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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

Anthony L. Jordan Health Corp. v. Axelrod

The Anthony L. Jordan Health Center, a not-for-profit corporation, challenged the New York State Department of Health's recalculation of its Medicaid reimbursement rates for the 1983-1984 and 1984-1985 periods. Following an appeal, the parties entered into a stipulation agreement. However, the Department, while recalculating the rates in accordance with the stipulation, unilaterally changed the group composition, resulting in a significant negative adjustment and recoupment from Jordan. The court determined that this regrouping constituted an 'error of judgment,' not a permissible correction for mathematical error or an audit finding. Consequently, the court found that the Department did not have the right to retroactively adjust the rates based on this discretionary change. The petition was granted.

Medicaid ReimbursementRate RecalculationAdministrative ReviewStipulation AgreementError of JudgmentGroup CompositionRetroactive AdjustmentHealth Care LawJudicial ReviewDepartment of Health
References
5
Case No. ADJ1904323 (GRO 0034275) ADJ3208896 (GRO 0034276) ADJ649343 (GRO 0034277)
Regular
Nov 01, 2010

SARAH SHIPP vs. GOTTSCHALKS, SPECIALTY RISK SERVICES

The Appeals Board granted reconsideration, rescinding the prior award due to the Workers' Compensation Judge's (WCJ) improper reliance on an Agreed Medical Evaluator's (AME) hernia analogy to rate upper extremity impairment. This analogy violated *Almaraz II* by not adhering to the AMA Guides and potentially incorporating pre-2005 rating schedules. The rater also used an incorrect impairment number and occupational adjustment. The case is remanded for further proceedings and a new decision by the WCJ, ensuring the rating is not based on the flawed hernia analogy.

Workers' Compensation Appeals BoardSarah ShippGottschalksSpecialty Risk ServicesJoint Findings and Awardindustrial injuryright shoulderleft shoulderright elbowthumb
References
4
Case No. ADJ4258585 (OXN 0130492) ADJ220258 (OXN 0130487)
Regular
Apr 17, 2018

ENRIQUE HERRERA vs. MAPLE LEAF FOODS, U.S. FIRE INSURANCE COMPANY, ALEA NORTH AMERICAN INSURANCE COMPANY

This notice informs parties that the Workers' Compensation Appeals Board (WCAB) intends to admit its rating instructions and a disability rater's recommended permanent disability rating into evidence. The WCAB previously granted reconsideration for further study. Parties have seven days to object to the rating instructions or the recommended rating, with specific procedures for addressing objections. If no timely objection is filed, the matters will be submitted for decision thirty days after service.

WORKERS' COMPENSATION APPEALS BOARDPermanent Disability RatingDisability Evaluation UnitRating InstructionsRecommended Permanent Disability RatingJoint RatingReconsiderationObjectionRater Cross-ExaminationRebuttal Evidence
References
0
Case No. OAK 308925
Regular
Sep 24, 2007

LINDA SEGOVIA vs. CITY OF STOCKTON, Permissibly Self Insured, Adjusted By BRAGG & ASSOCIATES

This case involves a police officer seeking workers' compensation for a 2003 spinal and extremity injury. The defendant appealed a $100\%$ permanent total disability award, arguing the wrong rating schedule was applied and that apportionment was improperly handled. The Appeals Board granted reconsideration and returned the case for further proceedings due to a recent court decision impacting which disability rating schedule applies to pre-2005 injuries.

Workers' Compensation Appeals BoardPermanent Total Disability1997 Schedule2005 ScheduleLabor Code Section 4660(d)ApportionmentAgreed Medical ExaminerPermanent and Stationary StatusVera v. Workers' Comp. Appeals Bd.Vocational Rehabilitation
References
4
Case No. POM 0281587
Regular
May 02, 2008

ALINDA YELLOWHAIR vs. HAIR MASTERS, THE HARTFORD, SPECIALTY RISK SERVICES (Adjusting Agent)

The Workers' Compensation Appeals Board granted reconsideration to correct a prior award that improperly included disability from an admitted non-industrial shoulder injury. The Board reduced the applicant's permanent disability rating from 24% to 16% by removing the shoulder component and found that the defendant failed to meet the burden of proof for apportioning head and neck injury disability due to a subsequent motor vehicle accident. Consequently, the award for permanent disability indemnity was adjusted to reflect the 16% rating.

Workers' Compensation Appeals BoardPermanent DisabilityReconsiderationApportionmentQualified Medical EvaluatorIndustrial InjuryNon-Industrial AccidentSubstantial EvidenceMedical OpinionCausation
References
6
Case No. ADJ7978937
Regular
Aug 26, 2014

KATHERINE JAMES vs. STATE OF CALIFORNIA, CSP KINGS COUNTY AT CORCORAN, Legally Uninsured; STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES, Adjusting Agency

The Appeals Board granted reconsideration and amended the original award, admitting defendant's Exhibit E and adjusting the temporary disability indemnity rate. While affirming the finding of a psychiatric injury, the Board rescinded all penalties and sanctions previously awarded. Defendant's assertion of a good faith personnel action defense was deemed reasonable, thus precluding penalties for delayed payment. Temporary disability amounts are to be adjusted by the parties, with jurisdiction reserved for future disputes.

Workers' Compensation Appeals BoardReconsiderationPsychiatric InjuryGastrointestinal SystemDepressionAnxietyPanic AttacksLoss of AppetiteTemporary DisabilityPenalties
References
14
Case No. ADJ949225 (MON 0333849)
Regular
Apr 29, 2015

Muriel Lazarus vs. Subsequent Injuries Benefits Trust Fund

In this case, applicant Muriel Lazarus is seeking reconsideration of a denial of benefits from the Subsequent Injuries Benefits Trust Fund (SIBTF). The original decision found she failed to prove her subsequent injury met the 35% permanent disability threshold. Lazarus argues her rating, when calculated using the Combined Values Chart, meets the threshold, while the SIBTF disputes this. The Board granted reconsideration, noting insufficient evidence on the pre-adjustment rating of her permanent disability. The matter is remanded to further develop the record on this specific issue.

Subsequent Injuries Benefits Trust FundSIBTFPermanent Disability ThresholdCombined Values ChartStraight Subtraction MethodCumulative Trauma InjurySpecific InjuryReport and RecommendationFurther Development of RecordPre-adjustment Rating
References
1
Case No. MISSING
Regular Panel Decision

Sheehan v. Metropolitan Life Insurance

Plaintiff James C. Sheehan moved for attorney's fees after successfully suing Metropolitan Life Insurance Company for wrongful termination of long-term disability benefits. The court had previously ruled that MetLife wrongfully terminated benefits and awarded Sheehan $218,235.24, which was affirmed on appeal. MetLife argued against the fee award or sought a reduction due to Sheehan's partial success. The court, presided over by Senior District Judge Haight, found Sheehan was a "prevailing party" and calculated a lodestar fee of $123,387.50 after adjusting hourly rates for some attorneys and disallowing time for pre-suit administrative proceedings. Due to Sheehan's partial success, the court applied a 30% downward adjustment, ultimately awarding $86,371.25 in attorney's fees to Sheehan.

ERISAAttorney's FeesDisability BenefitsWrongful TerminationLodestar MethodPartial SuccessPrevailing PartySecond CircuitDistrict CourtInsurance Policy
References
17
Case No. ADJ1146871 (SAC 0349672)
Regular
Jun 14, 2010

ZORICA ILIC vs. STANFORD HOSPITAL & CLINICS, SEDGWICK 2065 OAKLAND

This case involves an applicant with a $78\%$ permanent disability rating for admitted industrial injuries to her low back and psyche. The defendant sought reconsideration, arguing the administrative law judge erred in applying a diminished future earning capacity adjustment, Labor Code $\S 4664$ apportionment, and relying on applicant's medical evaluators. The primary issue deferred was the calculation of the State Average Weekly Wage (SAWW) adjustment under Labor Code $\S 4659(\text{c})$ pending a Supreme Court decision. The Workers' Compensation Appeals Board granted reconsideration to defer the SAWW adjustment calculation but otherwise affirmed the original findings, including the $78\%$ permanent disability rating.

Labor Code § 4663Labor Code § 4664Labor Code § 4659(c)SAWWDFECDuncan v. WCABReconsiderationPermanent DisabilityApportionmentQualified Medical Evaluators
References
2
Case No. ADJ3458168 (OAK 0347004)
Regular
Dec 09, 2011

JOSEPH BULGO vs. ALCATEL-LUCENT, LIBERTY MUTUAL INSURANCE COMPANY

This case involves a dispute over permanent disability benefits for an applicant who sustained industrial injuries to his bilateral upper extremities and cervical spine. The original award found 73% permanent disability, but both applicant and defendant sought reconsideration. The applicant argued the indemnity and life pension rates were incorrectly calculated and the award failed to address Labor Code section 4658(d) adjustments. The defendant contended the 73% rating was too high by including upper extremity strength loss. The Appeals Board granted reconsideration for the applicant, rescinded the original award, and deferred the issues of permanent disability rate, life pension, section 4658(d) adjustment, and attorney fees for further proceedings at the trial level, while denying the defendant's reconsideration request.

ALCATEL-LUCENTLIBERTY MUTUAL INSURANCE COMPANYWORKERS' COMPENSATION APPEALS BOARDFINDINGS AND AWARDRECONSIDERATIONPERMANENT DISABILITYBILATERAL UPPER EXTREMITIESCERVICAL SPINELABOR CODE SECTION 4658(d)LIFE PENSION
References
2
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