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Case Law Database

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

Case No. MISSING
Regular Panel Decision

Dryden Mutual Insurance v. Goessl

This case concerns an insurance coverage dispute arising from a fire during plumbing work. Plaintiff Dryden Mutual Insurance Company sought a declaration that it had no duty to defend or indemnify defendant Stanley Goessl, who operated as S&K Plumbing, in an underlying tort action. Dryden claimed Goessl was an employee of AP Daino & Plumbing, Inc., whose insurer, The Main Street America Group (MSA), also disclaimed coverage, asserting Goessl was not their employee. The Supreme Court initially found Dryden not liable and MSA liable, but the Appellate Court reversed this decision. The appellate ruling determined that Dryden Mutual Insurance Company is obligated to defend and indemnify Goessl as a sole proprietor, and MSA is not obligated because Goessl was an independent contractor, not an employee of AP Daino, according to their policy terms.

Insurance coverage disputeDeclaratory judgmentIndependent contractor classificationEmployee statusBusiness general liability policyContractors insurance policyDuty to defendDuty to indemnifyPlumbing businessTort liability
References
23
Case No. ADJ7889661
Regular
Jan 28, 2014

CONYANILL, STATE OF CALIFORNIA, CDCR - INMATE CLAIMS vs. STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES

In this case, the defendant sought to set aside an Order Approving Compromise and Release (OAC&R) due to a mutual mistake in omitting a Medicare Set-Aside (MSA) provision. The Appeals Board granted reconsideration and rescinded the OAC&R. The matter was returned to the trial level to determine the parties' intent regarding the MSA and ensure compliance with Medicare regulations. This action was taken to provide the WCJ an opportunity to properly address Medicare's interests.

Petition for ReconsiderationOrder Approving Compromise and ReleasePetition to Set AsideMutual MistakeMedicare Set-AsideMSARescindAgreed Medical ExaminerWCJAppeals Board
References
3
Case No. ADJ579864 (SAC 0353253)
Regular
Oct 01, 2010

Marcia Pratt vs. WELLS FARGO BANK, SPECIALTY RISK PLEASANTON

This case involves a dispute over attorney's fees awarded in a workers' compensation settlement. The applicant's attorney sought reconsideration of a $15,000 fee award, arguing it was insufficient given the case's complexity and the settlement's value. The Board granted reconsideration, determining that the Medicare Set-Aside (MSA) funding should be excluded from the fee calculation. Ultimately, the attorney was awarded $21,752, representing 15% of the "new money" received by the applicant after excluding MSA costs.

Workers' Compensation Appeals BoardJoint Fee Finding and OrderCompromise and Release Agreementattorney's feelien claimantstipulated awardpermanent disabilitylife pensionMediCare Set-aside AccountMSA
References
1
Case No. ADJ3407743, ADJ4033299
Regular
May 03, 2018

KIM KELLEY vs. INTERSTATE BRANDS CORP.; SELFINSURERS SECURITY FUND, Administered by TRISTAR RISK MANAGEMENT

The applicant sought reconsideration of a Compromise and Release order, specifically challenging the inclusion of a disputed body part (right knee) in the Medicare Set Aside (MSA) calculation. The Appeals Board found the petition for reconsideration was timely filed. However, the Board determined there was insufficient evidence to rule on the applicant's claims regarding the MSA calculation. Therefore, the Board dismissed the petition for reconsideration and recommended it be treated as a petition to set aside, allowing for the presentation of evidence.

Petition for ReconsiderationCompromise and ReleaseMedicare Set Aside (MSA)Joint OrderWCJ ReportPetition to Set AsideUnilateral MistakeMutual MistakeDue ProcessFair Hearing
References
2
Case No. ADJ8308192 ADJ11314956
Regular
Sep 12, 2019

LILY LOPEZ vs. ST PASCHAL BAYLON CATHOLIC CHURCH, YORK RISK SERVICES GROUP

The Workers' Compensation Appeals Board rescinded the trial judge's decision finding mutual mistake regarding a Medicare Set Aside (MSA) and CMS approval. The Board determined that CMS does not mandate MSA review, negating the finding of mutual mistake. However, due to concerns about the applicant being adequately advised of potential future Medicare benefit impacts without CMS review, the case is returned to the trial level for further proceedings. The applicant's petition for penalties was denied.

Medicare Set AsideMSACMS approvalmutual mistakejudicial errorCompromise and Releasenull and voidPetition to Set Asiderescindedvacated
References
7
Case No. ADJ2214463 (VNO 0522433)
Regular
Feb 19, 2009

RICARDO DUARTE PONCE vs. ROSS STORES, INC., SEDGWICK CLAIMS MANAGEMENT SERVICES

The Appeals Board granted reconsideration to set aside the Order Approving Compromise and Release (OACR). The defendant sought to vacate the OACR because the parties' settlement agreement, which included a Medicare Set Aside (MSA) allocation, was contingent on approval by the Centers for Medicare Services (CMS) that was never obtained. Since the applicant was a Medicare beneficiary and the settlement exceeded $25,000, federal regulations require CMS approval of the MSA. The Board rescinded the OACR and returned the matter for further proceedings.

Medicare Set AsideMSA allocationCenters for Medicare ServicesCMS approvalCompromise and ReleaseOACRPetition for ReconsiderationRescind OrderGood CauseEquitable Grounds
References
8
Case No. ADJ2854014 (VNO 0353387) ADJ622083 (VNO 0353389) ADJ2985353 (VNO 0278675) ADJ8101514
Regular
Feb 21, 2012

CAROLYN CHRISTIAN vs. TJ MAXX, AMERICAN CASULATY COMPANY

This case concerns a petition for reconsideration of an approved Compromise and Release (C&R) agreement by the defendant, TJ Maxx. The defendant argues the C&R must be revised because the applicant's knee replacement surgery occurred prior to the approval, potentially rendering the Medicare Set Aside (MSA) provision duplicative. The Appeals Board granted reconsideration and rescinded the Order Approving Compromise and Release. The matter is returned to the trial level to determine if the applicant's pre-approval surgery was consistent with the MSA terms.

Workers' Compensation Appeals BoardTJ MaxxAmerican Casualty CompanyCompromise and Release AgreementMedicare Set Aside (MSA)mutual mistake of factfraudduplicative compensationknee replacement surgeryrescinded order
References
0
Case No. ADJ8873556
Regular
Jun 03, 2016

LUIS ALVARENGA vs. SCOPE INDUSTRIES, COMMERCE & INDUSTRY INSURANCE, AIG CLAIMS

The Workers' Compensation Appeals Board granted reconsideration and rescinded an order approving a Compromise and Release (C&R). The defendant argued for rescission based on a mutual mistake regarding the necessity of CMS approval for the Medicare Set Aside (MSA) amount. While CMS approval is not mandatory, the Board found the C&R inadequate as written. Specifically, the settlement did not adequately account for the MSA amount in relation to the applicant's net recovery, and the applicant was not fully advised of potential Medicare benefit denials if CMS review was bypassed. The case is returned for further proceedings to address these adequacy issues.

Compromise and ReleaseMutual MistakeMedicare Set AsideCMS ApprovalPetition for ReconsiderationOrder Approving Compromise and ReleaseRescindGood CauseFuture Medical TreatmentAdequate Consideration
References
5
Case No. 533820
Regular Panel Decision
Apr 21, 2022

In the Matter of the Claim of Jose Perez

Claimant Jose Perez had an established claim for work-related injuries. A section 32 waiver agreement, including a payment of $300,000 and a Medicare Set-Aside (MSA) annuity, was approved by the Workers' Compensation Board in 2019. Perez's subsequent attempts to withdraw from the agreement were deemed untimely by the Board. However, the Board issued an amended decision deferring record development for 90 days, allowing the parties to negotiate a new agreement to clarify inconsistent MSA terms. The employer and carrier appealed this amended decision to the Supreme Court, Appellate Division, Third Judicial Department. The Appellate Division dismissed the appeal as interlocutory, ruling that the Board's decision did not finally resolve all substantive issues and was therefore not a proper subject for immediate appellate review.

Workers' Compensation LawSection 32 Waiver AgreementMedicare Set-Aside AnnuityUntimely WithdrawalInterlocutory DecisionAppellate ReviewFinality of OrderProcedural DefermentNegotiated SettlementClaim Settlement
References
5
Case No. MISSING
Regular Panel Decision

State v. Philip Morris Inc.

This case involves an appeal concerning the power of a Commercial Division Justice to initiate a sua sponte inquiry into an arbitration panel's award of legal fees rendered pursuant to a settlement agreement in a class action. The underlying litigation was initiated by the State of New York and its Attorney General against several tobacco companies. Justice Crane, who originally presided, approved a Master Settlement Agreement (MSA) that included a Fee Payment Agreement for private, binding arbitration of outside counsel's fees. Justice Ramos, who later took over the case, initiated a sua sponte inquiry into a $625 million arbitration award to outside counsel, citing CPLR Article 9 and inherent judicial authority, and appointed 'independent counsel' for the plaintiff class. The Appellate Division found that Justice Ramos lacked jurisdiction for such an inquiry, as the court's retained jurisdiction was limited to implementing or enforcing the Consent Decree, not modifying it. The court also held that Justice Crane's prior approval of the MSA, including the binding arbitration clause, was final and affirmed by the Appellate Division. The court further determined that CPLR Article 9 did not override the strong public policy favoring consensual arbitration in this context. Consequently, the Appellate Division reversed Justice Ramos's orders, dismissed his sua sponte proceeding, and vacated the appointment of independent counsel.

Arbitration Award ReviewAttorney Fees DisputeClass Action SettlementJudicial Sua Sponte AuthorityAppellate Court ReversalMaster Settlement AgreementJurisdiction LimitsCommercial Division PowersLegal Ethics InquiryTobacco Industry Litigation
References
27
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