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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

Sibley-Schreiber v. Oxford Health Plans (N.Y.), Inc.

This class action involves several plaintiffs challenging Oxford Health Plans' denial of insurance coverage for Viagra. Defendants moved to dismiss the complaint, alleging that the plaintiffs failed to exhaust administrative remedies. Plaintiffs countered that pursuing these remedies would have been futile given the defendants' public 'no pay' and 'six pill' policies and the lack of clear appeal processes. The court denied the defendants' motions to dismiss and for summary judgment, concluding that the plaintiffs had made reasonable efforts to seek coverage and that further administrative appeals would have been futile.

ERISAInsurance CoverageHealthcare BenefitsViagraErectile DysfunctionExhaustion of Administrative RemediesFutility DoctrineClass ActionMotion to DismissSummary Judgment
References
16
Case No. ADJ3824814 (AGO 0012776), ADJ2299798 (VNO 0327881)
Regular
Mar 06, 2012

PHILIP DAVIS vs. ROCKWELL INTERNATIONAL, now THE BOEING COMPANY, permissibly self-insured, adjusted by SEDGWICK CMS

The Appeals Board granted reconsideration and amended the award to include "Viagra" as a stipulated injured body part, based on the parties' prior agreement. The Board affirmed the denial of reimbursement for home care services from January 5, 1995, to November 22, 2000, as this issue was not clearly withdrawn from litigation. Furthermore, the Board upheld the denial of 24/7 home health care services from July 2, 2002, onward, as medical evaluations did not support such a need for orthopedic or pulmonary conditions. Finally, the applicant was admonished for exceeding the page limit for their reconsideration petition.

Viagranuclear waste workerhome care assistancepulmonary agreed medical examinerAMECompromise and ReleasestipulationsWorkers' Compensation Appeals BoardWCJFindings of Fact
References
3
Case No. MISSING
Regular Panel Decision

Claim of Hare v. Champion International

Claimant suffered head, neck, and back injuries in 1991 while working as a millwright for Champion International. His workers' compensation case was closed in 1993, with a finding of no compensable lost time after November 1991. In 1997, claimant's pain worsened, and he sought authorization for Viagra for work-related sexual dysfunction, which Champion's carrier denied. In 1999, Champion sold its mill, and the new owner did not rehire the claimant. He then sought compensation for lost time, alleging the non-rehire was due to his disability from the 1991 accident. The Workers’ Compensation Law Judge and subsequently the Workers’ Compensation Board found his unemployment was due to economic conditions and denied a causal link for sexual dysfunction. The appellate court affirmed the Board's decision, concluding that the claimant failed to prove his inability to obtain employment was due to his accident-related disabilities, and that the Board properly resolved conflicting medical evidence.

Workers' CompensationSexual DysfunctionLost WagesEconomic ConditionsRehireDisability ClaimMedical EvidenceCausationAppellate ReviewBurden of Proof
References
5
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