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

Case No. ADJ7006379
Regular
Sep 04, 2014

RAMAN KUMAR vs. SEARS HOLDING CORPORATION, ACE AMERICAN INSURANCE COMPANY

Defendant Sears Holding Corporation sought to terminate liability for home healthcare services, challenging a prior WCJ order that found no good cause to do so. The original order, based on a stipulation, required reimbursement for up to 10 hours per week of home healthcare at $15/hour. The defendant's petition was denied because the prior order was deemed final and res judicata, predating SB 863's amendments to home healthcare provisions. The defendant failed to demonstrate good cause, such as a change in the applicant's medical condition, to modify or terminate the existing award. The Appeals Board adopted the WCJ's reasoning, emphasizing that the burden is on the defendant to show why the services are no longer needed, a burden not met here.

Workers' Compensation Appeals BoardReconsiderationFindings and OrdersHome Healthcare ServicesPetition to Terminate LiabilityUtilization ReviewRequest for AuthorizationFinal OrderGood CauseSB863
References
Case No. OAK 0326235
Regular
May 01, 2008

ALMA CRANDELL vs. ANTIOCH UNIFIED SCHOOL DISTRICT, Permissibly Self-Insured

The Workers' Compensation Appeals Board denied the applicant's request for more home healthcare benefits and granted the defendant's request to reconsider the award. The Board affirmed the original award for home healthcare but deferred the issue of to whom the payments should be made, remanding it to the trial level for further development of the record. This deferral is to determine if the payments are due to the applicant's family who provided the care or if they should be made through a previously appointed guardian and trustee.

ReconsiderationHome HealthcareGuardian Ad LitemTrusteeLien ClaimantsLabor Code §4903(b)Labor Code §5313Labor Code §4903.2WCJ ReportDecision After Reconsideration
References
Case No. ADJ3904484 (VNO 0451173)
Regular
Nov 20, 2008

TONY WILLIAMS vs. MODERN HEALTHCARE, INC., AD-RX DRUGSTORE, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration of a decision awarding continuing temporary disability and home healthcare benefits. The Board found that the administrative law judge failed to adequately address the applicant's subsequent non-industrial and industrial injuries, which may be responsible for the current disability. Furthermore, the medical evidence relied upon by the judge did not sufficiently link the disability to the original 2002 injury, and the record lacked sufficient detail and organization for a proper decision.

Petition to ReopenNew and Further DisabilitySubsequent InjuryIndustrial InjuryTemporary DisabilityHome HealthcareDue ProcessPre-trial Conference StatementMedical ReportsAgreed Medical Examiner
References
Case No. ADJ155904 (LAO 0811479)
Regular
Sep 21, 2018

RAFAEL CHAVEZ vs. SUPREME TRUCK BODIES, SENTRY INSURANCE

In this workers' compensation case, the applicant, Rafael Chavez, sought reconsideration of a decision denying home healthcare benefits. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, finding the parties had stipulated to an Agreed Medical Evaluator (AME) for this issue, thereby waiving formal utilization review processes. The WCAB rescinded the prior order and ruled applicant entitled to 12 hours per day of home healthcare for up to six months, pending a new evaluation by the AME.

WCABPetition for ReconsiderationHome HealthcareAgreed Medical Evaluator (AME)Labor Code section 4600(h)Petition to ReopenNew and Further DisabilityLabor Code section 5410Medical TreatmentIndustrial Injury
References
Case No. ADJ754138 (SDO 0358006)
Regular
Jul 13, 2012

IGNACIO GOMEZ vs. PREMIUM ROOF SERVICES, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board reconsidered a decision regarding an applicant injured while employed as a roofer. The applicant was awarded home healthcare services, but the initial judge found no authority to order payment to the applicant's wife. The Board granted reconsideration, finding that the applicant has the right to choose his home healthcare provider, especially given the inadequate services previously provided by the defendant's agency. Therefore, the Board amended the award to ensure the applicant receives the stipulated attendant care/housekeeping services from his wife.

Workers' Compensation Appeals BoardPremium Roof ServicesInc.State Compensation Insurance FundIgnacio GomezFindings Award and Ordersrooferindustrial injurylow backstipulated award
References
Case No. ADJ2375135 (MON 0350920) ADJ3115402 (MON 0350919)
Regular
Nov 09, 2011

ISAIAS H. AYALA vs. D & D MOVE IT TREES COMPANY, STATE COMPENSATION INSURANCE FUND

The Appeals Board rescinded the WCJ's award of home care to the applicant, ordering the case returned for further proceedings and a new decision. This action stems from disputed stipulations regarding the admissibility of a PQME report and the reliability of a secondary treating physician's recommendations. Key issues to be clarified include the exact stipulations made, the admissibility of medical reports, and the reasonableness and necessity of the proposed 24/7 home care, along with its specific parameters. The WCJ must address these foundational issues before making a new determination on home care.

Workers' Compensation Appeals BoardReconsiderationHome CarePrimary Treating PhysicianSecondary Treating PhysicianPanel Qualified Medical Evaluator (PQME)AdmissibilityStipulationMedical TreatmentPsychiatric Injury
References
Case No. ADJ10954204
Regular
Sep 15, 2022

MARIA FLORES vs. PINNACLE HEALTH CORP., SUMMARY OF EVIDENCE INSURANCE COMPANY OF THE WEST, AFFINITY HOME HEALTH CARE SERVICES, FALLS LAKE FIRE & CASUALTY INSURANCE, SEDGWICK CMS, HOME HEALTH CARE SOLUTIONS, INC.

The Workers' Compensation Appeals Board denied a petition for reconsideration filed by Home Health Care Solutions. The applicant, an LVN, was injured in a car accident while traveling between patients for multiple agencies. The Board adopted the WCJ's report, which found the injury arose out of and occurred in the course of employment for Home Health Care Solutions. This decision was based on the fact that the applicant was required to use her own vehicle, which extended the employer-employee relationship beyond direct service. The WCJ also found the going and coming rule did not bar the claim due to the required use of transportation between patient locations.

Workers' Compensation Appeals BoardPetition for ReconsiderationGoing and Coming RuleAOE/COELVNCar AccidentAutomobile ExceptionTransitEmployment RelationshipRequired Vehicle Use
References
Case No. ADJ2057251
Regular
Nov 06, 2012

Santos Acevedo vs. Del Mar Die Casting Co., State Compensation Insurance Fund

This case concerns a cumulative trauma injury resulting in a stroke for applicant Santos Acevedo. A WCJ awarded home care services and modifications, finding the applicant in need of 9 hours of non-skilled assistance daily. Both the applicant and defendant State Compensation Insurance Fund sought reconsideration of this award. The Workers' Compensation Appeals Board granted reconsideration to allow further study of the factual and legal issues, aiming for a just and reasoned decision.

Workers' Compensation Appeals BoardDel Mar Die Casting Co.State Compensation Insurance FundSantos AcevedoHome Care IssuePetition for ReconsiderationCumulative Trauma InjuryStrokeHome Health Care AssistantIndustrial Injury
References
Case No. ADJ2271789
Regular
May 07, 2019

JEFFREY MITCHELL vs. ERNEST JOHN SMITH, UNINSURED EMPLOYERS BENEFITS TRUST FUND

This case involves a workers' compensation applicant seeking reconsideration of a decision awarding him 42 hours of weekly home health care, an ultralight wheelchair, and home modifications. The Uninsured Employers Benefit Trust Fund (UEBTF) argued against liability, claiming the treating physician did not use the correct form for home health care requests and that it had timely conducted utilization review. The Appeals Board affirmed the award, finding the UEBTF had a duty to investigate the need for services upon receiving medical reports and recommendations. Furthermore, the Board held that a prior stipulation obligated the UEBTF to continue providing home health care, and their utilization review process was either untimely or improperly conducted.

UEBTFReconsiderationFindings and AwardHome Health CareHome ModificationsUltralight WheelchairUtilization ReviewStipulationPanel Qualified Medical EvaluatorPrimary Treating Physician
References
Case No. ADJ1755508 (SRO 0142328)
Regular
Dec 21, 2012

SOSTENES REYES vs. PROTRADES CONNECTIONS, AMERICAN HOME ASSURANCE, Adjusted By CHARTIS INSURANCE

The Workers' Compensation Appeals Board granted reconsideration to amend a prior award. While affirming most findings, the Board corrected a clerical error, changing the start date for applicant's home health care services to December 3, 2011. The Board upheld the finding that the defendant unreasonably delayed payment for these services, imposing a 25% penalty. The parties were ordered to adjust the payment amounts accordingly, with jurisdiction reserved for any disputes.

WCABProtrades ConnectionsAmerican Home AssuranceChartis InsuranceSosthenes Reyesindustrial injurycognitive impairmentmemory impairmentpost-traumatic stress disorderpermanent total disability
References
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