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

Case No. ADJ4133886 (AHM 0150741)
Regular
Jan 18, 2011

HUGO ABADIA vs. QUICKSILVER, INC., ACE USA

This case involves a dispute over an applicant's entitlement to spinal surgery following an admitted industrial injury. The defendant seeks reconsideration of a decision awarding surgery, arguing the utilization review denial was timely and the applicant waived timeliness objections by agreeing to an Agreed Medical Examiner (AME) process. The Appeals Board granted reconsideration, finding the applicant waived their right to object to the timeliness of the utilization review by participating in the AME process. Consequently, the Board rescinded the award and remanded the case for further proceedings to address the medical necessity of the surgery, including the AME's reports.

Workers' Compensation Appeals BoardUtilization ReviewAgreed Medical ExaminerReconsiderationExpedited HearingFindings and AwardSpinal SurgeryLow Back InjuryWaiverTimeliness
References
Case No. ADJ6754074
Regular
Dec 14, 2010

BARBARA JACOME vs. DURHAM SCHOOL SERVICES, OLD REPUBLIC, SEDGWICK CMS

This case involves an applicant's petition for removal challenging a WCJ's order granting the defendant's request for a replacement Qualified Medical Evaluator (QME). The applicant argued the defendant's objection to the QME's report timeliness was conditional and not properly served, thereby waiving their right to a replacement. The Appeals Board granted removal, finding the defendant's objection, made after receiving the report, was insufficient and void. Therefore, the defendant was not entitled to a replacement panel, and the QME's report was deemed admissible.

Petition for RemovalQualified Medical EvaluatorReplacement PanelTimeliness ObjectionConditional ObjectionLabor Code SectionsCalifornia Code of RegulationsMedical DirectorAdministrative DirectorComprehensive Medical-Legal Evaluation
References
Case No. ADJ6669630
Regular
Jul 23, 2018

ROBERT SAXTON vs. SELECT A SERVICE RETAIL, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a prior decision regarding a lien claim by Western Imaging Services for copying services. The WCAB found that for most invoices, the defendant waived objections to reasonableness due to untimely and invalid objections. However, the WCAB noted potential issues with two specific invoices (82003-7 and 82003-8) and deferred the final determination of reimbursement for these and other contested invoices. The matter was returned to the administrative law judge for further proceedings on the validity of those specific invoices.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and AwardWorkers' Compensation Administrative Law JudgeReimbursementFee ScheduleObjectionsInvoicesReasonable and Necessary
References
Case No. ADJ1952983
Regular
Mar 15, 2018

JUAN RIVERA vs. IMPORT EXPORT CACTUS, STATE COMPENSAITON INSURANCE FUND

In this workers' compensation case, the defendant sought reconsideration of a prior ruling that deemed them to have waived objections to a specific invoice from lien claimant Scandoc Imaging. The WCAB denied reconsideration, finding that the defendant's objection, if any, was untimely, having been filed approximately four years after the invoice was submitted. California regulations require objections to medical-legal billings within 60 days to avoid waiver. Therefore, the defendant waived their objections to the reasonableness of the services and charges for invoice #234447-3.

WCABPetition for ReconsiderationFindings and Orderslien claimantinvoice objectionwaiver of objectionreasonableness of servicesLabor Code section 4622Scandoc ImagingImport Export Cactus
References
Case No. ADJ758842 (VNO 0559214)
Regular
Dec 17, 2010

JOHN PATCHETT vs. CITY OF LOS ANGELES

The Appeals Board denied the applicant's petition for removal, affirming the WCJ's decision to vacate the submission. This action was based on the DEU evaluator's testimony, which revealed deficiencies in the AMEs' reports concerning the AMA Guides. The Board found the applicant waived any objection to this testimony by failing to object at trial, and that the evaluator's expert opinion was permissible per *Blackledge v. Bank of America*. Defendant's objection, though not styled as a motion to strike, sufficiently raised the issues leading to the vacation of the rating.

Petition for RemovalOrder Vacating SubmissionDEU evaluatorAMA Guidesagreed medical evaluators (AMEs)rating instructionssubstantial evidenceobjective factors of disabilitywhole person impairmentformal rating
References
Case No. ADJ3133261 (VNO 0400017)
Regular
Aug 17, 2010

FELIPE TOLENTINO vs. CONCO CEMENT, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, XCHANGING INC., FREMONT COMPENSATION

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's petition for reconsideration as premature. The WCAB granted the defendant's petition for reconsideration regarding the temporary disability overpayment issue, deferring it for further proceedings. The Board affirmed the WCJ's findings on injury causation and permanent disability but amended the decision to clarify the overpayment issue. Finally, the WCAB issued a notice of intention to sanction defendant's counsel for attaching and citing unadmitted evidence.

Workers' Compensation Appeals BoardFELIPE TOLENTINOCONCO CEMENTCALIFORNIA INSURANCE GUARANTEE ASSOCIATIONXCHANGING INC.FREMONT COMPENSATIONliquidationADJ3133261VNO 0400017OPINION AND ORDERS DISMISSING PETITION FOR RECONSIDERATION AND GRANTING PETITION FOR RECONSIDERATION
References
Case No. ADJ6960749
Regular
Jun 07, 2010

AMALIA AGUILAR vs. PETALUMA VALLEY HOSPITAL, ST, JOSEPH HEALTH SYSTEM, THE HARTFORD, SEDGWICK CMS

This case involves a dispute over venue. The defendant timely objected to the applicant's initial filing venue, which was the attorney's principal place of business. The law mandates that if venue is based on the attorney's location and an objection is raised, venue must then be established in the county of the employee's residence or the injury site. Since the applicant resides in and was injured in Sonoma County, the Appeals Board granted the defendant's petition for removal. The Board rescinded a prior order that had set aside a change of venue and formally transferred the case to the Santa Rosa district office.

EAMSPetition for RemovalOrder Setting Aside Order of Change of VenueWCJPWCJDeclaration of Readiness to ProceedObjection to VenueLabor Code Section 5501.5WCAB Rule 10410Timeliness of Objection
References
Case No. ADJ9615494
Regular
Oct 08, 2019

CARLOS SOTO TORRES vs. THE CLIFF RESTAURANT, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded an Amended Findings of Fact and Order because essential documentation regarding the timeliness of medical-legal billings and reviews was missing. Specifically, the record lacked proof of service for the provider's invoice, the defendant's initial Explanation of Review (EOR), and the subsequent second bill review. This prevented determination of whether the defendant timely objected to the bill and whether the provider timely requested a second review, necessitating further proceedings at the trial level.

Workers' Compensation Appeals BoardReconsiderationAmended Findings of Fact and OrderQualified Medical EvaluatorQMEDr. Payam MoazzazZenith Insurance CompanyStatute of LimitationsLabor Code section 4903.5Independent Bill Review
References
Case No. ADJ9834159 (MF) ADJ9834161
Regular
Jul 30, 2018

ESAU HERNANDEZ vs. D.L. BONE AND SONS PAINTING, ICW GROUP/EXPLORER INSURANCE COMPANY, STATE COMPENSATION INSURANCE FUND

This case concerns a defendant's attempt to obtain a replacement Qualified Medical Evaluator (QME) panel after the applicant initially objected to the timeliness of the original QME's report. The Appeals Board treated the defendant's petition as one for removal and denied it. The Board found that the defendant, having failed to timely object to the QME's report itself, could not rely on the applicant's subsequent objection to request a new panel. The Board concluded that the defendant's failure to act promptly meant they were not entitled to a replacement QME panel, and no substantial prejudice or irreparable harm warranting removal was demonstrated.

Workers' Compensation Appeals BoardReconsiderationRemovalQualified Medical EvaluatorQME panelAdministrative Director RuleTimeliness objectionReplacement QME panelLabor CodeFindings of Fact
References
Case No. SFO 457386
Regular
Mar 14, 2008

ALEJO GONZALES vs. SEE'S CANDIES, LUMBERMEN'S MUTUAL CASUALTY COMPANY, BROADSPIRE

A lien claimant's objection to a dismissal order, despite an incorrect case number, was deemed timely filed by the Workers' Compensation Appeals Board. The Board rescinded its prior dismissal order, finding it null and void due to the timely objection. The case is now returned to the trial level for a merits-based adjudication of the lien claimant's claim.

Workers' Compensation Appeals BoardLien ClaimantObjectionPetition for ReconsiderationOrder of DismissalTimelinessClerical ErrorIndustrial InjuryShipping SupervisorRight Lower Extremity
References
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