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

Case No. ADJ1124701 (OAK 0304697)
Regular
Jan 25, 2010

GENE THOMAS vs. SLEEP TRAIN MATTRESS CENTER, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision favoring the applicant's spinal surgery, finding that proper procedural steps were not followed. The employer's utilization review (UR) had denied the surgery, but neither party followed the required second-opinion process under Labor Code section 4062(b). The WCAB returned the case to the trial level, allowing the employer ten days from receipt of the decision to object to the surgery and initiate the second-opinion process. This decision aligns with the WCAB's en banc ruling in *Cervantes*, which clarified the procedures for handling spinal surgery disputes after UR denials.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code section 4062(b)Spinal SurgerySecond OpinionCervantes v. El Aguila Food ProductsACOEM GuidelinesExperimental TreatmentEn Banc DecisionAdministrative Director Rules
References
4
Case No. ADJ3847846 (SDO 0345131)
Regular
Apr 24, 2009

Michelle Camp vs. San Diego Rural Fire Protection District

The Appeals Board granted reconsideration of the WCJ's decision regarding applicant Michelle Camp's temporary disability benefits and attorney's fees. The Board rescinded the original decision due to procedural errors, specifically the lack of a proper record including issues and stipulations, and the reliance on unverified letters as petitions. The case is remanded to the trial level for further proceedings, a corrected record, and a new decision. This action ensures all procedural requirements are met before a final determination is made.

Workers' Compensation Appeals Boardvolunteer firefightertemporary disability indemnityattorney's feepetition for reconsiderationproper recordissues and stipulationsMinutes of Hearing Summary of Evidenceunverified letterLab. Code
References
1
Case No. SJO 0245781
Significant

Michael A. Willette vs. Au Electric Corporation, State Compensation Insurance Fund

The Appeals Board, in an en banc decision, outlines the mandatory procedure for resolving post-utilization review medical treatment disputes for unrepresented employees, requiring the use of a panel Qualified Medical Examiner (QME). The prior decision was rescinded and the case was remanded to follow this new procedure.

Workers' Compensation Appeals BoardEn Banc DecisionReconsiderationFindings and AwardIndustrial InjuryLow Back InjuryTailbone InjuryAlarm InstallerState Compensation Insurance FundUtilization Review Reports
References
26
Case No. ADJ3852255 (SRO 0128541)
Regular
Dec 02, 2014

DENISE SITTON vs. LOK GROUP OF COMPANIES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior order finding the employer's Utilization Review (UR) decisions procedurally defective, despite being timely. The WCAB rescinded the prior order based on its subsequent en banc decision in *Dubon v. World Restoration, Inc.*, which established that only untimely UR decisions are invalid. The case is returned to the WCJ for further proceedings and a new decision consistent with the *Dubon II* ruling.

Utilization ReviewFindings and OrderPetition for ReconsiderationWCJDubon IIen banc decisionprocedural defectreasonable and necessarymedical treatmentepidural injection
References
1
Case No. ADJ4274323 (ANA 0387677), ADJ1601669 (ANA 0388466)
En Banc
Feb 27, 2014

JOSE DUBON vs. WORLD RESTORATION, INC.; STATE COMPENSATION INSURANCE FUND

The WCAB holds that it has jurisdiction over disputes regarding the procedural validity and timeliness of utilization review (UR) decisions, while Independent Medical Review (IMR) is solely for resolving medical necessity. A UR decision with material procedural defects is invalid, and in such cases, the WCAB, not IMR, will determine the medical necessity of the treatment.

Utilization ReviewIndependent Medical ReviewEn Banc DecisionWCAB JurisdictionProcedural DefectsMedical NecessityLabor Code Section 4610Substantial Medical EvidenceMaterial Procedural DefectsInvalid UR Decision
References
17
Case No. MISSING
Regular Panel Decision

Wilson v. Colvin

Plaintiff Ronald Wilson appealed the Commissioner of Social Security's denial of disability benefits. The case originated from an Administrative Law Judge's (ALJ) unfavorable decision in 2012, which became final after the Appeals Council denied review in 2014. Both parties filed motions for judgment on the pleadings. The District Court reviewed whether the ALJ applied correct legal standards and if the decision was supported by substantial evidence, considering a five-step evaluation process. The court concluded that the ALJ followed proper procedures, that his findings on Wilson's residual functional capacity were consistent with medical evidence, and that the vocational expert testimony was properly relied upon. Consequently, the Commissioner's motion was granted, Wilson's motion was denied, and the Commissioner's decision was affirmed.

Disability Benefits AppealSocial Security ActAdministrative Law JudgeAppeals Council ReviewJudgment on the PleadingsResidual Functional CapacityMedical EvidenceVocational Expert TestimonySubstantial Evidence ReviewLegal Standards Application
References
15
Case No. ADJ7069357
Regular
Jun 15, 2015

CHERYL MCMILLIN vs. MONSANTO COMPANY, ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board affirmed a prior decision and imposed $300 in sanctions against defendant's attorney and law firm. The sanctions were for failing to comply with procedural rules, including improper citation practices and impugning the applicant's attorney. The attorney apologized but did not fully address all procedural violations. The Board adopted the judge's report and recommendation in its decision.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings Award and OrderOpinion and Decision After ReconsiderationOrder Imposing SanctionsWCJPetitionObjection to Sanctionszealous representationunpublished case
References
0
Case No. ADJ3660322 (SBR 0332201) ADJ6737593
Regular
Sep 18, 2013

GLORIA DAVILA vs. JON LIN INC.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior decision. They rescinded the Administrative Law Judge's (ALJ) decision and returned the case for further proceedings. This decision is procedural, not a final determination on the merits. The parties can seek further reconsideration after the ALJ issues a new decision.

Petition for ReconsiderationGrant ReconsiderationRescind DecisionReturn to Trial LevelWorkers' Compensation Appeals BoardWCJ DecisionFurther ProceedingsZenith Insurance CompanyPrivilege StaffingJon Lin Inc.
References
0
Case No. MISSING
Regular Panel Decision

Frazer v. Additional Personnel, Inc.

Additional Personnel, Inc., an employer, appealed a Workers' Compensation Board decision from December 30, 1982. The Board had affirmed the proper cancellation of the employer's workers' compensation insurance policy by the State Insurance Fund, effective June 1, 1980, due to unpaid premiums. The employer was consequently uninsured when an accident occurred on November 20, 1980. The appellate court affirmed the Board's decision, finding that the State Insurance Fund had properly followed cancellation procedures and that a subsequent payment by the employer did not retroactively restore coverage. The court also dismissed the employer's procedural objections regarding the record.

Workers' CompensationInsurance CancellationPremium PaymentUninsured EmployerEstoppelAppellate ReviewAdministrative ProcedurePolicy LapseNew York LawState Insurance Fund
References
1
Case No. ADJ2742024 (SAC 0321214)
Regular
Aug 24, 2009

RAYMOND GASTINELL, JR. vs. EMPIRE PACIFIC WINDOWS CORPORATION, LIBERTY MUTUAL FIRE INSURANCE COMPANY

This case concerns an applicant's appeal of a Workers' Compensation Judge's (WCJ) decision terminating temporary disability benefits. The applicant argued the defendant's petition to terminate failed to comply with procedural rules and that the WCJ's decision was made by an unauthorized judge. The Appeals Board found the defendant's petition was missing from the file and that procedural deficiencies existed regarding notice and preparation for hearings. Consequently, the Board granted reconsideration, rescinded the prior order, and remanded the case for further proceedings to address the termination petition and the applicant's objections.

Permanent and stationary datePetition to Terminate Temporary DisabilityBoard Rule 10464interim orderQualified Medical EvaluatorDeclaration of Readiness to Proceedexpedited hearingviolation of Labor Code section 5900Electronic Adjudication Management System (EAMS)Petition for Reconsideration
References
2
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