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Case Law Database

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 The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr.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. ADJ3133261 (VNO 0400017)
Regular
Aug 17, 2010

FELIPE TOLENTINO vs. CONCO CEMENT, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, XCHANGING INC., FREMONT COMPENSATION

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's petition for reconsideration as premature. The WCAB granted the defendant's petition for reconsideration regarding the temporary disability overpayment issue, deferring it for further proceedings. The Board affirmed the WCJ's findings on injury causation and permanent disability but amended the decision to clarify the overpayment issue. Finally, the WCAB issued a notice of intention to sanction defendant's counsel for attaching and citing unadmitted evidence.

Workers' Compensation Appeals BoardFELIPE TOLENTINOCONCO CEMENTCALIFORNIA INSURANCE GUARANTEE ASSOCIATIONXCHANGING INC.FREMONT COMPENSATIONliquidationADJ3133261VNO 0400017OPINION AND ORDERS DISMISSING PETITION FOR RECONSIDERATION AND GRANTING PETITION FOR RECONSIDERATION
References
Case No. ADJ3905674 (SRO 0031254)
Regular
Feb 02, 2011

DAVID PELLETIER vs. UNITED STRUCTURES, INC., CIGA by its Servicing Facility CAMBRIDGE on behalf of FREMONT COMPENSATION, in liquidation

The Workers' Compensation Appeals Board denied reconsideration of its decision regarding attorney's fees. The applicant's attorney sought fees under Labor Code sections 4607 and 5814.5, arguing the defendant unreasonably failed to appoint a new case manager and pay prior bills. The Board affirmed the judge's finding that Labor Code § 4607 fees are inapplicable when the entire award is not terminated, and Labor Code § 5814.5 fees require an existing award and unreasonable refusal to pay. The Board found no evidence of unreasonable delay by the defendant in appointing a new case manager, thus denying the petition.

Workers' Compensation Appeals BoardReconsiderationAttorney's FeesLabor Code Section 4607Labor Code Section 5814.5Medical TreatmentCompromise and ReleasePetition for PenaltyNurse Case ManagerStipulations
References
Case No. ADJ8546489
Regular
Oct 13, 2016

THEMAS PRUETT vs. ASCO INC., STATE COMPENSATION INSURANCE FUND

The applicant seeks reconsideration of a decision denying further nurse case manager services. The WCAB granted reconsideration, holding that an employer cannot unilaterally terminate long-term, voluntarily provided nurse case manager services without medical evidence of changed circumstances. The Board found the applicant's treating physician recommended continued services, and the defendant bears the burden to prove services are no longer medically necessary. Therefore, the defendant must reinstate nurse case manager services until such medical evidence is presented.

Nurse Case ManagerUnilateral TerminationMedical NecessityBurden of ProofVoluntary ProvisionSubstantial Medical EvidencePetition for ReconsiderationLabor Code Section 4600Industrial InjuryFindings and Order
References
Case No. ADJ3180407 (LAO 0785803)
Regular
Nov 10, 2008

Carl Brewer vs. CAPITAL REPROGRAPHICS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for VILLANOVA INSURANCE, In Liquidation

This case concerns CIGA's petition for reconsideration of a WCJ's award of penalties for various payment failures, including attorney fees, home health care, and a case management nurse. CIGA argues these penalties are not "covered claims" under its statutory exemption. The Appeals Board granted reconsideration, rescinded the prior order, and returned the case to the trial level due to a missing case file.

CIGAVillanova InsurancePenaltiesAttorneys FeesHome Health CareGuardian Ad LitemCase Management NurseInsurance Code Section 1063.1(c)(8)Covered ClaimsReconsideration
References
Case No. ADJ2270309 (VNO 0113668) ADJ4503834 (VNO 0113665) ADJ3103605 (VNO 0113666) ADJ2309113 (VNO 0113667)
Regular
Nov 10, 2010

MARIA GARCIA vs. CITY OF LOS ABNGELES, Permissibly Self-Insured

The Workers' Compensation Appeals Board granted reconsideration of a previous award, finding merit in the applicant's contentions regarding denied medical treatments. The Board intends to admit a nurse case manager's report that was previously excluded. This reconsideration aims to further review the factual and legal issues to ensure a just decision regarding the applicant's extensive care needs stemming from long-term quadriplegia. The Board is specifically addressing disputes over various requested services, including nursing care, home modifications, and specific medical treatments.

Workers' Compensation Appeals BoardSupplemental Findings and AwardHomecareNursing ServicesBedsore TreatmentHousekeeping ServicesHospital BedQuadriplegiaInternal InjuryLabor Code §5803
References
Case No. ADJ3905924 (ANA 0339374)
Regular
Jul 24, 2014

JENNIFER PATTERSON vs. THE OAKS FARM, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for CALIFORNIA COMPENSATION INSURANCE COMPANY, in liquidation

This case concerns the unilateral termination of nurse case manager services by an employer, which the Workers' Compensation Appeals Board affirmed as a form of medical treatment. The Board held that employers cannot unilaterally cease approved nurse case manager services without substantial medical evidence showing they are no longer necessary. Additionally, the Board clarified that an injured worker does not need to obtain a Request for Authorization to challenge such a termination, and expedited hearings are appropriate for these disputes. Ultimately, the employer failed to meet its burden of proving a change in the applicant's condition justifying the discontinuation of services.

Nurse Case ManagerLabor Code 4600Expedited HearingUnilateral TerminationMedical TreatmentRequest For AuthorizationAgreed Medical EvaluatorUtilization ReviewIndependent Medical ReviewSubstantial Medical Evidence
References
Case No. ADJ7264010, ADJ7498085
Regular
Mar 16, 2017

SANDRA CATLIN vs. J.C. PENNEY, INC., AMERICAN HOME ASSURANCE CO.

This case involves a defendant's petition for removal of a WCJ's order requiring the applicant to undergo a treatment consultation with an Agreed Medical Evaluator (AME) under Labor Code § 4050 and directing the defendant to provide a nurse case manager. The defendant argued that § 4050 grants them the right to select a physician for examination and that the AME consultation order was improper, as was the indefinite appointment of a nurse case manager. The Appeals Board granted the petition for removal, affirming the WCJ's orders except for the AME re-evaluation, which was deferred due to a lack of statutory basis and evidence presented. The Board found that § 4050 has been largely subsumed by more specific statutes governing medical evaluations and treatment disputes.

Petition for RemovalAgreed Medical Evaluator (AME)Labor Code § 4050Nurse Case ManagerMedical TreatmentUtilization Review (UR)Compromise and Release (C&R)Declarations of Readiness to Proceed to Expedited Hearing (DOR)Medical ExaminationQualified Medical Examination
References
Case No. ADJ5832330
Regular
Dec 07, 2017

JULIAN MALDONADO vs. BEVERLY HILTON HOTEL, ACE AMERICAN INSURANCE

The Workers' Compensation Appeals Board granted the defendant's Petition for Removal to rescind an order removing Debbie Lee as a Nurse Case Manager. The Board found that Lee's duties were claims administration, not medical treatment, and there was no evidence she functioned as a Nurse Case Manager under relevant guidelines. Therefore, the defendant can continue using her services to facilitate claim handling without prejudice.

Petition for RemovalNurse Case ManagerMedical TreatmentClaims HandlingUtilization ReviewMedical Treatment Utilization Schedule (MTUS)Interlocutory OrderFinal OrderReconsiderationIndustrial Injury
References
Case No. ADJ10405277
Regular
Aug 10, 2018

JULIE VISH vs. SHARP HEALTH, ACE INSURANCE

The Workers' Compensation Appeals Board granted reconsideration and rescinded an earlier award ordering the defendant to authorize a nurse case manager. The Board found that the applicant's treating physician's recommendation for a nurse case manager, citing "complexity" and "miscommunication," lacked the specific medical reasoning required to establish necessity. The current ruling emphasizes that the applicant bears the burden of proving medical necessity through detailed evidence.

Nurse case managerUtilization reviewSubstantial medical evidenceMedical necessityLamin v. City of Los AngelesLabor Code section 4600(a)CausationCompensable injuryOpinion and OrderPetition for Reconsideration
References
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