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

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 The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr.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. ADJ19408921, ADJ19408487, ADJ19408920
Regular
Jun 16, 2025

Maria Vazquez vs. Holiday Inn Los Angeles Gateway, Indemnity Insurance Company of North America

Defendant filed a petition to set aside and reconsider an Order Approving Compromise & Release (OACR), claiming applicant's age and Medicare beneficiary status were overlooked in the settlement. The Appeals Board noted procedural irregularities regarding notice of case transmission and the absence of a hearing to establish a complete record concerning the Compromise and Release agreement's adequacy and Medicare interests. As a result, the Board dismissed the petition as premature and returned the matter to the trial level for a hearing to gather necessary evidence.

Order Approving Compromise & ReleaseMedicare Set AsidePetition for ReconsiderationMotion to Set AsideLabor Code Section 590960-Day RuleNotice of TransmissionWorkers' Compensation Medicare Set-Aside Arrangement (WCMSA)Good CauseMutual Mistake of Fact
References
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The Workers' Compensation Appeals Board granted reconsideration and rescinded an order approving a Compromise and Release (C&R).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
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
Case No. ADJ599176 (SAC 0333692) ADJ2396484 (RDG 0122019) ADJ7950339
Regular
Mar 21, 2017

Fernando Muniz Villalpando vs. Doherty Brothers, Martin Dusters, State Compensation Insurance Fund

This case involves an applicant seeking to self-administer his Medical Set-Aside Account (MSA) after previously agreeing to third-party administration by Bridge Pointe/NuQuest. The Appeals Board granted reconsideration, rescinded the prior order, and returned the matter to the trial level. The Board found that the trial judge needs to review the original agreement to determine if it allows for a change of administration or if applicant has contractual rights to pursue this. Further proceedings will assess applicant's competency for self-administration and any opposition from the defendant.

Medical Set-Aside AccountMSAPetition for ReconsiderationJoint Findings and OrderMedical Set-Aside Account administrationself-administrationBridge PointeNuQuestState Compensation Insurance FundCompromise and Release Agreement
References
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
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
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
Case No. ADJ3544094 (SAC 0351694) ADJ2331078 (SAC 0354152)
Regular
May 11, 2009

NORMA HODGES vs. CLARCOR, INC., ST. PAUL TRAVELERS

Defendant seeks reconsideration of an approved Compromise and Release (C&R) for alleged knee and back injuries due to a dispute over the applicant's Medicare eligibility. The C&R contained a provision stating the applicant was not Medicare eligible, but the defendant later learned she was listed as an active beneficiary. The Board granted reconsideration, rescinded the C&R, and returned the case to the trial level. This action allows for further proceedings to resolve the factual conflict regarding Medicare status and address any necessary Medicare set-asides.

Order Approving Compromise and ReleasePetition for ReconsiderationMedicare Secondary Payer lawsQualified Medical EvaluatorGood CauseFraudMutual Mistake of FactDuressUndue InfluenceRescind
References
Case No. ADJ6827349
Regular
Sep 21, 2012

RONALD JOLLIFFE vs. THOMAS HYDRAULIC & HARDWARE SUPPLY, INC., PREFERRED EMPLOYERS INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) denied Defendant's Petition for Removal, which sought to rescind the judge's order to correct a settlement agreement and increase Medicare Set Aside funding. The judge had suspended action on the Compromise and Release due to concerns about the settlement's adequacy regarding medical treatment costs and Medicare. The WCAB found that the judge had not yet determined the settlement's adequacy and therefore denied removal, returning the case for trial on that issue and other litigable matters.

Petition for RemovalCompromise and ReleaseMedicare Set AsideCMS determinationSecond Order Suspending ActionWCJadequacy of settlementtrial levellitigable issuesSocial Security Disability Insurance
References
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