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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ7232076
En Banc
Sep 26, 2011

Tsegay Messele vs. Pitco Foods, Inc.; California Insurance Company

The Appeals Board holds that the 10-day period for agreeing on an AME under Labor Code § 4062.2(b) is extended by five days when the initial proposal is served by mail, and clarifies the method for calculating this time period, finding both parties' panel requests premature.

Workers' Compensation Appeals BoardTsegay MesselePitco FoodsInc.California Insurance CompanyADJ7232076Opinion and Decision After ReconsiderationOrder Granting RemovalDecision After RemovalEn Banc
References
Case No. ADJ3885285 (FRE 0248529) ADJ3795787 (FRE 0247126)
Regular
Dec 30, 2008

Larry Shores vs. CITY OF MADERA; ACCLAMATION FRESNO

This case concerns a worker's compensation claim for a back and spine injury sustained by Larry Shores. The Board granted reconsideration, rescinded sanctions imposed on the defendant for litigation tactics, and rescinded a penalty for delayed temporary disability payments. However, it otherwise affirmed the finding of industrial injury, awarded penalties for unreasonable delay in medical treatment, and upheld the need for ongoing medical care, including surgery.

Workers' Compensation Appeals BoardLarry ShoresCity of MaderaAcclamation FresnoADJ3885285ADJ3795787Opinion and Order Granting ReconsiderationFindings and AwardWCJIndustrial Injury
References
Case No. ADJ7433042, ADJ7433045, ADJ7433048
Regular
Aug 06, 2013

MARIA GOMEZ vs. HARRIS RANCH BEEF CO., AIMS INSURANCE CO.

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration of a prior decision. The WCJ disallowed the lien claimant's lien for medical treatment, finding that the lien claimant failed to prove the treatment was reasonable and necessary, and its charges were reasonable. The Board affirmed the WCJ's decision, holding that the lien claimant did not meet its evidentiary burden, and denied the petition.

Lien claimantPetition for ReconsiderationJoint Findings of Fact and Ordersubstantial evidencedisallowance of liensCompromise and Releaseuntimely serviceex parte communicationsubstantial medical evidencereasonable and necessary treatment
References
Case No. LAO 0832662
Regular
Mar 18, 2008

RIVALDO CASTILLO vs. BENTLEY-SIMONSON, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior award, remanding the case to the trial level. The WCJ erred by applying the Official Medical Fee Schedule to a 2003 surgery and failing to consider the *Kunz* factors for reasonableness when determining the lien claimant's facility fees. The Board will allow the WCJ to determine the reasonableness of the lien claimant's charges under *Kunz*, with the OMFS as one factor.

Wilshire SurgicenterOpinion and Order Granting ReconsiderationFindings and AwardLien ClaimantOutpatient Surgery Facility FeesOfficial Medical Fee ScheduleKunz v. Patterson Floor CoveringLabor Code section 4600Reasonableness of Facility FeeUsual Fee
References
Case No. ADJ3371067 (VNO 0458070) ADJ4100976 (VNO 0493655)
Regular
Sep 11, 2013

WILLIAM JOHNSON vs. ENVIRONMENT INDUSTRIES dba VALLEY CREST, Permissibly Self-Insured; Adjusted by ESIS

The Workers' Compensation Appeals Board amended a prior award concerning lien claims for medical treatment by two doctors. The Board allowed Dr. Kottler's medical treatment liens based on a prior agreement, but reduced payment for his medical reports to the Official Medical Fee Schedule rates. Conversely, Dr. Singh's lien for medical treatment was rescinded as he failed to meet his burden of proof to establish the reasonableness and necessity of his treatment. The majority opinion found the agreement with Dr. Kottler enforceable, while a dissenting opinion disagreed with its interpretation and favored the fee schedule amounts.

Workers Compensation Appeals BoardReconsiderationMedical Treatment LiensOfficial Medical Fee ScheduleBurden of ProofCompromise and ReleaseAgreed Medical ExaminerPsychiatric TreatmentCustomary FeeMedical-Legal Reports
References
Case No. ADJ2367528 (SFO 0509283)
Regular
Mar 22, 2011

GUILLERMO BAYLEY vs. YMCA OF THE EAST BAY, TRAVELERS INSURANCE

This case involves a dispute over the payment for a 15-day hospitalization for an industrial injury. Stanford University Medical Center, a lien claimant, sought additional payment beyond the amount calculated under the Official Medical Fee Schedule (OMFS). The Appeals Board granted reconsideration, finding that California Code of Regulations, title 8, section 9792(c) allows for fees exceeding the OMFS if extraordinary circumstances related to the unusual nature of services rendered are proven. The case was returned to the trial level for further development of evidence regarding these extraordinary circumstances and to determine if the claimed fee is reasonable.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationInpatient Hospital Fee ScheduleOfficial Medical Fee Schedule (OMFS)Extraordinary CircumstancesDiagnosis-Related Group (DRG)Reasonable FeeLabor CodeMedical Treatment
References
Case No. ADJ2536829 (SDO 0332809)
Regular
Mar 21, 2018

MARGO RABENAU vs. SAN DIEGO IMPERIAL COUNTIES DEVELOPMENTAL SERVICES, INCORPORATED; Permissibly Self-Insured; administered by ESIS

This case concerns the denial of a defendant's petition for reconsideration regarding the continuation of non-medical transportation services for the applicant. The Workers' Compensation Appeals Board affirmed the judge's award, holding that the defendant improperly terminated these services. The Board ruled that the defendant must continue providing transportation until it demonstrates a change in the applicant's condition or circumstances, relying on precedent that prohibits unilateral termination of approved medical treatment. The defendant's petition was also noted for procedural deficiencies, including lack of verification.

Workers' Compensation Appeals BoardSan Diego Imperial Counties Developmental ServicesPermissibly Self-InsuredESISFindings and AwardNon-medical transportationMedical treatmentChange in applicant's conditionPatterson v. The Oaks FarmUnilaterally terminate
References
Case No. ADJ9725603
Regular
Nov 23, 2020

LUZ LOZA vs. GOLDBLATT GOLDBLATT/BAY AREA RESTAURANT MANAGEMENT, ARCH INSURANCE COMPANY, administered by YORK RISK SERVICES GROUP, INC.

The Workers' Compensation Appeals Board granted reconsideration of an administrative law judge's order finding the applicant entitled to pre-authorization for their treating physician to issue a PR-4 report at the medical-legal billing rate. While affirming the applicant's right to obtain the report, the Board clarified that the defendant retains the right to object to or raise defenses regarding the physician's billing. The Board reasoned that treating physicians are permitted to provide comprehensive medical-legal evaluations, and such reports are governed by specific medical-legal fee schedules, not the Official Medical Fee Schedule.

PR-4 reportmedical-legal billing ratepre-authorizationprimary treating physician (PTP)Qualified Medical Evaluator (QME)comprehensive medical evaluationOfficial Medical Fee SchedulePetition for ReconsiderationFindings of Fact and Order (F&O)Labor Code
References
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