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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 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

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
Case No. ADJ1047594 (VNO 0549852)
Regular
Dec 22, 2016

Diane De Los Reyes vs. Mediscan, Zurich American Insurance Company

In this case, the applicant, Diane De Los Reyes, sought reimbursement for self-procured medical treatment related to her work-induced Reactive Airway Disease and Anxiety Disorder. The Appeals Board found that some of the applicant's self-procured treatment was likely industrial and reversed the WCJ's finding that all such treatment was non-industrial. The Board therefore rescinded the original order and returned the matter to the WCJ for further proceedings to determine the extent of reimbursable self-procured medical treatment and associated penalties. The applicant's entitlement to reimbursement for medical mileage and penalties thereon was affirmed.

Workers' Compensation Appeals BoardReconsiderationAgreed Medical EvaluatorReactive Airway DiseaseAnxiety DisorderSelf-procured Medical TreatmentReimbursementPenaltiesMedical MileageLabor Code § 4600(a)
References
9
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
5
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. ADJ2500591 (MON 0340362) ADJ1965867 (LBO 0302615)
Regular
May 13, 2011

Kenneth Tarvin vs. ROADWAY EXPRESS, Administered by GALLAGHER BASSET SERVICES

This case involves a lien claimant, Dr. Kenneth Webb, seeking reconsideration of a decision that limited his reimbursement for applicant Kenneth Tarvin's medical treatment. Dr. Webb argued for reimbursement for more than the allowed 24 visits, citing two separate injuries and post-surgical treatment exemptions. However, the Appeals Board denied his petition, finding insufficient substantial medical evidence to rebut the established treatment guidelines or support treatment for the cumulative trauma claim. The Board affirmed the original finding of entitlement to payment for 22 treatments at the reasonable value of services rate.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantFindings of Fact and OrderReasonable Value of Services (RVS)Labor Code 4604.5(d)(1)24 visit capIndustrial InjuryCumulative TraumaCompromise and Release (C&R)
References
8
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
5
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. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. ADJ2301385
Regular
May 29, 2009

SANDRA SILVA vs. MEDTRONIC, ACE PROPERTY AND CASUALTY COMPANY, adjusted by ESIS

This case involves a lien claimant seeking reconsideration of a workers' compensation award for medical treatment expenses. The claimant argued the judge miscalculated the reimbursement amount for treatment services based on the official fee schedule. The Appeals Board granted reconsideration, agreeing to amend the award to reflect the correct medical treatment reimbursement of $2,118.50. This decision was made despite a procedural delay in acknowledging the petition for reconsideration due to an electronic filing error.

Reinherz Chiropracticlien claimantreconsiderationmedical-legal feesmedical treatment expensesofficial medical fee scheduleEAMSShipley v. Workers' Comp. Appeals Bd.due processLabor Code section 5909
References
1
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