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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

Claim of Vanostrand v. Felchar Manufacturing Corp.

The case involves an appeal from a Workers’ Compensation Board decision concerning a claimant found to have defrauded employers and carriers by overstating mileage and making false statements about her physical condition. The Board ruled that Workers’ Compensation Law § 114-a, which bars future wage replacement benefits for such violations, does not preclude the claimant from receiving future mileage expenses or medical coverage. The Appellate Division, Third Department, affirmed this decision, citing its previous ruling in Matter of Rodriguez v Burn-Brite Metals Co., which established that the penalties under Workers’ Compensation Law § 114-a are limited to wage replacement benefits and do not extend to medical benefits. The court also found no error in the Board's tacit refusal to require the claimant to directly repay the mileage overpayments to the subject carriers.

Workers' Compensation Law § 114-aMedical BenefitsMileage ExpensesFraudulent MisrepresentationStatutory InterpretationAppellate DecisionWage Replacement BenefitsBoard Decision ReviewAffirmative RulingLegal Precedent
References
2
Case No. MISSING
Regular Panel Decision

Claim of Simpson v. Glen Aubrey Fire Co.

A volunteer fireman suffered an acute lumbosacral strain requiring frequent hospital and doctor visits. He sought reimbursement for 290 miles of travel expenses. The Workers' Compensation Board approved reimbursement at 20 cents per mile, leading to this appeal. The court examined whether travel expenses for medical treatment are reimbursable under the Volunteer Firemen’s Benefit Law and Workers’ Compensation Law. It concluded that access to medical treatment implies the financial means to obtain it, upholding the humanitarian goals of the legislation.

Volunteer FiremanLumbosacral StrainMileage ReimbursementTravel ExpensesMedical TreatmentWorkers' Compensation LawVolunteer Firemen's Benefit LawStatutory InterpretationRemedial LawLiberal Construction
References
2
Case No. MISSING
Regular Panel Decision
May 03, 1985

Wolf v. Wolf

In two support proceedings, the petitioner mother appealed two orders. The first order, entered September 7, 1984, denied her petition for an upward modification of child support. The second order, entered May 3, 1985, denied her full reimbursement for certain child counseling expenses. The Family Court's decisions were affirmed on appeal. The court properly denied a general increase in the father's child support obligation and directed the mother to seek payment for counseling expenses through the father's medical insurance coverage.

child supportupward modificationcounseling expensesparental obligationsFamily Lawappellate reviewOrange County
References
0
Case No. ADJ165588 (SAL 0108801)
Regular
Mar 09, 2009

STEVEN G. CARR vs. COUNTY OF SANTA CRUZ, Permissibly Self-Insured, Adjusted By SEDGWICK CLAIMS MANAGEMENT SERVICES

The Board granted reconsideration and amended a prior award, clarifying which expenses are compensable for the applicant's industrial injury. The applicant, a deputy sheriff, was awarded expenses for his gym membership and associated travel, totaling $10,241.76. However, the Board disallowed most pharmaceutical expenses, only allowing those for Celebrex, Nabumetone, and Avapro, along with travel mileage for these prescriptions. The issue of medical mileage reimbursement for treatment of family members was remanded for further adjustment or adjudication.

DeputysheriffIndustrialinjuryHypertensionGymmembershipPharmaceuticalexpensesMileageexpenseMedicaltreatmentPetitionforreconsiderationWCJFindingsofFact
References
1
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
3
Case No. MISSING
Regular Panel Decision

Leone v. Sheriff's Department

This case addresses whether a municipality, which has paid both salary and medical treatment costs to a police officer injured in the line of duty under General Municipal Law § 207-c, is entitled to reimbursement for medical treatment expenses from a schedule award received by the employee under the Workers’ Compensation Law. The employer, a self-insured municipality, deducted both wages and medical expenses from the claimant's schedule award. The Workers’ Compensation Board affirmed a decision holding that the employer was not entitled to credit for medical payments from the schedule loss award. The court affirmed this decision, holding that medical expense payments made by a self-insured employer must be deemed Workers’ Compensation Law § 13 payments, for which the employer is not entitled to reimbursement under Workers’ Compensation Law § 30 (3). The court emphasized a liberal and harmonious interpretation of the relevant statutes to avoid disadvantaging police officers and firefighters.

Workers' CompensationGeneral Municipal LawPolice OfficersFirefightersMedical ExpensesSchedule AwardReimbursementSelf-Insured EmployerStatutory InterpretationLine of Duty Injury
References
6
Case No. ADJ4702564 (RDG 0094598) ADJ6944237
Regular
Apr 17, 2018

CLAUDETTE GILBERT vs. DEPARTMENT OF SOCIAL SERVICES, INHOME SUPPORTIVE SERVICES, YORK RISK SERVICES, ADVENTIST HEALTH OF CALIFORNIA, LIBERTY MUTUAL INSURANCE COMPANY

This case concerns a dispute over reimbursement for medical expenses following two lumbar spine injuries sustained by the applicant. The Department of Social Services (IHSS) sought reimbursement from Liberty Mutual Insurance Company for treatment costs after the applicant's 2008 injury, arguing the 1999 injury contributed to the need for care. However, the Appeals Board found Dr. Sommer's medical opinions lacked substantiality due to inconsistent apportionment and a failure to adequately explain the causal link between the 1999 injury and the 2008 treatment needs. Consequently, IHSS failed to meet its burden of proof, and their claims for reimbursement and shared medical expenses were denied.

Workers' Compensation Appeals BoardReconsiderationIn-Home Supportive Services (IHSS)Legally UninsuredYORK RISK SERVICESADVENTIST HEALTH OF CALIFORNIALIBERTY MUTUAL INSURANCE COMPANYlumbar spine injuryapportionmentmedical opinions
References
0
Case No. ADJ8460289
Regular
Sep 11, 2013

JUAN LUNA vs. CAPITAL DRYWALL, L.L.P.; SEABRIGHT INSURANCE

This case concerns a dispute over the admissibility of medical reports from physicians outside the defendant's Medical Provider Network (MPN). The Appeals Board rescinded the original findings and award, remanding the case for a new decision. This decision hinges on the employer's failure to provide adequate notice of the MPN and their denial of the employee's claim, entitling the employee to self-procure treatment and rendering those medical reports admissible. The arbitrator must now reconsider the findings regarding self-procured medical expenses and mileage reimbursement.

Workers' Compensation Appeals BoardReconsiderationMedical Provider Network (MPN)Collective Bargaining Agreement (ADR)Admissibility of ReportsSelf-Procured Medical TreatmentLabor Code Section 4600Notice RequirementsDenial of ClaimIndustrial Injury
References
1
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
4
Case No. ADJ1938020 (LAO 0877660)
Regular
Jul 21, 2010

FRANCISCO PEREZ vs. KING TACO RESTAURANTS, INC., AMERICAN CASUALTY

This case involves an applicant seeking reimbursement for travel expenses incurred to attend a Qualified Medical Evaluator (QME) appointment. The applicant relocated out of state after sustaining an industrial knee injury. The defendant initially disputed medical findings, triggering the QME process, and later refused to reimburse travel expenses to the out-of-state QME. The Workers' Compensation Appeals Board ruled that the applicant was entitled to travel expenses, citing relevant Labor Code sections and precedent. Sanctions were denied, and penalty issues were deferred.

ADJ1938020LAO 0877660King Taco RestaurantsInc.American CasualtyQualified Medical EvaluatorQME panelLabor Code Section 4062.2Labor Code Section 4061Labor Code Section 4600
References
3
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