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

Case No. ADJ4024660 (LAO 0887729)
Regular
Feb 03, 2017

ALFREDO COLLAZO vs. MECA NAG CORPORATION, EMPLOYERS COMPENSATION

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case to the trial level for a new decision. The WCJ erred in determining the lien claimant's entitlement to payment solely on a multiplier of Medicare rates, rather than a reasonable cost basis. The Board clarified that while the facility's charges are not subject to the Official Medical Fee Schedule, their entitlement must be based on their actual costs plus a reasonable profit. Therefore, further proceedings are required to properly assess the reasonable cost basis for the services rendered.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien ClaimantReasonable Cost BasisMedicare ReimbursementOfficial Medical Fee ScheduleLong Term Care HospitalKunz StudyTapia
References
2
Case No. ADJ8101494
Regular
Mar 14, 2017

ROBERTO ESCOBAR-IZARRARAS vs. ACCORN ENGINEERING, PACIFIC COMPENSATION INSURANCE COMPANY

The Appeals Board reconsidered a WCJ's decision disallowing the remainder of a hospital's lien. The WCJ found the lien unreasonable based on an incorrect standard, as the hospital's services were not subject to the Official Medical Fee Schedule and were to be paid on a "reasonable cost basis." The Appeals Board rescinded the prior decision, returning the case to the trial level for further proceedings and a new decision. This decision clarifies that the lien claimant bears the burden of proving the reasonableness of its charges on a cost basis, not just its usual fees.

WCABReconsiderationLien ClaimantMonrovia Memorial HospitalKunz studyReasonable Cost BasisOMFSLabor Code § 4600Burden of ProofPreponderance of the Evidence
References
2
Case No. MISSING
Regular Panel Decision

Claim of Maiorano v. Plumbing

Claimant applied for workers' compensation benefits after being injured as a plumber in New York City. Despite residing in Brooklyn, the claimant sought to have hearings in White Plains, Westchester County, for convenience. A Workers’ Compensation Law Judge denied this request, and the Workers’ Compensation Board affirmed, additionally assessing $500 in costs against the claimant’s counsel under Workers’ Compensation Law § 114-a (3) (ii). The appellate court affirmed the Board's decision, stating that the Board Chair has authority over hearing locations and the claimant failed to provide a reasonable basis for the change of venue. The court also upheld the penalty assessment, finding substantial evidence for the Board's determination that the request lacked a reasonable basis.

Workers' Compensation LawVenue ChangeAppellate ReviewProcedural DenialCost AssessmentJudicial AuthorityAdministrative DiscretionClaimant RightsBoard DecisionAffirmation
References
3
Case No. ADJ3172767
Regular
May 10, 2017

VICTOR GONZALEZ vs. CITISTAFF SOLUTIONS, STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed the WCJ's decision finding the lien claimant, Monrovia Memorial Hospital, was entitled to nothing for its services. The WCJ properly excluded the lien claimant's expert declaration as it was submitted after discovery closed. The lien claimant failed to meet its burden of proving its charges were reasonable and based on a reasonable cost basis, as required by precedent in cases exempt from the Official Medical Fee Schedule. Mere presentation of usual and customary charges, without evidence of reasonableness or comparability, is insufficient.

Workers' Compensation Appeals BoardVictor GonzalezCitistaff SolutionsState Compensation Insurance FundMonrovia Memorial Hospitallien claimantbill review expertdue processreasonableness of chargesOMFS exemption
References
2
Case No. ADJ 7511877, ADJ 7396932
Regular
May 03, 2017

MARIA MORALES vs. MONTEBELLO UNIFIED SCHOOL DISTRICT, YORK RISK SERVICES GROUP, INC.

The Appeals Board affirmed the WCJ's decision disallowing further payment on Monrovia Memorial Hospital's lien. The court found that Monrovia failed to provide sufficient evidence to establish that its requested charges were reasonable and consistent with a "reasonable cost basis" as required for long-term care hospitals exempt from the Official Medical Fee Schedule. Lien claimants bear the affirmative burden of proving the reasonableness of their liens by a preponderance of the evidence. The Board also noted that discovery was properly closed at the lien conference, precluding Monrovia's delayed introduction of evidence.

Workers' Compensation Appeals BoardJoint Findings and OrderIndustrial InjuryCervical SpineLumbar SpineRight HipBilateral KneesPsycheLien ClaimantMonrovia Memorial Hospital
References
2
Case No. ADJ10428582
Regular
Jul 19, 2019

MICHAEL GELI vs. CENTER FOR BEHAVIORAL SCIENCES, THE HARTFORD

This case involves a lien claimant, Monrovia Hospital, seeking reconsideration after a Workers' Compensation Appeals Board decision denying their claim for additional payment. The claimant argued a lack of due process due to an unavailable expert witness and that their services were exempt from the Official Medical Fee Schedule (OMFS). The Board denied reconsideration, finding the claimant failed to subpoena their expert and did not provide adequate evidence to demonstrate their charges were reasonable and customary under the "reasonable cost basis" standard for non-OMFS services. Ultimately, the WCJ's finding that the defendant reasonably paid the amount awarded was upheld.

Lien claimantPetition for reconsiderationDue processExpert witnessReschedulingSubpoenaCross-examinationOfficial Medical Fee Schedule (OMFS)Reasonable cost basisLong term care hospital
References
5
Case No. ADJ10160197 ADJ8200777
Regular
Sep 03, 2019

JOSE CARDENAS vs. COSTA VIEW FARMS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Monrovia Hospital's petition for reconsideration, upholding the original decision that the hospital was entitled to nothing further on its lien. The Board found that the hospital failed to meet its burden of proving its charges were based on a "reasonable cost basis" as required for long-term care facilities exempt from the Official Medical Fee Schedule. Expert testimony presented by both parties, particularly regarding cost-to-charge ratios derived from OSHPD data, supported the finding that the hospital's proposed methodologies did not adequately demonstrate reasonable costs. The Board affirmed that the hospital, not the defendant, bears the affirmative burden of proving the reasonableness of its lien.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings and OrderMonrovia HospitalCosta View FarmsZenith Insurance CompanyWCJLabor Code section 5906reasonable cost basis
References
2
Case No. ADJ1521645 (RIV 082425)
Regular
Jan 22, 2015

SILVESTRE LOPEZ TRUJILLO vs. TORRES FARM LABOR CONTRACTOR, REDWOOD FIRE AND CASUALTY INSURANCE, BERKSHIRE HATHAWAY HOME STATE COMPANIES

The Workers' Compensation Appeals Board (WCAB) reconsidered a decision regarding lien claimant Monrovia Memorial Hospital's claim for additional payment for services rendered to applicant Silvestre Lopez Trujillo. Although Monrovia Memorial Hospital is a long-term acute care hospital exempt from standard fee schedules and entitled to reasonable cost basis payment, it failed to prove its billed amount was reasonable. The WCAB found the hospital's claimed charges of $149,382.54 were grossly disproportionate to the $34,611.32 estimate for comparable services at another facility. Therefore, the WCAB rescinded the original findings and substituted new ones, finding the hospital was reasonably compensated and not entitled to further payment.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationIndustrial InjuryLumbar SpineLong-Term Acute Care HospitalFee Schedule ExemptionReasonable Cost BasisBurden of ProofMedical Bill Coding
References
2
Case No. 535808
Regular Panel Decision
Sep 21, 2023

In the Matter of the Claim of Romero Balbuena

The Workers' Compensation Board (Board) assessed a $1,000 penalty against counsel for the State Insurance Fund (SIF) for continuing proceedings without reasonable grounds, specifically for improper service of a Board review application on claimant Romero Balbuena. SIF's counsel appealed this penalty. The Appellate Division, Third Judicial Department, reviewed whether substantial evidence supported the Board's finding that SIF's counsel lacked a reasonable basis for attempting service at a Brooklyn address instead of the Bronx address listed in the Board's file. The Court found that SIF's counsel had a reasonable argument, as the Brooklyn address was in the Board's file on the application date and in claimant's medical records. Consequently, the Court modified the Board's decision by reversing the penalty assessed against SIF's counsel, while affirming the decision as so modified.

Workers' Compensation LawAttorney PenaltyImproper ServiceBoard ReviewReconsiderationSubstantial EvidenceAppellate ReviewState Insurance FundCounsel FeesAdministrative Procedures
References
6
Case No. 2007 NY Slip Op 30531(U)
Regular Panel Decision
Apr 05, 2007

Schirmer v. Athena-Liberty Lofts, LP

This case is an appeal from an Order of the Supreme Court, New York County, regarding a personal injury action. The plaintiff, a worker at a construction site, sustained injuries, leading to the site owner, Lofts, settling the claim after being found liable under Labor Law § 240 (1). Lofts then pursued indemnity claims against lighting contractor HP and the plaintiff's employer, Burgess. The Appellate Court modified the lower court's decision, vacating the finding that Lofts' settlement amount was reasonable due to Lofts' failure to properly demonstrate reasonableness and its mischaracterization of waiver arguments by HP and Burgess. The Court also affirmed the denial of HP's motion for summary judgment, citing unresolved factual issues concerning inadequate lighting as a cause of the accident.

Personal InjuryConstruction Site AccidentSummary JudgmentIndemnity ClaimLabor Law § 240(1)Appellate DivisionThird-Party ActionSettlement ReasonablenessCross ClaimsInadequate Lighting
References
4
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