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

Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
Case No. ADJ2259921
Regular
Jan 18, 2018

LYNN TILMON vs. COUNTY OF LOS ANGELES

This case involves a workers' compensation appeal concerning a medical provider's bill. The Workers' Compensation Appeals Board (WCAB) affirmed an award for lien claimant White Memorial Medical Center, finding the defendant, County of Los Angeles, failed to properly respond to a request for second bill review regarding a PPO contract. The WCAB amended the original award to adjust the interest rate to 7% and referenced the correct statutory basis for interest and penalties. The issue of Labor Code section 5813 attorney fees and costs was deferred, with jurisdiction reserved at the trial level.

Workers' Compensation Appeals BoardLynn TilmonCounty of Los AngelesSedgwick Claims Management ServicesWhite Memorial Medical CenterFindings and AwardReconsiderationIndependent Bill Review (IBR)Explanation of Review (EOR)Official Medical Fee Schedule (OMFS)
References
Case No. AHM 0125110
Regular
Mar 26, 2008

DAVID CEREGHINO vs. VONS COMPANIES, Permissibly SelfInsured

The Workers' Compensation Appeals Board denied the Lien Claimant's petition for reconsideration, upholding the original decision to award only a portion of the claimed surgical facility fee. The Board found the Lien Claimant failed to meet its burden of proving its charges were reasonable, despite arguments that the defendant's evidence was improperly admitted or insufficient. The Board concluded the amount awarded was supported by substantial evidence, including expert testimony and comparative fee schedules.

Workers' Compensation Appeals BoardLien ClaimantSan Antonio Ambulatory Surgery CenterPetition for ReconsiderationFindings and OrderWCJreasonable feefacility feeprima facie evidenceburden of proof
References
Case No. ADJ8147593
Regular
Dec 16, 2019

BETZAIDA MENDEZ vs. COUNTY OF LOS ANGELES, TRISTAR RISK MANAGEMENT

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration of a fee dispute. The Board found that an express contract, including an arbitration clause, existed between the lien claimant and the defendant for medical services. Pursuant to Labor Code Section 5304, the Board lacks jurisdiction to resolve fee disputes arising from such express agreements. Therefore, the petition was denied, affirming the WCJ's finding of an arbitrable contract.

Lien claimantPPO Contractfee disputearbitration provisionexpress agreementWCAB jurisdictionSection 5304medical treatment disputescontract interpretationexclusive jurisdiction
References
Case No. ADJ2283954 (VNO 0432216), ADJ964608 (VNO 0389951), ADJ2772045 (VNO 0441677), ADJ4352593 (VNO 0497775), ADJ267752 (PAS 0040169), ADJ414407 (PAS 0040492), ADJ1160769 (VNO 0494740), ADJ2170521 (VNO 0465060), ADJ2143182 (VNO 0499960), ADJ2945284 (VNO 0408504)
Regular
Oct 13, 2015

SEAN HANSEN, LISA LAWSON, TIMOTHY GILBERT, CARLOS GONZALEZ vs. CITY OF LOS ANGELES

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and returned multiple lien claims against the City of Los Angeles to the trial level. The WCAB found that the Workers' Compensation Judge (WCJ) erred by applying collateral estoppel based on a prior decision in *Halaby v. City of Los Angeles*. The WCAB clarified that the doctrine of laches is fact-specific and a prior finding of laches does not preclude relitigation of the issue in new cases. Therefore, the defendant must prove the elements of laches independently for each current lien claim.

Workers' Compensation Appeals BoardPermissibly Self-InsuredPetition for ReconsiderationDecision After ReconsiderationLiensLachesCollateral EstoppelWCJHalaby v. City of Los AngelesNegotiated Rates
References
Case No. ADJ1883569; ADJ4651472
Regular
Apr 20, 2018

CAROL HENSON vs. UNITED PARCEL SERVICE, LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The Board adopted the Administrative Law Judge's report, which found that the defendant failed to rebut the reasonableness of the lien claimant's billing. While lien billing alone isn't automatically reasonable, here, the defendant provided no evidence demonstrating unreasonableness. Consequently, the defendant bore the burden of proof to disprove the charges, which it did not satisfy.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantReasonableness of ChargesBurden of ProofRebuttal EvidenceExplanation of BenefitsPPO AllowanceKunz v. Patterson Floor CoveringsWCALJ
References
Case No. ADJ6603030
Regular
Jul 20, 2018

JEFF DEATON vs. SUPERIOR AMERICAN FLEET, U.S. FIRE INSURANCE COMPANY

This case concerns a defendant's petition for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision. The WCAB denied the petition, upholding a prior finding that one-on-one sitter services provided by a lien claimant were reasonable and necessary medical treatment. The defendant argued the WCJ erred in disregarding utilization review and a preferred provider organization agreement, but the WCAB found these arguments unpersuasive. The WCAB also noted the defendant waived the issue of a second review of medical bills by failing to raise it earlier.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings Award and OrderWCJlien claimantCare Meridianone-on-one sitter servicesreasonable and necessary medical treatmentpenaltyLabor Code 4603.2
References
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