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Case Law Database

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

Case No. ADJ8917716
Regular
May 03, 2016

INGA CZECH vs. BANK OF AMERICA, ACE AMERICAN INSURANCE COMPANY

Defendant Bank of America sought reconsideration of an award for medical treatment, arguing the Request for Authorization (RFA) was improperly served on their attorney, not the adjuster, thus not triggering utilization review timelines. The Workers' Compensation Appeals Board denied reconsideration, affirming that the applicant's physician's requested treatment was reasonable. The Board held that when an attorney receives an RFA and the defense has objected to its receipt, the attorney has a duty to transmit it to the claims administrator to fulfill the duty of good faith investigation. Therefore, the defendant's failure to process the treatment request after receiving it through their attorney resulted in liability for the awarded medical care.

Workers Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Request for Authorization (RFA)Declaration of Readiness to Proceed (DOR)Expedited HearingAdministrative Law Judge (WCJ)Agency LawAttorney NegligenceGood Faith Investigation
References
7
Case No. ADJ8833224
Regular
Feb 21, 2017

JOHN WEIMER vs. HILLYARD, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board found that an incomplete Request for Authorization (RFA) with an incorrect claim number was submitted on September 19, 2016. Despite the error, the RFA successfully identified the employee and triggered the defendant's duty to conduct utilization review on that date. Consequently, the defendant's utilization review denial on September 29, 2016, was deemed untimely, invalidating the denial. The case was returned for further proceedings to determine the necessity of the requested medical treatment.

DWC RFAUtilization ReviewTimelinessClaim NumberIncomplete RequestMedical TreatmentReconsiderationAdministrative Director RuleTreating PhysicianClaims Adjuster
References
1
Case No. MISSING
Regular Panel Decision
May 17, 2002

In re the Claim of Kearse

The claimant appealed a decision from the Unemployment Insurance Appeal Board, which upheld its prior ruling that the claimant's request for a hearing was untimely. The claimant had been disqualified from receiving unemployment benefits due to misconduct and charged with an overpayment, but failed to request a review hearing for several months, mistakenly believing her workers' compensation case was related. The Board, upon reconsideration, adhered to its finding that the request was untimely. The Appellate Division affirmed the Board's decision, reiterating that a claimant typically has 30 days to request a hearing unless there is a valid excuse. The court also declined to consider the claimant's belated assertions of post-traumatic stress disorder as a justification for the delay.

Unemployment BenefitsUntimely RequestMisconduct DischargeOverpaymentWorkers' CompensationPost-Traumatic Stress DisorderAppellate ReviewHearing TimelinessAdministrative DecisionNew York Appellate Division
References
4
Case No. MISSING
Regular Panel Decision

Claim of Domanico v. Woodmere Fire District

This case involves an appeal from a decision by the Workers’ Compensation Board, filed April 4, 2005, which denied an employer's request for reimbursement of wages paid to a claimant during a period of disability. The court examined whether a June 24, 2004 notice, issued by the self-insured employer, Woodmere Fire District, containing language about reimbursement, was sufficient as a request under Workers’ Compensation Law § 25 (4) (a). The court found the notice to be sufficient in form. However, a critical issue remained regarding the timeliness of this request; specifically, whether it was filed prior to the compensation award made at the January 7, 2005 hearing. Due to this unresolved issue, the court reversed the Board's decision and remitted the matter for further proceedings to determine the timeliness of the reimbursement request.

Workers' Compensation ReimbursementEmployer Wage ReimbursementDisability WagesTimeliness of Reimbursement RequestWorkers' Compensation LawBoard Decision AppealJudicial ReversalRemittal for Further ProceedingsNew York Workers' CompensationStatutory Interpretation
References
5
Case No. MISSING
Regular Panel Decision

Bland v. Gellman

A claimant had two workers' compensation claims, one managed by the Special Fund for Reopened Cases and the other by Travelers Insurance Company, with liability equally apportioned. The claimant's treating physician requested a variance for aquatic therapy, which both carriers denied. Although a Workers' Compensation Law Judge approved the treatment, the Workers' Compensation Board reversed, asserting that the variance request form (MG-2) was not properly served on the Board and that the review request was untimely. The Appellate Division reversed the Board's decision, finding substantial evidence that the MG-2 form was timely filed with the Board, referencing both claim numbers, and that the request for review of the denial was also timely. The court concluded that the Board's determination lacked substantial evidence and remitted the matter for further proceedings.

Variance RequestAquatic TherapyClaim DenialMG-2 FormTimely FilingAdministrative LawAppellate ReviewSpecial Fund for Reopened CasesTravelers Insurance CompanySubstantial Evidence
References
3
Case No. ADJ9755370
Regular
Aug 10, 2017

BERNARDINO GARDEA vs. CITY OF PASADENA

This case concerns the City of Pasadena's request for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision regarding the applicant's occupational group number. The WCJ initially recommended dismissal of the reconsideration petition as untimely. However, the defendant has now requested leave to file a supplemental petition to address issues raised in the WCJ's report. The WCAB has granted the defendant's request to file this supplemental petition. The defendant is ordered to file the supplemental petition within 20 days, either by mail or via EAMS, to avoid rejection.

Workers' Compensation Appeals BoardSupplemental PetitionReconsiderationOccupational Group NumberAdministrative Law JudgePetition for ReconsiderationWCAB Rule 10848Electronic Adjudication Management SystemEAMSCity of Pasadena
References
0
Case No. ADJ8505079
Regular
May 11, 2016

MATTHEW LOPEZ vs. CITY AND COUNTY OF SAN FRANCISCO

This case concerns Matthew Lopez's claim for workers' compensation benefits for a back injury. The City and County of San Francisco, the defendant, denied a Request for Authorization (RFA) for disc replacement surgery recommended by Dr. Jones, a consulting physician. The Appeals Board held that Dr. Jones, acting at the primary treating physician's behest and possessing specialized expertise, qualified as a secondary treating physician authorized to submit an RFA. Because the defendant failed to timely perform utilization review (UR) on Dr. Jones' RFA or communicate its decision, the Board affirmed the award of medical treatment, finding jurisdiction to determine its necessity.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationSecondary Treating PhysicianPrimary Treating PhysicianMedical NecessityLabor Code section 4610DWC Form RFAAdministrative Director RulesPeer Review
References
6
Case No. ADJ10084576
Regular
Oct 06, 2016

ROSE SMITH vs. MEGGITT SENSING SYSTEMS PLC, THE HARTFORD

This case involves Rose Smith's workers' compensation claim where the defendant, Meggit Sensing Systems and its insurer, The Hartford, seek reconsideration of an order allowing Smith to obtain medical treatment outside their Medical Provider Network (MPN). The Appeals Board denied the petition, affirming the WCJ's finding that the defendant's failure to authorize a requested third medical opinion constituted a denial of care. This denial entitled the applicant to seek treatment outside the MPN at the defendant's expense. The defendant argued the request was procedurally deficient and not a request for treatment, but the Board found the failure to respond to the RFA for a third opinion, in context, was a failure to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Request for Authorization (RFA)Petition for ReconsiderationDenial of Medical TreatmentThird Medical OpinionUtilization Review (UR)Primary Treating PhysicianCumulative TraumaLoss of Control
References
3
Case No. MISSING
Regular Panel Decision

Claim of Lewis v. Stewart's Marketing Corp.

A claimant sustained serious injuries in 1997 and was awarded workers' compensation benefits. In 2008, a dispute arose regarding the permanency and degree of disability, with conflicting medical reports submitted by the claimant (permanent total disability) and the employer (moderate partial disability). The Workers' Compensation Law Judge denied the employer's request to cross-examine the claimant and his physician, subsequently ruling that the claimant had a permanent total disability. Upon appeal, the Workers’ Compensation Board affirmed this decision. The appellate court reversed the Board's decision, emphasizing that denying the employer's timely request for cross-examination was improper, especially given the conflicting medical evidence, and remitted the matter for further proceedings.

Workers’ CompensationDisability AssessmentPermanent Total DisabilityIndependent Medical ExaminationCross-Examination RightsProcedural Due ProcessConflicting Medical EvidenceRemittalAppellate ReviewBoard Decision Reversal
References
3
Case No. MISSING
Regular Panel Decision

Ramaglia v. New York State Department of Transportation

Petitioners, including union representative Joseph Ramaglia, requested payroll records from a steel company under the Freedom of Information Law (FOIL) through the Department of Transportation (DOT). They sought to determine if the steel company, a contractor for overpass replacement on the Long Island Expressway, was violating prevailing wage laws. DOT denied the request, stating it neither possessed nor was required to collect these records, as the steel company was merely a materials supplier, not directly involved in public works construction. Petitioners commenced a CPLR article 78 proceeding to compel DOT to obtain and produce the records. The Supreme Court dismissed their application, agreeing that DOT had no obligation to the supplier's records. On appeal, the court affirmed, ruling that the prevailing wage law does not apply to contracts for the sale of goods, even custom or shop-finished products, especially when such work is a normal part of manufacturing and not typically done on-site.

Freedom of Information LawFOIL RequestPublic Works ContractPrevailing Wage LawMaterials SupplierPayroll RecordsCPLR Article 78Administrative LawAppellate ReviewLabor Law
References
5
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