failed to communicate the decisions to the treating physician within the statutory 24-hour timeframe. Consequently, the Board found the UR invalid, allowing the WCAB to determine medical necessity based on substantial evidence. This decision upholds the applicant's right to ongoing prescription refills.

Workers' Compensation Appeals BoardUtilization ReviewReconsiderationFindings and AwardPrescription RefillsMedical TreatmentDefective DenialTimeliness RequirementsLabor Code § 4610Dubon v. World Restoration
References
8
Case No. MISSING
Regular Panel Decision

Haygood v. Hardwick

Andrew Hardwick appealed a Supreme Court order that denied his motion to dismiss a petition to invalidate his independent nominating petition and subsequently granted the petition, invalidating his nomination. The petitioners had alleged widespread fraud and forgery in the signatures collected for Hardwick's independent nominating petition. Hardwick contended that these allegations lacked sufficient specificity, a claim the court rejected, finding that the petition to invalidate adequately incorporated specific objections filed with the Nassau County Board of Elections. The Supreme Court's decision to invalidate was affirmed on appeal, as the court found Hardwick to be chargeable with knowledge of the fraudulent methods employed to gather signatures. Evidence showed subscribing witnesses were paid for collecting signatures before being registered to vote, and dates on petitions were altered, further substantiating the fraud. Additionally, the non-appearance of key subscribing witnesses led to an adverse inference against Hardwick.

Election LawIndependent Nominating PetitionPetition InvalidationFraudulent SignaturesForgeryVoter RegistrationCampaign FinanceAppellate DecisionNassau County ElectionCounty Executive
References
15
Case No. MISSING
Regular Panel Decision
Dec 11, 2002

Claim of Speer v. Wackenhut Corp.

The claimant sought workers' compensation benefits for mental depression, alleging it resulted from being removed from a security guard position by their employer. The Workers' Compensation Board initially ruled the injury non-compensable under Workers' Compensation Law § 2 (7), deeming it a direct consequence of lawful personnel decisions. The claimant subsequently filed applications for full Board review and reconsideration, both of which were denied by the Board. This appeal concerns the denials of those applications. The court dismissed the appeal from the May 1, 2002 denial as untimely and affirmed the December 11, 2002 denial, finding that the Board did not abuse its discretion by not requiring transcription of oral arguments before rendering its decision.

Workers' CompensationMental DepressionStress-related InjuryPersonnel DecisionsReconsideration DenialFull Board ReviewAppellate ProcedureTimeliness of AppealOral Argument TranscriptionAdministrative Discretion
References
3
Case No. MISSING
Regular Panel Decision

Bush v. Mechanicville Warehouse Corp.

This case involves an appeal from the denial of a third-party defendant's (Yankee One Dollar Stores, Inc.) motions for summary judgment against a defendant (Mechanicville Warehouse Corp.). The plaintiff, Bush, was injured at work and sued Mechanicville, who then brought a third-party action against Yankee for indemnification. Yankee argued that plaintiff did not sustain a 'grave injury' under Workers’ Compensation Law § 11 and that there was no written contractual indemnification agreement. The appellate court affirmed the denial of summary judgment regarding the 'grave injury' claim, finding sufficient evidence of permanent total disability due to a traumatic brain injury. However, the court reversed the denial of summary judgment for contractual indemnification, ruling that Workers’ Compensation Law § 11 requires an *express written contract* of indemnification from the employer, which was not present between Yankee and Mechanicville.

Summary JudgmentThird-Party ActionWorkers' Compensation Law § 11Grave InjuryContractual IndemnificationBrain InjuryPermanent Total DisabilityHoldover TenantExpress AgreementAppellate Review
References
18
Case No. ADJ4564735 (SFO 0469452)
Regular
Aug 17, 2016

GEORGE FLEET vs. NORTHWEST AIRLINES, LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Northwest Airlines' Petition for Reconsideration, upholding the finding that the utilization review (UR) denial for bilateral knee surgery was untimely. The Board adopted the Judge's report, which found that the initial Request for Authorization (RFA) was faxed on July 23, 2015, making the subsequent UR denial invalid. Because the UR denial was untimely, jurisdiction returned to the Board to determine the medical necessity of the treatment, which was found to be warranted based on substantial medical evidence.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Dubon IIRequest for Authorizationbilateral knee arthroscopic surgerymedical necessityuntimely denialFax Confirmationsubstantial medical evidence
References
1
Case No. MISSING
Regular Panel Decision

Kosakow v. New Rochelle Radiology Associates, P.C.

Nancy Kosakow sued her former employer, New Rochelle Radiology Associates, alleging FMLA violations and wrongful denial of severance pay under ERISA. The court previously found FMLA claims collaterally estopped but remanded the ERISA claim to the Plan Administrator for a determination on severance eligibility. The Administrator denied severance, finding Kosakow not "terminated" and, even if so, not entitled to severance. This court reversed the "not terminated" finding, stating Kosakow was terminated due to a reduction in force. However, the court affirmed the Administrator's denial of severance, concluding that the "where applicable" clause in the Plan gave the Administrator broad discretion and that Kosakow's circumstances did not warrant severance. The court found that the denial was not unreasonable, even when considering a severance payment made to another full-time employee under different circumstances.

ERISASeverance PayFMLATerminationSummary JudgmentDe Novo ReviewPlan Administrator DiscretionEmployee BenefitsReduction in ForcePolicy Manual
References
8
Case No. ADJ693974 (OAK 0242212)
Regular
Apr 26, 2019

Glory Shreeve vs. Village Shops/ Ethan Allen Carriage House, Superior National Insurance Company, BROADSPIRE, California Insurance Guarantee Association

In this Workers' Compensation Appeals Board case, applicant Glory Shreeve sought authorization for medical treatment, which was denied by the defendant's Utilization Review (UR) provider. Applicant argued the UR denials were untimely because requests for additional information were not made by a licensed physician, thus invalidating the delays and granting the Board jurisdiction over medical necessity. The Board affirmed the Administrative Law Judge's decision, finding that the UR provider's requests for additional information did not violate Labor Code Section 4610(e) and that the denials were issued within the extended timeframes permitted by DWC Rule 9792.9.1. Consequently, the Board held it lacked jurisdiction to determine the reasonableness and necessity of the requested medical treatment due to the timely UR denials.

Utilization ReviewRequest for AuthorizationLabor Code section 4610(e)DWC Rule 9792.9.1TimelinessJurisdictionMedical NecessityCalifornia Insurance Guarantee Association (CIGA)Petition for ReconsiderationAdministrative Law Judge (WCJ)
References
2
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