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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

Atlantic Casualty Insurance v. Value Waterproofing, Inc.

Atlantic Casualty Insurance Company sought a declaratory judgment that it had no duty to defend or indemnify Value Waterproofing, Inc. in an underlying breach of contract and negligence lawsuit. Value counterclaimed, requesting a declaration that Atlantic Casualty was required to defend and indemnify. The court granted Atlantic Casualty's request, finding that Value failed to provide timely notice of the claim, thereby prejudicing Atlantic Casualty's investigation capabilities. Additionally, the court ruled that Value's work on a commercial property was not covered by its residential-only roofing insurance policy, further justifying the denial of coverage.

Insurance disputeBreach of contractNegligenceDeclaratory judgmentTimely noticeCoverage exclusionCommercial General LiabilityResidential roofingPolicy interpretationPrejudice
References
46
Case No. ADJ9873183
Regular
Feb 24, 2020

WONDA BRAZILE TRAYLOR vs. COUNTY OF LOS ANGELES/PUBLIC HEALTH SERVICES; Permissibly SelfInsured, Administered by TRISTAR RISK MANAGEMENT

The WCAB affirmed the prior award finding the County of Los Angeles liable for copy services provided by lien claimant Med-Legal, LLC. The defendant failed to issue a timely and compliant Explanation of Review (EOR) for invoice 1313134, thereby waiving objections to its reasonableness. Consequently, the lien claimant is entitled to the reasonable value of the invoice, plus penalties and interest retroactive to receipt. The case is remanded to the WCJ to determine the exact reasonable value of the services.

WCABReconsiderationLien ClaimantCopy ServicesExplanation of ReviewMedical-Legal ExpensesLabor Code Section 4622PenaltiesInterestReasonable Value
References
2
Case No. ADJ9052447
Regular
Oct 13, 2018

JACQUELINE FINDLER vs. WALMART, AVIZENT, YORK INSURANCE

The Workers' Compensation Appeals Board denied the petition for reconsideration in *Findler v. Walmart*. The WCAB adopted the findings of the WCJ, who found that the lien claimant failed to provide sufficient evidence of the reasonable value of services rendered. This was because the applicable fee schedule did not control for services provided before its effective date. Therefore, the lien claimant was required to present evidence of reasonable value, which they did not adequately do.

Jacqueline FindlerWalmartAvizentYork InsuranceADJ9052447Petition for ReconsiderationWorkers' Compensation Appeals BoardWCJOpinion and Order DenyingAdministrative Director Rule 9983
References
4
Case No. ADJ9668315
Regular
Jan 10, 2020

MARTIN AMADOR vs. CAL CENTRAL HARVESTING, STAR INSURANCE COMPANY

This case concerns a lien claimant, Citywide Scanning, seeking payment for medical-legal discovery services. The Workers' Compensation Appeals Board (WCAB) affirmed the initial award but deferred the issue of the reasonable value of services. The WCAB found the defendant waived objections to the invoices by failing to provide timely explanations of review, thus incurring a penalty and interest. However, the WCAB returned the matter for further proceedings to establish a reasonable value, as the initial evidence was insufficient.

WCABReconsiderationLien ClaimantCitywide ScanningFindings of FactAward and OrderMedical-Legal Discovery ServicesCopy ServicesExplanation of Review (EOR)Labor Code Section 4622
References
4
Case No. ADJ2831572 (OXN 0131269)
Regular
Dec 09, 2008

GRACIELA BELTRAN vs. TECHSTAFF WEST, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the original finding that the reasonable value of their services was $4,792.00, not the $12,435.54 claimed. The Board affirmed the Administrative Law Judge's decision, finding the lien claimant failed to meet its burden of proving the reasonableness of its charges under established precedent. The judge properly considered various evidence, including comparative data and the reasonableness of the charges in context, to arrive at the determined amount.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and OrderReasonable ValueIndustrial InjuryCompromise and ReleaseDiagnostically Related GroupMedicareFee Schedule
References
2
Case No. No. 12
Regular Panel Decision
Apr 01, 2021

The Matter of the Claim of Estate of Norman Youngjohn v. Berry Plastics Corporation

Decedent Norman Youngjohn, employed by Berry Plastics Corporation, suffered work-related injuries to his right shoulder and left elbow in 2014, leading to a workers' compensation claim. Before his permanent partial disability benefits claim for a schedule loss of use (SLU) award was resolved, Youngjohn died in March 2017 from a heart attack unrelated to his work injuries. He left no surviving spouse, minor children, or qualifying dependents. His estate sought the full value of the posthumous SLU award, arguing that 2009 amendments to the Workers' Compensation Law, which permitted lump sum SLU payments, rendered WCL § 15 (4) (d) inapplicable. This section limits an estate's recovery for unaccrued SLU benefits to reasonable funeral expenses in cases of unrelated death without qualifying survivors. The Workers' Compensation Board limited the award to funeral expenses, while the Appellate Division held that the estate was entitled to the portion accrued up to the date of death plus reasonable funeral expenses. The New York Court of Appeals affirmed the Appellate Division's order, concluding that the 2009 amendments on lump sum payments did not implicitly alter WCL § 15 (4) (d)'s limitation on an estate's recovery of posthumous SLU awards. The Court emphasized that section 15 (4) (d) remains in effect and must be harmonized with the amendments, limiting recovery to benefits accrued before death and reasonable funeral expenses for the remainder.

Workers' Compensation LawPermanent Partial DisabilitySchedule Loss of Use (SLU)Lump Sum PaymentEstate RecoveryFuneral ExpensesStatutory InterpretationAccrual of BenefitsNew York Court of AppealsUnrelated Death
References
35
Case No. MISSING
Regular Panel Decision

Claim of Korthals v. Valu Home Centers, Inc.

Claimant sustained back injuries in 2003 and 2009 while employed by Valu Home Centers, Inc. and Spectrum Human Services, respectively. A 2009 independent medical examination apportioned liability for her condition across both injuries and prior motor vehicle accidents. After claimant's 2011 back surgery, Spectrum's carrier requested further action, prompting Valu's carrier to seek a liability transfer for the 2003 claim to the Special Fund for Reopened Cases. The Workers’ Compensation Board approved this transfer, ruling no prior request to reopen the 2003 claim existed. The Special Fund appealed, contending the 2009 medical report served as an application to reopen. The court reversed the Board's decision, determining that the medical report submitted in 2009 indeed constituted a timely application to reopen the 2003 claim, thereby preventing liability transfer to the Special Fund.

Workers' Compensation LawSpecial Fund for Reopened CasesLiability ApportionmentClaim ReopeningIndependent Medical ExaminationWorkers' Compensation Board DecisionAppellate ReviewBack InjuryPrior InjurySeven-Year Rule
References
5
Case No. 2007 NY Slip Op 30531(U)
Regular Panel Decision
Apr 05, 2007

Schirmer v. Athena-Liberty Lofts, LP

This case is an appeal from an Order of the Supreme Court, New York County, regarding a personal injury action. The plaintiff, a worker at a construction site, sustained injuries, leading to the site owner, Lofts, settling the claim after being found liable under Labor Law § 240 (1). Lofts then pursued indemnity claims against lighting contractor HP and the plaintiff's employer, Burgess. The Appellate Court modified the lower court's decision, vacating the finding that Lofts' settlement amount was reasonable due to Lofts' failure to properly demonstrate reasonableness and its mischaracterization of waiver arguments by HP and Burgess. The Court also affirmed the denial of HP's motion for summary judgment, citing unresolved factual issues concerning inadequate lighting as a cause of the accident.

Personal InjuryConstruction Site AccidentSummary JudgmentIndemnity ClaimLabor Law § 240(1)Appellate DivisionThird-Party ActionSettlement ReasonablenessCross ClaimsInadequate Lighting
References
4
Case No. ADJ7834593
Regular
Oct 06, 2014

GEORGE MOEN, III vs. COUNTY OF SAN BERNARDINO

The Appeals Board granted reconsideration of a WCJ's decision regarding a lien claim for a human tendon used in applicant's knee surgery. While the WCJ correctly found the services were necessary, neither party provided sufficient evidence to determine the reasonable value of the lien. The Board rescinded the WCJ's decision and returned the case for further development of the record. Lien claimant must prove its bill was not bundled and present evidence of a reasonable fee.

Workers' Compensation Appeals BoardLien ClaimantAccess MediquipIndustrial InjuryKnee InjuryDeputy SheriffACL Tendon ReplacementPatella Tendon AllograftHuman TendonBundled Payment
References
1
Case No. MON 0292635
Regular
May 20, 2008

ZENA GARCIA vs. SANTA MONICA MALIBU UNIFIED SCHOOL DISTRICT

The Appeals Board denied the lien claimant's petition for reconsideration, upholding the administrative law judge's decision that the lien claimant failed to meet its burden of proving the reasonableness of its charges for surgery. Despite prior direction to develop the record regarding rebuttal evidence, the lien claimant presented no further evidence, leaving its charges appearing disproportionate. The Board affirmed the use of the 2004 fee schedule as a guide to establish the reasonable value of the services.

KunzOutpatient Surgery Fee ScheduleReconsiderationLien ClaimantReasonable ValueRebuttal EvidenceBurden of ProofGeographic ComparablesComparative StudyIndustrial Injury
References
2
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