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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

Matter of Terranova v. Lehr Construction Co.

In 2009, Claimant sustained a right knee injury at work, leading to workers' compensation benefits and a 10% schedule loss of use award. Concurrently, Claimant settled a third-party action for $173,500. A dispute arose concerning the carrier's credit and the apportionment of litigation expenses from the third-party settlement, specifically whether Burns v Varriale or Matter of Kelly v State Ins. Fund applied to a schedule loss of use award. The Workers’ Compensation Board ruled that Matter of Kelly controlled, denying Claimant ongoing payments for litigation expenses. The appellate court affirmed, clarifying that for schedule loss of use awards, future benefits are ascertainable, making Matter of Kelly applicable.

Schedule Loss of UseThird-Party SettlementWorkers’ Compensation BenefitsLitigation ExpensesCarrier CreditApportionment of Counsel FeesFuture BenefitsIndependent Medical ExaminationOrthopedist ReportCourt of Appeals Precedent
References
5
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. MISSING
Regular Panel Decision

Heinsohn v. Trans-Con Adjustment Bureau

Robert Heinsohn sued his former employer, Trans-Con Adjustment Bureau, alleging wrongful termination after suffering a work-related injury, claiming the company discharged him to avoid a workers' compensation claim. The trial court granted the company's motion for a directed verdict, citing no evidence of damages. Heinsohn appealed this decision. The appellate court found sufficient evidence of damages, including lost wages and medical expenses, to overcome a directed verdict. Consequently, the court reversed the trial court's judgment and remanded the case for a new trial, asserting that a jury should have been allowed to consider the evidence.

Workers' CompensationRetaliatory DischargeEmployment LawDirected VerdictDamagesLost WagesMedical ExpensesAppellate ReviewTexas LawBurden of Proof
References
6
Case No. 04-15-00021-CV
Regular Panel Decision

Board of Adjustment of the City of San Antonio v. Michael and Theresa Hayes

The County Court reversed the Board of Adjustment's action regarding Appeal No. A-14-049. This reversal means that the City of San Antonio Permit No. 1951114 to construct a guardrail remains revoked. Additionally, the Board of Adjustment's action from January 13, 2014, in Case Number A-13-0732 remains final. The court also denied the Board of Adjustment's plea to the jurisdiction and their objection to the evidence.

Zoning DisputeAdministrative AppealBuilding PermitsLocal GovernmentProperty RightsJudicial ReviewTexas LawGuardrail RegulationCode EnforcementSan Antonio
References
6
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. MISSING
Regular Panel Decision

In Re American Plumbing & Mechanical, Inc.

Gerald Riggs and Rick Jepson, former senior executives of AMPAM Riggs, an operating subsidiary of American Plumbing & Mechanical, Inc. (a Chapter 11 debtor), applied for payment of administrative expenses claims, specifically year-end bonuses based on exceeding EBITDA targets. They argued entitlement under a pre-petition incentive plan and that the payments constituted ordinary course business expenses, which a prior court order allegedly authorized. The Plan Agent and the Official Creditors' Committee objected, contending that Riggs and Jepson were ineligible as they had resigned in April 2004 before bonus payments, and that AMPAM Riggs had not actually met its 2003 EBITDA target once certain late-reported insurance claims were properly factored in. The court found that after adjusting the 2003 EBITDA for these claims, the target was not met, meaning no 15% bonus was owed. Additionally, the court ruled that even if the bonuses were earned, they did not qualify as administrative expenses under Bankruptcy Code section 503(b)(1)(A) because they were not attributable to services rendered post-petition and did not confer a discernible benefit to the estate, especially since the applicants had voluntarily resigned. The application for payment of administrative expense claims was therefore denied.

BankruptcyAdministrative ClaimIncentive Bonus PlanEBITDA AdjustmentPost-Petition ServicesChapter 11 ReorganizationFiduciary DutyCreditors' CommitteeVoluntary ResignationBenefit to Estate
References
27
Case No. ADJ165588 (SAL 0108801)
Regular
Mar 09, 2009

STEVEN G. CARR vs. COUNTY OF SANTA CRUZ, Permissibly Self-Insured, Adjusted By SEDGWICK CLAIMS MANAGEMENT SERVICES

The Board granted reconsideration and amended a prior award, clarifying which expenses are compensable for the applicant's industrial injury. The applicant, a deputy sheriff, was awarded expenses for his gym membership and associated travel, totaling $10,241.76. However, the Board disallowed most pharmaceutical expenses, only allowing those for Celebrex, Nabumetone, and Avapro, along with travel mileage for these prescriptions. The issue of medical mileage reimbursement for treatment of family members was remanded for further adjustment or adjudication.

DeputysheriffIndustrialinjuryHypertensionGymmembershipPharmaceuticalexpensesMileageexpenseMedicaltreatmentPetitionforreconsiderationWCJFindingsofFact
References
1
Case No. SA:11-CV-788
Regular Panel Decision
Dec 16, 2013

Davis v. Perry

Plaintiffs, including Wendy Davis and LULAC, filed motions for attorneys' fees, expenses, and costs after successfully challenging Texas's Senate redistricting plan (Plan S148). They argued the plan diluted minority voting strength and lacked preclearance under the Voting Rights Act. The Court initially enjoined Plan S148 and implemented an interim plan (S172), which was later adopted by the Texas Legislature. Despite the Supreme Court's *Shelby County* decision invalidating a key VRA section, the Court found plaintiffs to be 'prevailing parties' due to the significant judicially sanctioned interim relief. The Court granted the fee motions in part, adjusting the requested amounts based on the reasonableness of hours, hourly rates, and allowable expenses, while disallowing fees for unverified support staff and clerical tasks.

Attorneys' FeesRedistrictingVoting Rights ActSection 5 VRASection 2 VRAFourteenth AmendmentFifteenth AmendmentInterim ReliefPrevailing PartyLodestar Method
References
84
Case No. 3-92-291-CV
Regular Panel Decision
Mar 10, 1993

Ronald David Patton v. National Union Fire Insurance Company of Pittsburgh, Pennsylvania, Jean Auvenshine and American International Adjustment Company, Inc.

Ronald David Patton sued National Union Fire Insurance Company, Jean Auvenshine, and American International Adjustment Company, Inc., alleging violations of the duty of good faith and fair dealing related to his workers' compensation claim. Patton had injured his back in 1985, and his claim was formally denied by National Union in June 1987. The trial court granted a take-nothing summary judgment in favor of the appellees, ruling that Patton's suit was barred by the two-year statute of limitations. The Court of Appeals affirmed this judgment, holding that the cause of action accrued at the time of the denial of coverage in June 1987, and that the tort was not a continuous one, nor was the statute of limitations tolled by subsequent events or the involvement of an adjuster.

Workers' CompensationInsurance Bad FaithStatute of LimitationsSummary JudgmentDuty of Good Faith and Fair DealingTexas Court of AppealsDenial of CoverageAccrual of Cause of ActionContinuous TortInsurance Adjuster Liability
References
4
Case No. MISSING
Regular Panel Decision

Austin v. Meade

This negligence action arose from an automobile accident where the defendant conceded liability, and a jury awarded the plaintiff damages for lost earnings, future medical expenses, future loss of earnings, and pain and suffering. A dispute arose regarding the reduction of the verdict due to the prohibition against recovering basic economic loss under Insurance Law § 5104 (a). The Supreme Court initially reduced the verdict by the amount the plaintiff received from other sources for lost wages ($38,977.94). On appeal, the court clarified that the proper methodology involves calculating the plaintiff's basic economic loss (including medical expenses and a portion of lost earnings) and reducing the verdict accordingly. The appellate court modified the judgment, ruling that the verdict should be reduced by $42,967.10, representing basic economic loss for lost earnings, and affirmed the judgment as so modified, resulting in a final judgment for the plaintiff of $265,905.70.

NegligenceAutomobile AccidentDamagesLost EarningsMedical ExpensesBasic Economic LossInsurance LawVerdict ReductionCollateral Source RuleAppellate Review
References
6
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