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

Case No. LAO 823855, LAO 823856
Regular
Oct 03, 2007

PEDRO M. RODRIGUEZ vs. RALPHS GROCERY COMPANY

The applicant sought reconsideration of a denial of workers' compensation benefits, which was based on the finding that his claims were filed after notice of termination. The Board affirmed the denial, concluding that the applicant's job abandonment led to a termination prior to the filing of his claims. The Board also determined that the employer properly denied both the specific and cumulative trauma claims, thus negating a presumption of compensability.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderFindings of FactAdministrative Law JudgeApplicantDefendantRalphs Grocery CompanySecurity GuardIndustrial Injury
References
Case No. ADJ4564735 (SFO 0469452)
Regular
Aug 17, 2016

GEORGE FLEET vs. NORTHWEST AIRLINES, LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Northwest Airlines' Petition for Reconsideration, upholding the finding that the utilization review (UR) denial for bilateral knee surgery was untimely. The Board adopted the Judge's report, which found that the initial Request for Authorization (RFA) was faxed on July 23, 2015, making the subsequent UR denial invalid. Because the UR denial was untimely, jurisdiction returned to the Board to determine the medical necessity of the treatment, which was found to be warranted based on substantial medical evidence.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Dubon IIRequest for Authorizationbilateral knee arthroscopic surgerymedical necessityuntimely denialFax Confirmationsubstantial medical evidence
References
Case No. ADJ7503292
Regular
Mar 26, 2013

RIGOBERTO MENDOZA vs. PIZZA MIZZA, GUARD INSURANCE GROUP

The Workers' Compensation Appeals Board denied Rigoberto Mendoza's petition for reconsideration, upholding the Workers' Compensation Administrative Law Judge's (WCJ) finding that Mendoza did not sustain the alleged industrial injury. The WCJ's decision was based on an evaluation of witness credibility and inconsistencies in Mendoza's account of the injury. Specifically, the WCJ found the employer's testimony more credible regarding the timing and nature of the reported injury. The Board gave great weight to the WCJ's credibility determination, leading to the denial of reconsideration.

WCABPetition for ReconsiderationDenialCredibilityGarza v. Workers' Comp. Appeals Bd.ApplicantEmployerIndustrial InjuryBack InjuryLeg Injury
References
Case No. ADJ873701 (ANA 0299104) ADJ1741214 (ANA 0299113)
Regular
Sep 04, 2018

SHELLEE SMITH vs. SMITH'S FOOD AND DRUG, a subsidiary of the Kroger Company, permissibly self-insured, administered by SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves an untimely denial of a request for zolpidem by the defendant employer. The Workers' Compensation Appeals Board (WCAB) granted reconsideration because the trial judge's decision on medical necessity lacked substantial evidence due to a missing medical report. The matter is returned to the trial level to determine the reasonableness and necessity of the zolpidem treatment based on the correct evidence. The WCAB clarified that even with an untimely denial, the applicant must still prove the medical necessity of the requested treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardZolpidemUtilization ReviewIndependent Medical ReviewRequest for AuthorizationUntimely DenialMedical NecessityBurden of Proof
References
Case No. ADJ3211441 (POM 0273310)
Regular
Jun 26, 2015

JOSE CONTRERAS vs. MACDONALD CARBIDE, STATE COMPENSTION INSURANCE FUND

This case concerns defendant's petition for removal following a WCJ's finding of an untimely utilization review (UR) decision. The WCJ determined that due to the defendant's failure to timely deny a treatment request, the WCAB could determine medical necessity, citing *Dubon II*. The defendant argued the WCAB loses jurisdiction after an Independent Medical Review (IMR) determination. The Appeals Board denied removal, affirming the WCJ's authority to address medical necessity when UR is untimely and concluding no substantial prejudice would result from denial.

Petition for RemovalFindings of Factindustrial injurybilateral kneesbilateral hipsspinepsycheprimary treating physicianRequest For AuthorizationUtilization Review
References
Case No. ADJ10809651
Regular
Jun 19, 2018

JOSE LUIS CASTELLANOS vs. CACIQUE, INC.; TRAVELERS INSURANCE COMPANY

This case involves an applicant's workers' compensation claim for multiple injuries sustained as a delivery driver. The defendant employer sought reconsideration of an award finding the claim compensable, arguing the post-termination defense applied and the denial was timely. The Appeals Board denied reconsideration, upholding the WCJ's findings. The Board determined the employer's denial was untimely under Labor Code section 5402(b), creating a presumption of compensability. Furthermore, the Board found the post-termination defense did not bar the claim as the applicant's date of injury, under section 5412, was after his termination.

Workers' Compensation Appeals BoardIndustrial InjuryDelivery DriverCervical SpineLumbar SpineThoracic SpineShouldersHandsWristsAnkles
References
Case No. ANA 0403219
Regular
May 15, 2008

PHILLIP EVANS vs. COAST GENERAL TIRE, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Appeals Board granted reconsideration, finding the applicant's injury presumed compensable under Labor Code section 5402 due to the employer's untimely denial and failure to provide a claim form. The applicant's unrebutted testimony establishes the industrial nature of the fall and injury. However, the nature and extent of the injury require further medical evaluation through the panel QME process.

Labor Code section 5402presumption of compensabilityequitable estoppelclaim formuntimely denialpanel QMEmedical-legal evaluationindustrial injuryStatute of Limitationsfindings and order
References
Case No. ADJ11008689
Regular
Feb 19, 2019

EVELYN A. RAZO-GALIANA, CARLOS CABRERA RAZO (deceased) vs. LAS POSAS COUNTRY CLUB, HARTFORD ACCIDENT AND INDMENITY

The Workers' Compensation Appeals Board granted reconsideration of a dismissal for untimely filing of a death benefit claim. The applicant argued the claim was presumed compensable due to delayed denial and timely filed under relevant statutes. The Board found the defendant failed to meet its burden of proof regarding the statute of limitations. The case is returned to the trial level for further proceedings to determine the "date of injury" for cumulative trauma, which is crucial for calculating the 240-week filing deadline.

Labor Code section 5406(b)Arndt v. Workers' Comp. Appeals Bd.untimely denialpresumptively compensabledate of injurycumulative traumasection 5412employee knowledgeadverse employment factorsburden of proof
References
Case No. ADJ612384
Regular
Jun 04, 2009

ROSARIO LOPEZ vs. READY PAC PRODUCE, GALLAGHER BASSETT

This case involves applicant Rosario Lopez's petition for removal to the Workers' Compensation Appeals Board (WCAB). The petition, seeking to rescind an order taking the case off calendar, was dismissed because it was not verified, a mandatory requirement under WCAB rules. While the applicant argued for compensability under Labor Code section 5402(b) due to an untimely denial and preclusion of a QME under section 4062.2, these merits were not reached. The WCAB adopted the WCJ's report which, if it had reached the merits, would have denied the petition.

Petition for RemovalUnverified PetitionWCJ ReportQualified Medical EvaluationsLabor Code Section 5402(b)Labor Code Section 4062.2WCAB Rule 10843(b)DismissalTimely DenialInadequate Denial
References
Case No. ADJ14941977
Regular
Mar 27, 2023

ARTHUR ORCUTT vs. OAK HILL LOGISTICS, SERVICE AMERICAN INDEMNITY CO., SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The petition was deemed untimely as it was filed 25 days after the Findings and Award, exceeding the statutory 20-day limit. The Board adopted the Administrative Law Judge's report, which found the defendant's arguments regarding the timeliness of a Utilization Review denial and a violation of Labor Code §4600.4 to be without merit. Furthermore, the Judge's finding that the requested medical treatment was reasonable and necessary was upheld, despite the defendant's contentions regarding the applicant's balance issues.

WCABPetition for ReconsiderationDeniedFindings and AwardLabor Code § 5900Labor Code § 5903Cal. Code Regs. tit. 8 § 10605EAMSuntimely petitionUR denial
References
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