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Case Law Database

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

Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
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. ADJ1124123 (BGN 0064929) ADJ3374432 (BGN 0061307)
Regular
Oct 22, 2018

MARY BAKER vs. SWEEETHEART CUPS; CIGA by SEDGWICK CMS for FREMONT INSURANCE in liquidation and PORTEOUS FASTENERS/PACIFIC INDEMNITY COMPANY, CHUBB INSURANCE

The Workers' Compensation Appeals Board granted CIGA's petition for reconsideration, reversing the finding that CIGA remained liable for permanent total disability indemnity and medical treatment for the applicant's industrial injuries. The Board found that because the applicant's injuries resulted in a joint and several award with a solvent insurer, Pacific Indemnity, CIGA has no obligation to pay as "other insurance" was available. The decision clarifies that CIGA is absolved of liability for medical treatment jointly caused by both injuries, but remains liable for treatment solely caused by the September 1979 injury. Pacific Indemnity is now solely responsible for all remaining permanent total disability indemnity and medical treatment costs, adjusting for payments already made by CIGA.

CIGASweetheart CupsPorteous FastenersFremont InsurancePacific IndemnityChubb InsuranceWilkinson doctrinejoint and several liabilitycovered claimsother insurance
References
10
Case No. SBR 0338719, SBR 0338720
Regular
Mar 24, 2008

SANDRA SERNA vs. CORNER DRUG STORE, AMERICAN AUTO INSURANCE COMPANY, FIREMAN'S FUND

This case involves a dispute over temporary disability indemnity and ongoing medical treatment for an applicant's low back injury. The defendant sought reconsideration arguing the WCJ erred in awarding temporary disability benefits past the physician's declared permanent and stationary date and awarding medical treatment not properly submitted for decision. The Appeals Board granted reconsideration, rescinded the WCJ's award, and remanded the case for further proceedings to clarify the permanent and stationary date and the medical treatment award.

Workers' Compensation Appeals BoardReconsiderationPermanent and Stationary DateTemporary Disability IndemnityModified DutyMedical TreatmentLabor Code Section 4600Primary Treating PhysicianFindings and AwardRescinded
References
3
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. ADJ3077776 (AHM 0101525) ADJ4163115 (AHM 0101526)
Regular
Apr 29, 2011

MARIO FERNANDEZ vs. COMPASS TELECOM SERVICES, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION Administered By SEDGWICK CLAIMS For LEGION INSURANCE CO., In Liquidation, SPECTRASITE COMMUNICATIONS, ZURICH AMERICAN INSURANCE COMPANIES

This case involves an applicant with two industrial injuries to his cardiovascular system. The Board affirmed the WCJ's findings on permanent disability and the need for further medical treatment, but clarified liability. Specifically, the Board allowed CIGA credit for permanent disability advances and clarified that Zurich is liable for temporary disability, future medical treatment, and medical-legal expenses. The issue of attorney fees in one case was deferred for further proceedings at the trial level.

CIGALegion InsuranceZurich American Insurance CompaniesCOMPASS TELECOM SERVICESSPECTRASITE COMMUNICATIONSMARIO FERNANDEZADJ3077776ADJ4163115ReconsiderationFindings Award and Order
References
15
Case No. ADJ8253233
Regular
Mar 24, 2017

CHERYL BROWN vs. KERN MEDICAL CENTER/COUNTY OF KERN

The Workers' Compensation Appeals Board granted reconsideration, amending a prior award to defer issues regarding temporary partial disability and the Employment Development Department's reimbursement. The Board affirmed other findings, including the applicant sustaining injury to her low back and reaching permanent and stationary status on November 18, 2013, with a 41% permanent disability rating. Furthermore, the issue of whether the applicant can seek treatment outside the defendant's Medical Provider Network was deferred pending further development of the record. The award for permanent partial disability was corrected to commence from November 18, 2013.

WCABPetition for ReconsiderationFindings of FactAwardTemporary Partial DisabilityPermanent Partial DisabilityMedical Provider NetworkMPNAgreed Medical ExaminerAME
References
0
Case No. ADJ2653887 (SAL 0116844)
Regular
Dec 24, 2008

CARROL BARRIE vs. STATE OF CALIFORNIA, DEPARTMENT OF CORRECTIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration, amending a prior finding to award further medical treatment for admitted industrial hernias. While the original finding denied permanent disability and further treatment, the Board found a stipulation by the parties and the Agreed Medical Evaluator's opinion supported the need for ongoing medical follow-up. The Board affirmed the original finding that the injury did not cause ratable permanent disability based on the AME's report and statutory guidelines.

Workers' Compensation Appeals BoardIndustrial InjuryVentral HerniaUmbilical HerniaRegistered NursePermanent DisabilityFurther Medical TreatmentAgreed Medical EvaluatorAMA GuidesLabor Code Section 5802
References
2
Case No. ADJ2549459 (LAO 0836064) ADJ3590497 (LAO 0852732) ADJ108951 (LAO 0852733)
Regular
Oct 17, 2011

TINA LABRIEL vs. LOS ANGELES UNIFIED SCHOOL DISTRICT, Permissibly Self-Insured

The Workers' Compensation Appeals Board denied the defendant's Petition for Removal because the requested stay of a medical examination was moot. The Board noted that the WCJ has discretion to consider post-hearing medical reports for permanent disability determinations, as the case still requires the development of the record. Furthermore, proceedings regarding further medical treatment are within the WCJ's purview, especially as applicant's award for treatment is final. The case remains pending at the trial level for final determination of permanent disability.

Removal PetitionWCJ RefusalStay Medical ExaminationMandatory Settlement ConferenceIrreparable HarmAgreed Medical ExaminerPermanent Disability RatingApportionment of DisabilityMedical Treatment AwardDiscovery Rules
References
2
Case No. ADJ8867364
Regular
Nov 09, 2016

MANYA PRYBYLA vs. STATER BROS. MARKET, THE HARTFORD

In this workers' compensation case, the Appeals Board granted reconsideration to address disputes over permanent disability and apportionment, as well as a claim for future medical treatment. The Board found that the Agreed Medical Examiner's apportionment, based on subjective factors rather than the strict subtraction method required by the AMA Guides and SB 899, was legally insufficient. Therefore, the Board deferred the issues of permanent disability, apportionment, attorney fees, and further medical treatment, returning the case to the trial level for further development of the record and a new decision.

Workers' Compensation Appeals BoardReconsiderationFindings Award and OrderIndustrial InjuryPermanent DisabilityApportionmentFuture Medical TreatmentAgreed Medical Examiner (AME)Whole Person Impairment (WPI)DRE Rating Method
References
0
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