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Case Law Database

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

Case No. ADJ1702197
Regular
Oct 01, 2012

LUIS CARDOZO vs. KOOS FASHION dba CDK FASHION, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied a lien claimant's petitions for reconsideration, removal, and disqualification of the administrative law judge. The claimant, Beverly Hills Center for Arthroscopic and Outpatient Surgery, argued the judge improperly approved a global settlement for $375,000, claiming duress, lack of due process, and inadequate compensation. The Board found the WCJ's reports adequately addressed these contentions and upheld the settlement approval.

Lien ClaimantReconsiderationRemovalDisqualificationWCJGlobal SettlementDuressDue ProcessAdequate CompensationBias
References
0
Case No. LAO 0857845
Regular
Oct 12, 2007

NATIVIDAD URIAS vs. VISHAY TRANSDUCERS, LIBERTY MUTUAL INSURANCE COMPANY

This case involves a workers' compensation applicant seeking further medical treatment for admitted industrial injuries to her right shoulder and bilateral upper extremities. The Workers' Compensation Appeals Board granted reconsideration to clarify the scope of awarded medical treatment. The Board affirmed the need for a right carpal tunnel release surgery as recommended by the applicant's physician but reversed the award of arthroscopic shoulder surgery, finding it premature without a specific recommendation or request for authorization.

Workers' Compensation Appeals BoardReconsiderationFindings and AwardExpedited HearingFurther Medical TreatmentArthroscopic Shoulder SurgeryCarpal Tunnel ReleasePrimary Treating PhysicianQualified Medical EvaluatorUtilization Review
References
0
Case No. ADJ306310
Regular
Mar 23, 2009

MATTHEW T. MORAN vs. ABHE & SVOBODA, INC., ZURICH NORTH AMERICA, BRANDVOLD & ASSOCIATES

The Appeals Board granted reconsideration and rescinded the WCJ's March 23, 2009 decision, which awarded further medical treatment including arthroscopic surgery. The Board found the medical record, particularly regarding the conflict between the treating physician's and QME's opinions on the need for surgery and the causation of the left shoulder tear, was not adequately developed. The matter was returned for further proceedings, specifically to obtain an Agreed Medical Evaluator or have the WCJ appoint an expert to resolve the conflicting medical opinions.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardAdministrative Law JudgeQualified Medical EvaluatorIndustrial InjuryLeft ShoulderArthroscopic SurgeryMR ArthrogramRotator Cuff Tear
References
17
Case No. ADJ8171086
Regular
Oct 07, 2015

Patricia Smith vs. Scholle Packaging, Liberty Mutual Insurance Company

This case concerns Patricia Smith's petition for removal of a WCJ order denying her requested arthroscopic knee surgery. The WCJ found the defendant's utilization review (UR) denial of the surgery request was timely, divesting the WCJ of jurisdiction. The Appeals Board denied the petition for removal, finding the UR determination was timely under Labor Code section 4610(g)(1) and applicable regulations. Therefore, Smith's sole remedy is to pursue an Independent Medical Review (IMR) of the UR decision.

Workers' Compensation Appeals BoardPetition for RemovalUtilization Review (UR)Primary Treating Physician (PTP)Request for Authorization (RFA)Arthroscopic SurgeryIndustrial Knee InjuryExpedited HearingJurisdictionLabor Code Section 4610
References
1
Case No. ADJ6909317
Regular
Feb 24, 2015

ANA ZELAYA vs. SUSAN CALDWELL dba WALNUT ACRES RESIDENTIAL CARE, ENDURANCE INSURANCE COMPANY

The Workers' Compensation Appeals Board imposed $\$ 250$ sanctions each on lien claimants Hekmat Orthopaedics and Beverly Hills Center for Arthroscopic and Outpatient Surgery, jointly and severally with their hearing representative, Zoila Webster. This decision stemmed from their frivolous Petitions for Reconsideration, which caused unnecessary delay. While the Board declined to award attorney fees requested by the defendant, both lien claimants and Webster are warned that fees may be imposed for future similar conduct. Payment of sanctions is due within twenty days to the Workers' Compensation Appeals Board.

Workers' Compensation Appeals BoardRemovalSanctionsLien claimantsFrivolous petitionsHearing representativeJointly and severallyOpinion and DecisionNotice of IntentPetition for Costs
References
0
Case No. ADJ7471902
Regular
Sep 15, 2017

Steven Seloever vs. Samuel J. Piazza and Sons Trucking, Oak River Insurance, Administered By Berkshire Hathaway Homestate Companies

This Workers' Compensation Appeals Board case denied a lien claim for medical services provided by Beverly Hills Center for Arthroscopic and Outpatient Surgery. The lien was filed on December 31, 2012, over five years after the date of injury (November 16, 2007), exceeding the statutory deadline under Labor Code section 4903.5(a). The Board found the claimant's argument for tolling due to lack of notification regarding a Compromise and Release was invalid, as the lien was not filed at the time of the notification. Therefore, the lien was properly disallowed as time-barred.

Labor Code section 4903.5(a)time-barredlien claimdate of injuryOrder Approving Compromise and Releasestatutory deadlinetollingperfected lienreimbursementevidentiary burden
References
0
Case No. ADJ1313860
Regular
Mar 07, 2017

Kevin Voelker vs. D. Frey Plastering Co., State Compensation Insurance Fund

This case involves a workers' compensation applicant challenging an Independent Medical Review (IMR) determination that denied authorization for shoulder surgery. The applicant argued the IMR incorrectly applied guidelines for acromioplasty/impingement syndrome instead of guidelines for a rotator cuff tear, which was the actual condition for which surgery was requested. The Appeals Board granted reconsideration, finding the IMR's determination was based on a plainly erroneous mistake of fact readily apparent from the submitted records, not requiring expert opinion. Consequently, the Board rescinded the IMR determination and remanded the matter for a new IMR process.

Workers' Compensation Appeals BoardIndependent Medical ReviewPetition for ReconsiderationFindings and OrderPlainly Erroneous Finding of FactMedical Treatment Utilization ScheduleRequest for AuthorizationRotator Cuff TearAcromioplastyImpingement Syndrome
References
3
Case No. MISSING
Regular Panel Decision

Abreu-Mercedes v. Chater

Plaintiff Benigno Abreu-Mercedes sought judicial review of a final decision by the Commissioner of Social Security, which denied his claims for Disability Insurance Benefits and Supplemental Security Income. After an Administrative Law Judge's decision in February 1994, which was upheld by the Appeals Council in July 1994, the plaintiff appealed. The District Court reviewed whether the Commissioner's findings were supported by substantial evidence and whether newly submitted medical records constituted a basis for reversal or remand. The court found substantial evidence supported the denial of benefits and ruled the new medical evidence, including an arthroscopic surgery in June 1994, was not material to the relevant period under review. Consequently, the defendant's motion for judgment on the pleadings was granted.

Disability Insurance BenefitsSupplemental Security IncomeSocial Security ActAdministrative Law JudgeSubstantial Evidence ReviewResidual Functional CapacityMedical ImpairmentPleadings MotionNew EvidenceMateriality
References
13
Case No. MISSING
Regular Panel Decision

Suarez v. Abe

Plaintiff, with a history of right knee injuries and surgeries since age 15, sustained another injury in a workplace mishap in March 1993, leading to disability payments. After a subsequent diagnosis of a new lateral meniscus tear in April 1998, his treating physician requested authorization for arthroscopic surgery. Eleven days after the Workers' Compensation Board directed the carrier to authorize the surgery, plaintiff was involved in a motor vehicle accident, claiming it caused a 'serious injury' to his already compromised knee. The Supreme Court initially denied the defendants' motion for summary judgment, but the appellate court reversed, finding the plaintiff failed to provide objective medical evidence that the motor vehicle accident aggravated his preexisting knee condition to the statutory 'serious injury' threshold.

Summary JudgmentSerious Injury ThresholdPreexisting InjuryAggravation of InjuryMotor Vehicle AccidentObjective Medical ProofNo-Fault InsuranceAppellate ProcedureKnee PathologyMedical Affidavit
References
9
Case No. 2019 NY Slip Op 03692
Regular Panel Decision
May 09, 2019

Matter of Global Liberty Ins. Co. v. McMahon

Global Liberty Insurance Co. appealed an order denying its petition to vacate an arbitration award in favor of Mark S. McMahon, M.D. The dispute stemmed from a no-fault claim where Global partially paid for arthroscopic surgery, relying on the CPT Assistant newsletter for its valuation. The lower arbitrator and master arbitrator refused to consider CPT Assistant, leading to an award for McMahon. The Appellate Division determined that the Official New York Workers' Compensation Medical Fee Schedule, applicable to no-fault claims, incorporates the CPT book which references CPT Assistant. Consequently, the court found the arbitration award legally incorrect due to the exclusion of CPT Assistant. The court reversed the Supreme Court's order, granted Global's petition, vacated the award, and remanded the matter for a new arbitration.

No-Fault LawInsurance LawArbitration AwardVacate AwardMedical Fee ScheduleCPT AssistantWorkers' Compensation BoardAppellate ReviewStatutory InterpretationRemand
References
2
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