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Case Law Database

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

Case No. ADJ3842696 (SAL 0105756) ADJ4430006 (SAL 0111994)
Regular
Apr 23, 2010

JOSE VILLA vs. CHALONE WINE GROUP, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, ZENITH INSURANCE

The Workers' Compensation Appeals Board granted reconsideration to allow the California Insurance Guarantee Association (CIGA) reimbursement for its bill review expenses. The Board found that bill review costs are an essential and necessary part of adjusting medical claims, akin to "incurred losses" as defined by the Uniform Statistical Reporting Plan. This decision amends a prior ruling that excluded such expenses, recognizing their role in controlling medical overpayments. The parties are now to adjust the specific amount of reimbursement for these expenses.

CIGACalifornia Insurance Guarantee Associationbill review expensesincurred lossesloss adjustment expensemedical cost containmentuniform statistical reporting planinsolvency insurancecovered claimsLabor Code
References
4
Case No. ADJ1643143 (SRO 0122410)
Regular
May 25, 2010

JUAN ESCUTIA vs. NICK LERAS WATER TRUCKS, et al.

The Workers' Compensation Appeals Board affirmed a prior decision holding the State Compensation Insurance Fund (SCIF) liable for reimbursement to the California Insurance Guarantee Association (CIGA). CIGA, adjusting claims for an insolvent insurer, sought reimbursement for various administrative expenses, including bill review, court reporter fees, and opposing counsel fees incurred while administering an injured worker's claim. The Board found these costs, particularly bill review expenses, were part of "incurred losses" under the California Workers' Compensation Uniform Statistical Reporting Plan and thus reimbursable. This decision establishes that CIGA can recover such administrative costs from a solvent insurer when adjusting claims for an insolvent carrier.

CIGASCIFBill ReviewIncurred LossesLoss Adjustment ExpensesInsurance Code Section 1063.1(c)(9)Labor Code Section 5500.5(e)California Workers' Compensation Uniform Statistical Reporting PlanReconsiderationFindings and Orders
References
7
Case No. ADJ128210 (SAL 0093437) ADJ593542 (SAL 0093436)
Regular
Apr 12, 2010

JORGE RAMIREZ vs. LINO FINATTI, JR., CIGA on behalf of RELIANCE INSURANCE COMPANY, in liquidation, administered by INTERCARE SERVICES, CLARENDON INSURANCE COMPANY, adjusted by NORTH AMERICAN RISK SERVICES

This case involves a dispute over reimbursement for workers' compensation expenses between the California Insurance Guarantee Association (CIGA) and Clarendon Insurance Company. CIGA, covering for Reliance Insurance Company in liquidation, sought reimbursement for administrative expenses in addition to indemnity and medical costs. The arbitrator initially denied administrative expenses due to insufficient justification, but the Appeals Board granted reconsideration. The Board applied the *Ramos* decision, allowing CIGA to recover administrative costs like bill review and utilization review from Clarendon for the applicant's low back injuries.

CIGAReliance Insurance CompanyClarendon Insurance Companyadministrative expensesreimbursementbill reviewmedical managementutilization reviewsubpoenaing recordsjoint and several liability
References
2
Case No. ADJ7038469
Regular
Sep 17, 2014

AZIZA SAYED vs. GIORGIO ARMANI, FEDERAL INSURANCE COMPANY

The defendant's petition to appeal an Administrative Director's Independent Bill Review (IBR) determination was dismissed. The Board found the petition premature as it was not first heard by a trial level Workers' Compensation Judge (WCJ). Additionally, the petition failed to comply with numerous procedural requirements, including proper captioning, verification, service, and stating specific grounds for appeal. Consequently, both the petition for reconsideration and the petition appealing the IBR determination were dismissed.

Workers' Compensation Appeals BoardIndependent Bill ReviewPetition for ReconsiderationAdministrative DirectorLabor Code section 4603.6MAXIMUS Federal ServicesInc.Lien claimantOfficial Medical Fee ScheduleWCAB Rules of Practice and Procedure
References
0
Case No. MISSING
Regular Panel Decision

Haddad v. City of Albany

The petitioner appealed a Supreme Court judgment that dismissed their application, which combined a CPLR article 78 proceeding and an action for declaratory judgment. The application challenged the respondent's denial of a request to rescind waste removal violation bills issued by the Department of General Services (DGS) of the City of Albany. The Supreme Court had found that the petitioner failed to exhaust administrative remedies and that claims regarding preemption of local waste ordinances by state penal law were without merit. During the pendency of the appeal, the Board of Zoning Appeals (BZA) administratively reviewed the violations, reversing some charges and upholding others. The appellate court affirmed the Supreme Court's judgment, concluding that a violation of the City of Albany's waste code was not a criminal violation under Penal Law § 55.10, and that the petitioner was indeed required to exhaust administrative remedies for their constitutional claims, as these claims implicated specific aspects of the administrative proceeding rather than the administrative scheme itself.

WasteManagementAdministrativeLawMunicipalCodePenalLawExhaustionOfRemediesDeclaratoryJudgmentAppellateReviewEnvironmentalViolationsPublicHealthPropertyMaintenance
References
10
Case No. ADJ9417187
Regular
Jun 05, 2018

CARLOS CAMMON vs. COUNTY OF ORANGE permissibly selfinsured, administered by YORK RISK SERVICES GROUP, INC.

This case involves lien claimants Western Medical Center and Cedars Sinai seeking reconsideration of a decision regarding their unpaid medical bills. The administrative law judge had ruled the bills were subject to independent bill review and deemed satisfied due to a failure to request second bill review. The Appeals Board rescinded the original decision, finding that the threshold issue of whether the defendant was a beneficiary of a PPO contract needed to be determined first. Furthermore, the timeliness of Cedars Sinai's second bill review request remains unresolved, necessitating further proceedings to develop the record on this issue.

Workers' Compensation Appeals BoardLien ClaimantsIndependent Bill Review (IBR)Second Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.3PPO ContractExplanation of Review (EOR)Guardian Ad LitemStipulations with Request for Award
References
0
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
0
Case No. 2017 NY Slip Op 04330 [151 AD3d 1127]
Regular Panel Decision
Jun 01, 2017

Matter of Turner v. Graphic Paper Inc.

Claimant, a truck driver, sustained multiple work-related injuries between 2009 and 2012. A Workers' Compensation Law Judge (WCLJ) classified him with a permanent partial disability and found a 66.7% loss of wage-earning capacity. Claimant sought reimbursement for medical and transportation expenses and challenged decisions regarding disputed medical bills. The Workers' Compensation Board denied his applications for review, finding that he failed to specify issues or grounds for review and that some issues were untimely raised. The Appellate Division affirmed the Board's decisions, concurring that the claimant's applications for review were deficient and that certain appeals were abandoned due to lack of arguments in the brief.

Workers' CompensationPermanent Partial DisabilityWage-Earning CapacityAdministrative ReviewAppellate ProcedureApplication for ReviewTimelinessMedical ExpensesTravel ExpensesCounsel Fees
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. ADJ7868976
Regular
May 02, 2018

JAMES BARRIOS vs. BUENA VISTA FOOD PRODUCTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board granted reconsideration of a judge's order requiring defendants to pay the balance of a lien claimant's bill. The primary dispute concerns the reasonable value of medical services under the Official Medical Fee Schedule (OMFS). Neither the lien claimant's testimony nor the defendant's bill review expert provided substantial evidence to establish the OMFS amount due. Therefore, the case is remanded for further proceedings to develop the record, potentially through an agreed bill reviewer or an appointed independent reviewer.

Petition for ReconsiderationFindings and OrderCompromise and Releaselien claimantDr. Paynebill reviewofficial medical fee scheduleOMFSsubstantial evidenceindependent bill review
References
1
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