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

Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
Case No. ADJ3560082 (ANA 0380953)
Regular
Mar 12, 2009

MARGARITA SERRANO vs. 3 DAY BLINDS, STATE COMPENSATION INSURANCE FUND

This case involves a lien claim by Huntington Beach Hospital for medical services rendered to an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration to reverse a prior finding, determining that contractual agreements between the hospital, Blue Cross, and the defendant insurer (SCIF) constitute an "express agreement" under Labor Code section 5304. This express agreement, which includes binding arbitration provisions, divests the WCAB of jurisdiction over the lien dispute. Therefore, the WCAB rescinded its prior award and ordered the parties to arbitrate the dispute according to the terms of their contract.

Workers' Compensation Appeals BoardState Compensation Insurance FundHuntington Beach HospitalComprehensive Contracting Hospital AgreementWorkers' Compensation Managed Care Service AgreementOther PayorLabor Code Section 5304Labor Code Section 4609Express AgreementBinding Arbitration
References
Case No. ADJ2200226
Regular
Apr 08, 2014

RUDY GALLARDO vs. SOUTHERN CALIFORNIA EDISON

The WCAB reversed a prior decision, finding it lacked jurisdiction over a hospital's lien claim for unpaid services. The Appeals Board held that an "express agreement," as required by Labor Code Section 5304 to divest the WCAB of jurisdiction, existed through a chain of contracts between the hospital, a network administrator (Blue Cross), and the self-insured employer. This chain of agreements fixed the payment amounts, thus precluding the WCAB from adjudicating the fee dispute. Any claims of contract breach or non-compliance with other statutes like Section 4609 must be pursued in a different forum.

WCAB jurisdictionLabor Code Section 5304express agreementchain of contractsHuntington HospitalSouthern California EdisonBlue Cross of CaliforniaOfficial Medical Fee Schedulelien claimfee dispute
References
Case No. ADJ253443 (POM 0286361)
Regular
Jan 17, 2014

JUAN MANUEL RESENDIZ vs. DANNY'S TRIMMING & BINDING CORP., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration, rescinding the WCJ's finding that it lacked jurisdiction over a lien dispute between Good Samaritan Hospital and State Fund. The Board found the contracts between State Fund, Blue Cross, and Good Samaritan potentially created an "express agreement" under Labor Code Section 5304, divesting the Board of jurisdiction. However, the Board also noted Good Samaritan failed to meet its initial burden of proof regarding the necessity of its services and that State Fund may not have provided proper notice of its payor status under the contract. The case is returned to the trial level for further evidence development on these issues.

Workers' Compensation Appeals Boardlien claimantPetition for ReconsiderationFindings of FactjurisdictionState Compensation Insurance FundOfficial Medical Fee ScheduleLabor Codeexpress agreementarbitration
References
Case No. ADJ6711454
Regular
May 23, 2016

EDWARD GUTIERREZ vs. CITY OF SANTA ANA

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision denying jurisdiction over a lien dispute between Western Medical Center and the City of Santa Ana. The WCAB found that an interlocking chain of contracts between the medical provider and the employer/insurer, referencing Labor Code Section 5304, created an "express agreement" fixing medical treatment rates. This agreement divested the WCAB of jurisdiction, and Labor Code Section 5307.11 did not grant jurisdiction when it was otherwise excluded by Section 5304.

Workers' Compensation Appeals BoardLien DisputeJurisdictionLabor Code Section 5304Labor Code Section 4609Labor Code Section 5307.11Express AgreementContracted RateMedical TreatmentParticipating Hospital Agreement
References
Case No. ADJ4449218
Regular
Mar 04, 2010

LUIS ALVARADO vs. STAFFING SERVICES, INC., STATE COMPENSATION INSURANCE FUND

Here is a summary of the case in a maximum of four sentences for a lawyer: The Workers' Compensation Appeals Board denied reconsideration of the Administrative Law Judge's (ALJ) decision, which found jurisdiction over a dispute between an injured worker's applicant and defendant Staffing Services, Inc. The ALJ correctly determined that there was no express agreement between Staffing Services and the lien claimant, Beverly Hills Pharmacy, fixing payment amounts, thus Labor Code section 5304 did not divest the Board of jurisdiction. The Board also found that removal was not appropriate for this final determination. Procedural arguments regarding a denied continuance due to the defense attorney's illness were also rejected.

Workers' Compensation Appeals BoardReconsiderationRemovalLien ClaimantExpress AgreementLabor Code Section 5304JurisdictionStaffing Services Inc.State Compensation Insurance FundBeverly Hills Pharmacy
References
Case No. ADJ2200226
Regular
Jun 18, 2014

RUDY GALLARDO vs. SOUTHERN CALIFORNIA EDISON

The Workers' Compensation Appeals Board (WCAB) denied Huntington Hospital's petition for reconsideration. The WCAB affirmed its prior decision that it lacked jurisdiction over Huntington's lien claim against Southern California Edison. This denial was based on Labor Code section 5304, which precludes WCAB jurisdiction when an express agreement fixes payment amounts, as was the case with the hospital's services. Therefore, Huntington must pursue its breach of contract claims in a different forum.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationLabor Code Section 5304Express AgreementJurisdictionBreach of ContractOfficial Medical Fee ScheduleFindings of FactAdministrative Law Judge
References
Case No. ADJ745778 (SRO 0132381)
Regular
Mar 13, 2009

CYNTHIA GORDON vs. CALISTOGA SPA, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted the defendant's petition for reconsideration, reversing a prior decision. The WCAB found that it lacks jurisdiction over medical treatment payment disputes when an express agreement exists between the parties, as stipulated by Labor Code section 5304. In this case, a chain of contracts, including one between the hospital and Blue Cross Life and Health, and another between Blue Cross and the defendant insurer, created an express agreement. This contractual arrangement precluded the WCAB from determining the payment due to the medical provider.

WCAB jurisdictionLabor Code section 5304medical treatment disputeexpress agreementarbitration clauseequitable estoppellacheschain of contractsmedical provider contractinsurer contract
References
Case No. ADJ9376664
Regular
Apr 30, 2018

Sergio Huizar vs. Palm Springs Volkswagen, Employers Compensation Insurance Company

The Workers' Compensation Appeals Board (WCAB) denied a lien claimant's petition for reconsideration, upholding the administrative law judge's finding that the WCAB lacks jurisdiction over the dispute. The dispute concerned the reasonable value of medical services provided by the lien claimant to the applicant. The WCAB determined that an express agreement existed between the lien claimant and the defendant, as established by a series of contracts linking them through Blue Cross. This express agreement, which stipulated payment at 91% of the Official Medical Fee Schedule, divested the WCAB of jurisdiction under Labor Code section 5304.

WCABLien ClaimantPetition for ReconsiderationJurisdictionLabor Code Section 5304Medical ServicesReasonable ValueExpress AgreementOfficial Medical Fee Schedule (OMFS)Participating Physician Contract
References
Case No. ADJ6912133
Regular
Sep 25, 2015

RAMON RUIZ vs. NIKCON, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) denied a lien claimant's Petition for Reconsideration. The WCAB found that an express agreement existed fixing medical payment amounts, thereby divesting the Board of jurisdiction under Labor Code section 5304. This agreement, established through a chain of contracts, mandated arbitration for payment disputes. The WCAB adopted the judge's reasoning and found no basis for WCAB jurisdiction over the lien claimant's dispute.

WCABLabor Code Section 5304lien claimantpetition for reconsiderationexpress agreementmedical paymentsjurisdictionarbitrationchain of contractsWaters v. Los Angeles Clippers
References
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