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

Case No. MISSING
Regular Panel Decision

Abreo v. URS Greiner Woodward Clyde

A plaintiff sustained personal injuries while working on a scaffold during a renovation project, alleging violations of Labor Law §§ 200, 240 (1), and 241 (6). Defendants Colgate Scaffolding and URS Greiner Woodward Clyde (now URS Corporation-New York), the alleged general contractor and scaffolding provider, respectively, moved for summary judgment to dismiss the complaint. The Supreme Court denied their motions in part. On appeal, the denial of summary judgment for URS concerning Labor Law § 240 (1) and § 241 (6) claims was affirmed, as triable issues of fact existed and the cited Industrial Code provisions were deemed specific. Colgate's appeal from one order was dismissed as they were not aggrieved, and their motion for summary judgment was also found to lack a prima facie case. The plaintiff was awarded costs.

Personal InjuryLabor LawScaffolding AccidentSummary JudgmentAppellate DecisionConstruction AccidentElevation-Related RiskIndustrial Code ViolationsNegligenceWorkers' Safety
References
14
Case No. 2022 NY Slip Op 00941 [202 AD3d 505]
Regular Panel Decision
Feb 10, 2022

Locke v. URS Architecture & Eng'g-N.Y., P.C.

Plaintiff Michael Locke sustained injuries after slipping on soapy water in a designated restroom at a construction site managed by URS. Locke had repeatedly notified URS of an overflowing sink causing water to pool, but URS attributed responsibility to prime general contractor Tri-Rail. The Supreme Court granted summary judgment to plaintiffs on common-law negligence and Labor Law claims against URS, while denying URS's motion to dismiss and for contractual indemnification against Tri-Rail, and denying Crescent's motion to dismiss. The Appellate Division modified the Supreme Court's order, dismissing the common-law negligence and Labor Law § 200 claims against Crescent and granting URS conditional contractual indemnification against Tri-Rail, pending liability apportionment. The court found URS liable under Labor Law §§ 241(6) and 200 due to its control over the injury-producing activity and notice of the dangerous condition.

Workers' CompensationConstruction Site AccidentSlip and FallPremises LiabilityLabor Law §200Labor Law §241(6)Industrial Code ViolationSummary JudgmentContractual IndemnificationCommon-Law Negligence
References
9
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
6
Case No. ADJ2172104 (SAC 0326562)
Regular
Jan 15, 2015

THOMAS MEEKER vs. OREGON PACIFIC BUILDING PRODUCTS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT COMPENSATION INSURANCE COMPANY

This case involves a dispute over the validity of a utilization review (UR) denial for an applicant's requested prescription medication. Initially, the administrative law judge found the UR denial invalid because the reviewing physician did not examine all relevant medical reports. However, following the en banc decision in *Dubon II*, the Appeals Board reversed this finding. The Board ruled that under *Dubon II*, only untimely UR decisions are invalid; other defects, like incomplete medical review, must be addressed through the Independent Medical Review (IMR) process. Therefore, the UR denial was deemed valid as it was timely.

Utilization ReviewRequest for AuthorizationProvigilDubon IIIndustrial InjuryPermanent DisabilityFuture Medical TreatmentPetition for ReconsiderationAdministrative Law JudgeWorkers' Compensation Appeals Board
References
14
Case No. ADJ339088 (SDO 0304788)
Regular
Aug 30, 2016

Gregory Parrent vs. SBC-PACIFIC BELL TELEPHONE COMPANY

This case clarifies the utilization review (UR) and independent medical review (IMR) process for medical treatment recommendations within a Medical Provider Network (MPN). The Appeals Board affirmed that even when a physician is part of the defendant's MPN, their treatment recommendations are subject to UR by the employer if disputed. If UR denies or modifies the recommendation, the dispute must then proceed to IMR, not the Appeals Board. The applicant's contention that MPN physicians' recommendations are exempt from UR was rejected, emphasizing a uniform standard of care and review for all medical treatment.

Workers' Compensation Appeals BoardSBC-Pacific Bell Telephone CompanySedgwick Claims Management ServicesPetition for ReconsiderationMedical Provider Network (MPN)Independent Medical Review (IMR)Utilization Review (UR)Labor Code section 4600primary treating physicianRequest for Authorization (RFA)
References
5
Case No. 2022 NY Slip Op 01011
Regular Panel Decision
Feb 16, 2022

Hamm v. Review Assoc., LLC

The plaintiff, Peter Hamm, an employee, sustained injuries after falling from a ladder while servicing a security system at premises owned by Review Associates, LLC and leased by Fresh Direct, LLC. He initiated a personal injury action alleging common-law negligence and violations of Labor Law §§ 200, 240(1), and 241(6). The Supreme Court initially granted summary judgment to the defendants, dismissing the complaint. On appeal, the Appellate Division modified this order, denying summary judgment for the Labor Law § 240(1) claim against both defendants due to triable issues of fact regarding whether the work constituted "repairs" or "routine maintenance." Additionally, the court denied summary judgment for the common-law negligence and Labor Law § 200 claims against Fresh Direct, LLC, as it failed to establish a lack of notice regarding the defective ladder. The court affirmed the dismissal of the Labor Law § 241(6) claim against both defendants and the common-law negligence and Labor Law § 200 claims against Review Associates, LLC.

Personal InjuryLadder AccidentLabor Law § 240(1)Labor Law § 200Common-law NegligenceSummary JudgmentAppellate DivisionDuty to Maintain Safe PremisesRoutine Maintenance vs. RepairDangerous Condition
References
44
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
5
Case No. ADJ 1390531 (LBO 0388008)
Regular
Apr 11, 2018

SARITA JANE BISSETT-GARCIA vs. PEACE AND JOY CENTER, VIRGINIA SURETY COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding a prior finding that the defendant's utilization review (UR) process was untimely. The WCAB found that the UR denial for home care assistance was issued within the statutory five business days, despite an alleged deficiency in the initial denial letter. Consequently, the WCAB determined it lacked jurisdiction to review the medical necessity of the requested treatment, as only timely UR decisions are subject to WCAB review.

Workers' Compensation Appeals Boardutilization reviewadministrative law judgereconsiderationcompromise and release agreementmedical treatmentLabor Code section 4610Administrative Director Rule 9792.9.1primary treating physicianindependent medical review
References
2
Case No. ADJ2426407 (VEN 0086297)
Regular
Sep 12, 2014

ROCHELLE STOCK vs. CAMARILLO STATE HOSPITAL, STATE COMPENSATION INSURANCE FUND

The applicant challenged the admissibility of a Utilization Review (UR) denial for a hospital bed, arguing that UR is not applicable to requests from an MPN physician. The WCJ admitted the UR denial, finding the applicant's objection lacked merit and that the UR process is mandatory for all treatment requests, even those from MPN physicians. The Appeals Board dismissed the applicant's reconsideration petition as premature. However, treating it as a removal petition, the Board affirmed the WCJ's decision, clarifying that MPN participation does not preclude UR review for treatment authorization.

Workers Compensation Appeals BoardUtilization ReviewMedical Provider NetworkPetition for ReconsiderationRemovalFindings and AwardIndependent Medical ReviewPrimary Treating PhysicianMedical Treatment AuthorizationLabor Code Section 4610
References
1
Case No. ADJ6939280
Regular
Nov 08, 2018

ROBIN GONZALEZ vs. FIRST PRESBYTERIAN CHURCH OF SANTA BARBARA, STATE COMPENSATION INSURANCE FUND

This case concerns applicant Robin Gonzalez's claim for ongoing home health care services following a spinal injury. The employer's insurer denied these services via a timely Utilization Review (UR) based on the Medical Treatment Utilization Schedule (MTUS). The Workers' Compensation Appeals Board (WCAB) affirmed the trial judge's decision, holding that the WCAB lacks jurisdiction to review the UR denial because the process was timely and the dispute over medical necessity must be resolved through the Independent Medical Review (IMR) process, as established in Dubon II. Applicant's treating physician can submit a new request if medically necessary, as the prior UR denial is effective for 12 months.

Workers' Compensation Appeals BoardUtilization ReviewIndependent Medical ReviewMedical Treatment Utilization ScheduleJurisdictionHome Health CarePermanent DisabilityPetition to ReopenFailed Back SyndromeDubon II
References
6
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