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

Case No. ADJ3842696 (SAL 0105756) ADJ4430006 (SAL 0111994)
Regular
Apr 23, 2010

JOSE VILLA vs. CHALONE WINE GROUP, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, ZENITH INSURANCE

The Workers' Compensation Appeals Board granted reconsideration to allow the California Insurance Guarantee Association (CIGA) reimbursement for its bill review expenses. The Board found that bill review costs are an essential and necessary part of adjusting medical claims, akin to "incurred losses" as defined by the Uniform Statistical Reporting Plan. This decision amends a prior ruling that excluded such expenses, recognizing their role in controlling medical overpayments. The parties are now to adjust the specific amount of reimbursement for these expenses.

CIGACalifornia Insurance Guarantee Associationbill review expensesincurred lossesloss adjustment expensemedical cost containmentuniform statistical reporting planinsolvency insurancecovered claimsLabor Code
References
Case No. ADJ7049850 ADJ7289794 ADJ7523255
Regular
May 11, 2015

FREDDIE B. GUZMAN vs. MARTENS CHEVROLET, EMPLOYERS COMPENSATION INSURANCE COMPANY

This case involves an applicant seeking reconsideration of an order denying his petition to enforce an award for out-of-pocket medical and travel expenses. The Workers' Compensation Appeals Board granted the petition for reconsideration, finding the applicant was denied due process. The Board rescinded the prior order and returned the matter for further proceedings and a new decision, noting the applicant's right to a hearing was violated. This decision allows for a proper hearing to address the disputed reimbursement claims.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition to Enforce AwardSelf-Procured TreatmentOut-of-Pocket ExpensesDue ProcessWCJ OrderHearing DenialMedical Expenses ReimbursementTravel Expenses Reimbursement
References
Case No. ADJ4157637
Regular
Mar 18, 2010

BEATRICE WEISS vs. TECHNOLOGY FUNDING, LUMBERMEN'S MUTUAL CASUALTY COMPANY, BROADSPIRE, a CRAWFORD COMPANY

This case involves an applicant who sustained a spinal injury in 2000 and was awarded permanent total disability and ongoing medical treatment, including assisted living. The Workers' Compensation Appeals Board (WCAB) clarified that the applicant is entitled to full reimbursement for assisted living costs incurred after exhausting long-term care insurance, as medical treatment for industrial injuries is not apportionable, even if concurrent non-industrial conditions exist. However, the WCAB reversed an award for personal duty aides, finding insufficient evidence of their necessity due to the industrial injury, and denied claims for interest on unpaid bills and guardianship costs. The WCAB affirmed reimbursement for dental expenses necessitated by medication for the industrial injury, while excluding attorney fees for enforcing treatment denials.

Workers' Compensation Appeals BoardBeatrice WeissTechnology FundingLumbermen's Mutual Casualty CompanyBroadspireCrawford CompanyADJ4157637SFO 0445495Opinion and Decision After Reconsiderationpermanent total disability
References
Case No. SFO 0438557 SFO 0438562
Regular
May 05, 2008

LISA BURKE vs. WINTERLAND PRODUCTIONS, HARTFORD INDEMNITY & ACCIDENT COMPANY

The Workers' Compensation Appeals Board granted reconsideration to address whether reimbursed expenses should be included in calculating an applicant's temporary disability indemnity rate. The Board reversed the prior award, ruling that reimbursed expenses for meals, lodging, and fuel are special expenses, not remuneration, and therefore should not be included in calculating the applicant's average weekly wage. The decision clarifies that such reimbursements do not constitute "advantages received by the injured employee as part of his remuneration" under Labor Code section 4454.

Workers' Compensation Appeals BoardTemporary Disability IndemnityReimbursed ExpensesEarnings CalculationLabor Code Section 4454RemunerationSpecial ExpensesAverage Weekly WageCumulative TraumaConcert Tour Salesperson
References
Case No. VNO 0301388
Regular
Sep 05, 2007

JACQUELYN GREEN vs. GENERAL MOTORS CORPORATION, SEDGWICK CLAIMS MANAGEMENT

This case involves an employer's attempt to present non-medical evidence regarding the reasonableness of expenses for an applicant's home elevator. The Appeals Board granted removal, reversing the trial judge's exclusion of these exhibits and witnesses. The Board found that while the medical necessity of the elevator was stipulated, the "reasonable expense" of its installation was a valid issue for which non-medical evidence should be admissible.

removalevidentiary rulingnon-medical exhibitsmedical necessitydue processsubstantial prejudiceirreparable harmpermanent disabilitystipulated awardreasonable expense
References
Case No. ADJ8577504
Regular
Jun 23, 2015

JESUS PONCE vs. LAFAYETTE TEXTILES, CYPRESS INSURANCE COMPANY

This case concerns a lien claimant, Western Imaging Services, seeking reimbursement for photocopying expenses. The Appeals Board clarified that Western did not need to prove applicant sustained an industrial injury to recover its lien. However, Western must demonstrate that a contested claim existed when the expenses were incurred, that they were for proving or disproving that claim, and that they were reasonable and necessary. The Board rescinded the WCJ's decision and remanded the case to determine which specific expenses meet these criteria.

Workers' Compensation Appeals BoardLien ClaimantMedical-Legal ExpenseContested ClaimBurden of ProofIndustrial InjuryReconsiderationReasonable and Necessary ExpensesSubpoenaed RecordsPhotocopied Records
References
Case No. ADJ9522703
Regular
Jul 04, 2018

MAYRA MENDOZA vs. SAFEWAY, INC., ALBERTSONS HOLDINGS

This case concerns whether applicant's medical mileage and self-procured medical expenses were included in a prior Compromise and Release (C&R) agreement. The applicant sought reconsideration of the WCJ's finding that these expenses were resolved by the C&R. The Appeals Board affirmed the WCJ's decision, finding that the plain language of the C&R explicitly included medical mileage and self-procured medical treatment as resolved issues within the settlement amount. Therefore, the applicant's subsequent claims for these expenses were denied.

Workers' Compensation Appeals BoardReconsiderationCompromise and ReleaseWCJLabor Code section 5813medical mileageout-of-pocket medical expensesself-procured medical treatmentindustrial injurychecker/stocker
References
Case No. ADJ6984629
Regular
Oct 30, 2013

ROBERTA LYNNE MULLER vs. RIVERSIDE COUNTY HOSPITAL, CITY OF RIVERSIDE WORK COMP DIVISION

The Workers' Compensation Appeals Board denied the lien claimant's petition for reconsideration, upholding the administrative law judge's decision to disallow the lien. The lien claimant failed to meet its burden of proof to establish that the incurred expenses for subpoenas were reasonable and necessary for a contested claim. The Board found that the mere issuance of subpoenas did not demonstrate a contested claim or the necessity of the records, especially since the injury was admitted and records may have already been provided. Therefore, the lien was denied as the claimant did not prove entitlement to payment for valid medical-legal expenses.

Lien claimantPetition for ReconsiderationWorkers' Compensation Appeals Boardmedical-legal expensescontested claimsubpoenas duces tecumburden of proofreasonable and necessaryCompromise and Releaselien trial
References
Case No. ADJ1868495 (VNO 0452398) ADJ4538828 (VNO 0468076)
Regular
Dec 14, 2012

JORGE HERNANDEZ vs. CRESCENT TRUCK LINES, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, SEDGWICK CLAIMS MANAGEMENT SERVICES, RELIANCE NATIONAL INSURANCE COMPANY

This case concerns the California Insurance Guarantee Association (CIGA) seeking reimbursement from the State Compensation Insurance Fund (SCIF) for costs incurred administering workers' compensation claims. The WCJ initially awarded CIGA reimbursement for benefits paid but not for associated administration expenses. The Appeals Board granted CIGA's reconsideration petition, ruling that CIGA is entitled to reimbursement for both benefits and specific claim administration expenses, including medical-legal costs. The Board amended the findings and award to reflect this, returning the matter to the trial level for further proceedings.

CIGAReliance National Insurance CompanySedgwick Claims Management ServicesState Compensation Insurance Fund (SCIF)Petition for ReconsiderationJoint Findings and Award (F&A)reimbursementassociated expensesmedical treatmentloss adjustment expense
References
Case No. ADJ10106412 ADJ10106414
Regular
Jul 29, 2019

MARGARET KLAUS vs. ANTELOPE VALLEY UNION HIGH SCHOOL DISTRICT

This case involves a dispute over the employer's unreasonable delay in paying applicant's self-procured medical expenses and mileage. The Workers' Compensation Appeals Board (WCAB) denied the applicant's petition for attorney's fees under Labor Code section 5814.5, finding it inapplicable. However, the WCAB granted the defendant's petition for reconsideration, agreeing that the employer unreasonably delayed payment on certain expenses not listed in the initial request. Ultimately, the WCAB amended the original award to reflect a calculated penalty on the delayed compensation, subtracting an overpayment and attorney's fees.

Labor Code section 5814Petition for ReconsiderationUnreasonable DelaySelf-Procured ExpensesMileage ReimbursementPharmacy ExpensesPenaltiesAttorney's FeesLabor Code section 5814.5Findings and Award
References
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