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Case Law Database

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

Case No. ADJ3998532 (VNO 0450822) ADJ1852772 (VNO 0450819)
Regular
Jul 29, 2011

JOY A. SKEETE-PENEGAR (JOY PENEGAR) vs. BANK OF AMERICA, ARROWOOD INDEMNITY COMPANY

Lien claimants Dr. Silver and Dr. Bresler petitioned for reconsideration after the WCJ limited their fees to the Official Medical Fee Schedule (OMFS). The Appeals Board granted reconsideration, amending Dr. Bresler's award due to calculation errors from $8,235.00 to $8,157.41, and affirming Dr. Silver's award of $250.00. The Board found that the OMFS applied as the employer accepted liability for treatment and paid some services, and the lien claimants failed to prove fees exceeding the OMFS were reasonable. Penalties under Labor Code section 5814 were denied as they are not payable to lien claimants.

OMFSPetition for ReconsiderationLien ClaimantsBill Review ExpertLabor Code Section 4603.2(b)(1)PenaltiesSelf-Procured TreatmentCompensable Industrial InjuryAgreed Medical ExaminerReasonable Fee
References
19
Case No. ADJ1159851
Regular
Sep 28, 2009

JONATHAN NORTON vs. NAVIGATOR YACHTS, INC., INTERCARE INSURANCE SERVICES

The Workers' Compensation Appeals Board (WCAB) granted reconsideration to lien claimant Dr. Mehdi Habibi, M.D., regarding a WCJ's decision on medical billing. The WCJ previously limited Dr. Habibi's payment to $3,970.35, applying the Official Medical Fee Schedule (OMFS), and disregarded Dr. Habibi's arguments for fees exceeding the OMFS based on the *Gould* factors. The WCAB found the WCJ improperly relied on unadmitted evidence and failed to consider the *Gould* factors for determining reasonable fees above the OMFS. The case is returned to the WCJ to re-evaluate evidence and apply the correct legal standards.

Workers' Compensation Appeals BoardPetition for ReconsiderationOfficial Medical Fee ScheduleGould v. Workers' Comp. Appeals BoardLien ClaimantReasonable FeesMedical TreatmentExcessive ChargesBill ReviewReconsideration Granted
References
1
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
0
Case No. ADJ7590683
Regular
Mar 23, 2015

FELIPE GARCIA vs. E RECYCLING OF CALIFORNIA, ZURICH NORTH AMERICA

The Workers' Compensation Appeals Board (WCAB) granted reconsideration to review a judge's decision awarding a hospital fees exceeding the Official Medical Fee Schedule (OMFS). The WCAB rescinded the judge's order, finding that the relevant statutes for payment in excess of the OMFS were deleted in 2004. Therefore, the lien claimant is entitled to payment only according to the OMFS. The case was returned to the trial level to determine if any additional OMFS payment is due.

Workers' Compensation Appeals BoardLien ClaimantOfficial Medical Fee ScheduleInpatient Hospital Fee ScheduleExtraordinary CircumstancesUrgent InjuryLabor CodeJurisdictionReconsiderationFindings and Order
References
7
Case No. ADJ1923190
Regular
Jul 19, 2010

Richard Martinez vs. SIFLING BROTHERS, ZENITH INSURANCE COMPANY

Lien claimants, Dr. Silver and Dr. Bresler, sought payment for medical services exceeding the Official Medical Fee Schedule (OMFS). They argued their services warranted higher fees due to "extraordinary circumstances" and defendant's alleged improper billing practices. The Workers' Compensation Appeals Board denied their petitions for reconsideration, finding they failed to meet the burden of proof. The board held that lien claimants must demonstrate extraordinary circumstances justifying fees above the OMFS and present evidence of their usual and customary fees.

Workers' Compensation Appeals BoardRichard MartinezSifling BrothersZenith Insurance CompanyDavid BreslerDavid SilverSupplemental Findings and AwardOfficial Medical Fee ScheduleLien ClaimantsReconsideration
References
8
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
10
Case No. ADJ7220223
Regular
Aug 08, 2016

IOAN RUS vs. CALIFORNIA FACILITIES & EQUIPMENT MAINTENANCE COMPANY, INC., STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed its prior decision, denying a lien claimant further payment. The Board found that current Labor Code section 5307.1, unlike the statute in *Gould v. Workers' Comp. Appeals Bd.*, does not permit rebuttal of the Official Medical Fee Schedule (OMFS). Therefore, the lien claimant cannot recover fees exceeding the OMFS based on their arguments. The Board also stated it cannot rule on the constitutionality of the statute.

Workers' Compensation Appeals BoardOpinion and Decision After ReconsiderationLien ClaimantOfficial Medical Fee Schedule (OMFS)Gould v. Workers' Comp. Appeals Bd.Rebuttal of PresumptionLabor Code § 5307.1Medical-Legal ExpensesConstitutionality of StatuteGreener v. Workers’ Comp. Appeals Bd.
References
2
Case No. ADJ6845555, ADJ7392921, ADJ8509830
Regular
May 09, 2017

GLORIA ALOMIA vs. AAREN SCIENTIFIC, INC.; CYPRESS INSURANCE COMPANY

The Appeals Board affirmed the WCJ's decision regarding lien claimant Monrovia Memorial Hospital's payment, awarding them $\$52,000.00$. Monrovia sought additional payment and interest, arguing their services were not subject to the Official Medical Fee Schedule (OMFS) and should be paid on a reasonable cost basis. The Board found that while Monrovia is exempt from OMFS, lien claimants bear the burden of proving their charges are reasonable, not just their usual and customary fees. The claim for interest was also denied as Monrovia did not meet the criteria for payment under Labor Code section 4603.2.

Workers' Compensation Appeals BoardReconsiderationIndustrial InjuryCervical SpineLumbar SpineBilateral ShouldersBilateral WristsLien ClaimantMonrovia Memorial HospitalOfficial Medical Fee Schedule (OMFS)
References
2
Case No. ADJ4662216 (MON 0235398) ADJ1137113 (MON 0264731)
Regular
Jul 17, 2017

REBECCA WERTZ vs. HERBALIFE, AIG CLAIMS SERVICES

This case concerns Dr. Silver's lien claim for fees exceeding the Official Medical Fee Schedule (OMFS). The Appeals Board affirmed the WCJ's decision denying the lien claim, finding no statutory or regulatory basis for an "extraordinary circumstances" exception to the OMFS for services rendered after January 1, 2004. The Board also rejected due process claims regarding the exclusion of evidence and the inability to cross-examine the defendant's bill review expert. The Board concluded that lien claimant failed to prove the services were extraordinary or to demonstrate entitlement to equitable relief.

Workers' Compensation Appeals BoardLien ClaimantOfficial Medical Fee ScheduleOMFSExtraordinary CircumstancesAdministrative Director RuleSB 228Labor Code Section 5307.1Equitable ReliefDue Process
References
13
Case No. ADJ638016 (VNO 0518817)
Regular
Mar 22, 2011

Roger Schleifstein vs. Leslie's Pool Supply, ST. PAUL'S TRAVELERS INSURANCE

This case concerns a lien claim by Grossman Medical Group for $188,310.89 in unpaid medical treatment expenses following an industrial injury. The WCAB affirmed the WCJ's decision disallowing the lien, finding Grossman Medical failed to prove its charges exceeded the Official Medical Fee Schedule (OMFS) due to extraordinary circumstances. Applicant's private health insurer, CIGNA, had already paid a significant portion of the bill, and the Appeals Board held that the statutory changes eliminating the exception for billing above OMFS in disputed claims applied. The dissenting opinion argued that Grossman Medical met its burden by demonstrating reasonable and customary fees supported by comparable cases, particularly where treatment was extensive.

Lien claimantGrossman Medical GroupOfficial Medical Fee ScheduleOMFSusual and customary feesextraordinary circumstancesreasonablenesslabor codeappeals boardcompromise and release
References
5
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