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

Case No. ADJ3172767
Regular
May 10, 2017

VICTOR GONZALEZ vs. CITISTAFF SOLUTIONS, STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed the WCJ's decision finding the lien claimant, Monrovia Memorial Hospital, was entitled to nothing for its services. The WCJ properly excluded the lien claimant's expert declaration as it was submitted after discovery closed. The lien claimant failed to meet its burden of proving its charges were reasonable and based on a reasonable cost basis, as required by precedent in cases exempt from the Official Medical Fee Schedule. Mere presentation of usual and customary charges, without evidence of reasonableness or comparability, is insufficient.

Workers' Compensation Appeals BoardVictor GonzalezCitistaff SolutionsState Compensation Insurance FundMonrovia Memorial Hospitallien claimantbill review expertdue processreasonableness of chargesOMFS exemption
References
Case No. ADJ4024660 (LAO 0887729)
Regular
Feb 03, 2017

ALFREDO COLLAZO vs. MECA NAG CORPORATION, EMPLOYERS COMPENSATION

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case to the trial level for a new decision. The WCJ erred in determining the lien claimant's entitlement to payment solely on a multiplier of Medicare rates, rather than a reasonable cost basis. The Board clarified that while the facility's charges are not subject to the Official Medical Fee Schedule, their entitlement must be based on their actual costs plus a reasonable profit. Therefore, further proceedings are required to properly assess the reasonable cost basis for the services rendered.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien ClaimantReasonable Cost BasisMedicare ReimbursementOfficial Medical Fee ScheduleLong Term Care HospitalKunz StudyTapia
References
Case No. ADJ 7511877, ADJ 7396932
Regular
May 03, 2017

MARIA MORALES vs. MONTEBELLO UNIFIED SCHOOL DISTRICT, YORK RISK SERVICES GROUP, INC.

The Appeals Board affirmed the WCJ's decision disallowing further payment on Monrovia Memorial Hospital's lien. The court found that Monrovia failed to provide sufficient evidence to establish that its requested charges were reasonable and consistent with a "reasonable cost basis" as required for long-term care hospitals exempt from the Official Medical Fee Schedule. Lien claimants bear the affirmative burden of proving the reasonableness of their liens by a preponderance of the evidence. The Board also noted that discovery was properly closed at the lien conference, precluding Monrovia's delayed introduction of evidence.

Workers' Compensation Appeals BoardJoint Findings and OrderIndustrial InjuryCervical SpineLumbar SpineRight HipBilateral KneesPsycheLien ClaimantMonrovia Memorial Hospital
References
Case No. ADJ6884625
Regular
Jun 19, 2012

JASON PETERSON, KIRSTIE MCCRAINE-PETERSON vs. CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION, STATE COMPENSATION INSURANCE FUND

This case concerns the death of Jason Peterson, a correctional officer, from a pulmonary embolism after injuring his calf in a kickboxing class. The applicant, his widow, claimed the injury and death were work-related, arguing the kickboxing class was a reasonable expectancy of employment due to a general fitness requirement and incentive program. The Workers' Compensation Appeals Board (WCAB) affirmed the WCJ's decision, finding the claim barred by Labor Code Section 3600(a)(9) because the decedent's belief that kickboxing was required was not objectively reasonable, as mere general assertions of fitness expectations are insufficient. Commissioner Brass dissented, believing the decedent's participation was both subjectively and objectively reasonable given its likely benefit to his job performance as a correctional officer.

Labor Code Section 3600(a)(9)Pulmonary EmbolismCorrectional OfficerKickboxingOff-duty Recreational ActivityReasonable Expectancy of EmploymentSubjective BeliefObjective ReasonablenessEzzy testCity of Stockton v. Workers' Comp. Appeals Bd. (Jenneiahn)
References
Case No. ADJ4225434 (LAO0864755)
Regular
Dec 10, 2008

CHING YEN vs. C & C INTERNATIONAL GROUP, STATE COMPENSATION INSURANCE FUND

This case involves an applicant injured in a car accident while traveling to a wedding with her employer. The applicant claimed her participation in the trip was a reasonable expectancy of her employment as an account assistant, which involved driving and travel. The Board denied reconsideration of the workers' compensation judge's finding that the injury was industrial, determining the applicant's subjective belief of being required to attend the trip was objectively reasonable given her job duties and her employer's direction.

Workers' Compensation Appeals BoardIndustrial InjuryReasonable ExpectancyOff-duty recreational activitySubjective beliefObjectively reasonableMotor vehicle accidentAccount assistantCommercial travelSpecial mission
References
Case No. ADJ3463668 (AHM 0129255) ADJ3379175 (AHM 0128291)
Regular
Nov 07, 2013

LEO CORCORAN vs. C.A.T., INC.; TIG SPECIALTY INSURANCE SOLUTIONS

The Workers' Compensation Appeals Board denied a petition for reconsideration filed by a lien claimant, Midas Recovery Services, representing the Sheet Metal Workers Trust Fund. The claimant sought over $330,000 for services rendered, but the Board affirmed the judge's award of only $23,694.58. This was because the lien claimant failed to meet its burden of proving the reasonableness and necessity of its services and their value. Specifically, the provided documentation did not adequately itemize or detail the goods and services rendered to support the claimed amount.

WCABPetition for Reconsiderationlien claimantburden of proofreasonablenessnecessityreasonable valueC.A.T.Inc.TIG Specialty Insurance Solutions
References
Case No. ADJ8334555
Regular
Apr 05, 2013

JOSE HERNANDEZ vs. BRYAN MIMAKI dba PACIFIC RIMS, PALMS; ZENITH INSURANCE COMPANY

This case concerns whether a knee injury sustained by an employee, Jose Hernandez, while playing basketball on company premises during lunch is compensable. The defendant argued the injury did not arise out of employment, as it stemmed from voluntary participation in an athletic activity not required by the employer. The Appeals Board denied reconsideration, affirming the finding that the injury was industrial. The majority found the employee's subjective belief of employer expectation was objectively reasonable, given the employer provided a court and balls and supervisors encouraged participation. Commissioner Lowe dissented, arguing the applicant failed to demonstrate an objectively reasonable belief of employer expectation, as he could opt out and faced no repercussions.

Workers' Compensation Appeals BoardIndustrial InjuryRight KneeField WorkerBasketball GameOff-Duty Recreational ActivityLabor Code Section 3600(a)(9)Reasonable Expectancy of EmploymentSubjective BeliefObjective Reasonableness
References
Case No. ADJ4225526 (GOL 0092072)
Regular
Apr 20, 2017

JESUS ARROYO vs. JOHN CRAVENS PLASTERING, STATE COMPENSATION INSURANCE FUND

This case involves Jesus Arroyo's petition for reconsideration of a Workers' Compensation Appeals Board decision. The Board denied reconsideration, adopting the reasoning of the workers' compensation administrative law judge. Medical evidence from Dr. Markovitz established that Arroyo suffered a total and permanent disability resulting from industrial injuries, including an aortic aneurysm repair and subsequent strokes. The Board found Dr. Markovitz's opinions constituted substantial medical evidence, despite conflicting defense opinions, and affirmed that all necessary medical care and permanent disability were industrially caused.

Workers' Compensation Appeals BoardJesus ArroyoJohn Cravens PlasteringState Compensation Insurance FundPetition for ReconsiderationAgreed Medical ExaminerGerald Markovitzechocardiogramaortic root dilationexpanding aortic aneurysm
References
Case No. ADJ252083 (NOR 0166266) ADJ3827633 (LAO 0784953) ADJ3395707 (LAO 0784956) ADJ629194 (LAO 0849490) ADJ2985386 (LAO 0784955) ADJ2625573 (LAO 0784951)
Regular
Apr 12, 2011

CLAUDIA DYER vs. BOEING/McDONNELL DOUGLAS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, CHARTIS INSURANCE

The Workers' Compensation Appeals Board denied CIGA's petition for reconsideration, upholding the WCJ's findings of industrial injuries to the applicant's knees, neck, back, shoulders, hips, hands, and ankle across multiple dates. The Board found the WCJ's decision was supported by substantial evidence, specifically Dr. Nelson's well-reasoned medical opinions on causation and apportionment. CIGA's petition was also found deficient for failing to comply with procedural requirements for referencing the record. Finally, CIGA was estopped from asserting the statute of limitations defense due to the employer's knowledge of the injury and failure to provide notice of rights.

CIGAFremont InsuranceliquidationPetition for ReconsiderationJoint Findings and Awardindustrial injuryaircraft mechanickneesneckback
References
Case No. ADJ6490669
Regular
Sep 05, 2012

FELIX CHAVEZ vs. T.D. HAYES COMMUNICATIONS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied reconsideration of a decision concerning applicant Felix Chavez's claim. The Board upheld the judge's credibility findings and admonished lien claimants for procedural missteps. Importantly, the Board clarified that an employer's alleged failure to properly notice their Medical Provider Network (MPN) does not automatically obligate them to reimburse self-procured treatment outside the MPN if reasonable treatment was not neglected or refused. Furthermore, the lien claimants failed to prove the necessity and reasonableness of the claimed medical services and costs.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeMedical Provider Network (MPN)Self-Procured TreatmentNotice RequirementsNeglect or RefusalReasonable Medical TreatmentBurden of ProofReasonably Required Treatment
References
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