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Case Law Database

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

Case No. ADJ2635006 (STK 0206833)
Regular
Nov 01, 2010

SAMUEL B. JOHNSON, III vs. CHEVRON ENVIRONMENTAL MANAGEMENT COMPANY

The Workers' Compensation Appeals Board dismissed the applicant's Petition for Reconsideration because the WCJ's order denying discovery requests was not a final order. The Board also denied the applicant's Petition for Removal, finding no substantial prejudice or irreparable harm justifying this extraordinary remedy. The Board affirmed the WCJ's discovery ruling as reasonable and returned the matter to the trial level. The applicant may seek reconsideration of a final order.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalWCJdiscovery requestsRequest for AdmissionsRequest for Authenticationfinal ordersubstantial prejudiceirreparable harm
References
Case No. ADJ1871643 (SDO 0291759)
Regular
Oct 23, 2017

JOSE GOMEZ vs. DEPARTMENT OF CORRECTIONS, REHABILITATION PAROLE & COMMUNITY SERVICES, Legally Uninsured, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, affirming the WCJ's award of medical treatment. The defendant's Utilization Review denial was deemed untimely because their Request for Information was served more than five business days after the initial request, excluding the day after Thanksgiving. The Board clarified that the day after Thanksgiving is considered a normal business day for UR purposes under Labor Code section 4600.4. Therefore, the defendant's untimely RFI did not extend the UR deadline, and the requested medical treatment was properly authorized.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationRequest for InformationTimelinessBusiness DayLabor Code Section 4600.4Petition for ReconsiderationFindings and AwardPrimary Treating Physician
References
Case No. ADJ7199986 ADJ7399845
Regular
Oct 03, 2011

ELMIRA SMITH vs. PACIFIC AUTISM CENTER FOR EDUCATION, TRI- STAR RISK MANAGEMENT

The applicant sought removal to challenge a finding that defendant's requested Qualified Medical Evaluator (QME) panel was properly assigned. The Appeals Board granted removal, rescinded the finding, and determined that *neither* panel was properly assigned. Both panel requests were found to be premature as they were made before the statutory 10-day period for agreeing on an Agreed Medical Evaluator had expired, plus an additional five days for mail service. This decision clarifies the timing requirements for QME panel requests following an unsuccessful attempt to select an AME.

Petition for RemovalQualified Medical Evaluator (QME)Agreed Medical Evaluator (AME)Labor Code section 4062.2(b)WCAB Rule 10507Messele v. Pitco FoodsInc.Premature RequestPanel AssignmentMedical Unit
References
Case No. ADJ4261717 (FRE 0227914), ADJ2564944 (FRE 0224116)
Regular
Jan 19, 2017

Ann Swengel vs. CAMBRIDGE; AON CORPORATION, AMERICAN CASUALTY COMPANY OF READING, PENNSYLVANIA

The Appeals Board granted the defendant's petition for reconsideration, reversing the prior order that mandated a gym membership. The Board found that because the defendant timely submitted the request for authorization (RFA) to Utilization Review (UR), the UR's denial is not subject to review by the Board, nor is it subject to Independent Medical Review (IMR) if not timely appealed. Consequently, the applicant's petition for reconsideration and for penalties was denied. The Board emphasized that their jurisdiction regarding UR determinations is limited to timeliness.

Utilization ReviewIndependent Medical ReviewPetition for ReconsiderationFindings of Fact and OrderPrimary Treating PhysicianRequest for AuthorizationAdministrative Director's DeterminationMedical Treatment Utilization ScheduleLabor Code Section 5814.5Stipulations with Request for Award
References
Case No. ADJ4655433 (STK 0183897) ADJ4135432 (STK 0183898)
Regular
Sep 08, 2010

CARMELA GARCIA vs. E & J GALLO WINERY, P.S.I.

This case concerns a request for supplemental attorney's fees following an unsuccessful petition for writ of review by defendant E & J Gallo Winery. The Court of Appeal previously granted the applicant's request for fees under Labor Code § 5801 and remanded the matter. The applicant's attorney requested $3,150.00 for services related to answering the petition, which the defendant did not dispute in amount, only in principle. The Workers' Compensation Appeals Board found the requested amount reasonable and issued a supplemental award of $3,150.00 in attorney's fees.

Workers' Compensation Appeals BoardLabor Code § 5801attorney's feessupplemental awardpetition for writ of reviewremittiturreasonable basisapplicantdefendantE & J Gallo Winery
References
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
Case No. ADJ308368 (SAC 0337296)
Regular
Feb 24, 2011

JENNIFER ROBERSON vs. BEYER PONGATZ & ROSEN, STATE COMPENSATION INSURANCE FUND INSURED SACRAMENTO

In this workers' compensation case, the applicant sought reconsideration of a finding that the defendant insurer was not obligated to serve the applicant or her attorney with a request for additional information sent to the applicant's physician. The applicant argued this lack of service prevented her from knowing if timely requests were made. However, the Board dismissed the petition because the underlying issue was moot, as the requested medical treatment had already been authorized. Therefore, the applicant was no longer aggrieved by the service dispute.

Workers' Compensation Appeals BoardPetition for ReconsiderationDismissalMootnessAggrieved PartyWCJTreating PhysicianTreatment RequestAdditional InformationService of Process
References
Case No. ADJ409820 ADJ1572678 ADJ3967299 ADJ349576
Regular
Dec 08, 2010

VELEDA BURTON vs. FEDERAL EXPRESS, permissibly self-insured; SEDGWICK CLAIMS SERVICES

In this workers' compensation case, the applicant, Veleda Burton, sought to disqualify the administrative law judge (WCJ) presiding over her five consolidated claims. The WCJ denied the petition, finding no stated grounds for disqualification and noting that the request was untimely as an automatic reassignment request. The Workers' Compensation Appeals Board (WCAB) adopted the WCJ's report, expressly incorporating its reasoning, and denied the petition for disqualification. The WCAB also concluded the request was untimely under California Code of Regulations, title 8, section 10453.

Petition for DisqualificationAdministrative Law JudgeReassignmentUntimely RequestCal. Code Regs. tit. 8 § 10453WCJ ReportDeniedFederal ExpressSedgwick Claims ServicesVeleda Burton
References
Case No. ADJ9178558 ADJ9178559
Regular
Feb 05, 2015

JAVIER RIVERA vs. JACO ENVIRONMENTAL, INC., ZURICH AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a Petition for Removal filed by Zurich American Insurance Company concerning a dispute over Qualified Medical Evaluator (QME) panel selection. The administrative law judge had found both parties requested QME panels timely, but ruled the defendant's request invalid for seeking a different specialty without justification. The Board agreed that removal was not warranted and upheld the decision to assign a QME in pain management, the same specialty as the primary treating physician. The Board also clarified the interpretation of Rule 31.1(b), emphasizing the requirement for supporting documentation when requesting a QME in a different specialty.

Petition for RemovalQualified Medical Evaluator (QME) panelprimary treating physicianspecialtypain managementMedical Directortimely requestjustificationRule 31.1(b)extraordinary remedy
References
Case No. ADJ 11017618
Regular
Oct 29, 2020

Robert Shelven vs. RALPHS GROCERY COMPANY, SEDGWICK CMS, INC.

In this workers' compensation case, the applicant sought reconsideration of a decision denying their petition. The core issue was whether a February 2020 request for a cervical spine epidural injection constituted the "same treatment recommendation" as a previously denied September 2019 request, thereby preventing mandatory utilization review under LC § 4610(k). The Board denied reconsideration, adopting the WCJ's reasoning that the February 2020 request, while for one level instead of two, was for the "same treatment" at C5-C6 which had been denied within the prior 12 months. The Board further agreed that no documented change in facts material to the basis of the prior denial was presented, thus the Court lacked jurisdiction to determine the medical necessity of the treatment.

Utilization ReviewRequest for AuthorizationCervical Spine Epidural InjectionLC § 4610(k)Medical Treatment Utilization ScheduleInternational Medical Reviewtimelinessjurisdictionreasonable and necessaryFindings and Order
References
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