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Case Law Database

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

Case No. SBR 0332538
Regular
Mar 28, 2009

RUBY JONES vs. STATE OF CALIFORNIA / DEPARTMENT OF MENTAL HEALTH, STATE COMPENSATION INSURANCE FUND, PREMIER OUTPATIENT SURGERY CENTER, INC.

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case for further proceedings on the reasonableness of Premier Outpatient Surgery Center's (POSC) $\$16,578.00$ lien claim for surgical services. While POSC was properly licensed as a surgical clinic and did not require a fictitious-name permit, the Appeals Board found the record insufficient to establish the reasonableness of the charged fee, noting a significant disparity between the billed amount and what was paid based on Medicare rates. The Board also rescinded the award of attorney's fees to POSC's counsel, finding no basis for such an award under Labor Code sections 5811 or 5813.

Workers' Compensation Appeals BoardRuby JonesState Compensation Insurance FundPremier Outpatient Surgery Centerfictitious-name permitMedical Board of CaliforniaDepartment of Health Servicessurgical clinic licenseoutpatient settingreasonable fee
References
6
Case No. FRE 0222651
Regular
Jul 15, 2008

CHRISTOPHER HUNT vs. MADERA COUNTY ROAD DEPARTMENT

The Appeals Board granted reconsideration of a WCJ's decision that limited a lien claimant's facility fees to the Official Medical Fee Schedule. The Board found the WCJ erred by not applying the correct *Kunz* standard for determining the reasonableness of outpatient surgery facility fees, which considers factors beyond the fee schedule. The case is remanded for further proceedings to properly develop the record according to *Kunz*.

KunzOfficial Medical Fee Scheduleoutpatient surgery facility feeslien claimantreconsiderationen banc decisionreasonableness of feesusual feegeographical areacontractually negotiated fees
References
5
Case No. 25 NY3d 907
Regular Panel Decision
2015-XX-XX

Government Employees Insurance v. Avanguard Medical Group, PLLC

This case addresses whether no-fault insurance carriers are obligated to pay facility fees to New York State-accredited office-based surgery (OBS) centers for the use of their premises and support services. The court concluded that neither existing statutes nor regulations mandate such payments. Plaintiffs, a group of GEICO insurers, successfully sought a declaratory judgment that they are not legally required to reimburse Avanguard Medical Group, PLLC, for OBS facility fees, totaling over $1.3 million. The decision affirmed the Appellate Division's ruling, emphasizing that OBS facility fees are not explicitly covered by statute or fee schedules, nor do they fall under reimbursable "professional health services" as per 11 NYCRR 68.5. The court highlighted the distinct regulatory frameworks for OBS centers compared to hospitals and ambulatory surgery centers, declining to mandate policy changes best left to the legislature.

No-Fault InsuranceOffice-Based Surgery (OBS)Facility FeesInsurance LawBasic Economic LossFee SchedulesWorkers' Compensation BoardDepartment of Financial ServicesStatutory InterpretationRegulatory Framework
References
16
Case No. 2025 NY Slip Op 02248 [237 AD3d 1379]
Regular Panel Decision
Apr 17, 2025

Matter of Jehle v. DOCCS Coxsackie Corr. Facility

William Jehle, a correction officer, sustained a work-related injury, prompting his employer, DOCCS Coxsackie Correctional Facility, to continue paying his full wages. The employer sought reimbursement, and Jehle's attorney filed for counsel fees. The Workers' Compensation Law Judge (WCLJ) established the claim, found a temporary total disability, awarded a credit to the employer for wage reimbursement, and granted counsel fees of $4,300 as a lien against this reimbursement. The Workers' Compensation Board affirmed the WCLJ's decision, deeming the lien proper under Workers' Compensation Law § 24 (2) (b). The Appellate Division, Third Department, further affirmed the Board's decision, holding that an award for previously unawarded benefits constitutes an 'increase' under the law, and that counsel fees are appropriately a lien against the employer's reimbursement, dismissing arguments of the employer subsidizing fees.

Counsel FeesLien on AwardEmployer ReimbursementTemporary Total DisabilityWorkers' Compensation LawAppellate ReviewCorrection OfficerWage ReimbursementStatutory InterpretationClaimant Attorney Fees
References
3
Case No. RIV 0032677
Regular
Jan 23, 2008

LUIS VALENCIA vs. VILLA AMALFIRISTORANTE, CALIFORNIA INDEMNITY INSURANCE

The Workers' Compensation Appeals Board denied reconsideration, affirming the administrative law judge's decision regarding the reasonableness of an outpatient surgery center's facility fees. The Board reiterated that the lien claimant bears the burden of proving their charges are reasonable and that the defendant presented credible evidence rebutting the billed amount. The decision also clarified that reasonableness considers various factors beyond just the facility's usual accepted fees, and inadmissible evidence from the lien claimant was appropriately excluded.

Workers' Compensation Appeals BoardLien ClaimantFacility FeeReasonablenessBurden of ProofOutpatient Surgery CenterMedical Treatment ExpenseReconsiderationEvidenceAdministrative Law Judge
References
5
Case No. OAK 0293725
Regular
May 22, 2008

MARGARITA CHAVEZ vs. WESTERN NATIONAL PROPERTIES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded the initial denial of the lien claim by Bay Surgery Center (BSC). BSC's claim for facility fees was initially denied because it allegedly failed to prove it operated as an "outpatient setting" and thus was exempt from needing a fictitious business name permit. The Board found that BSC presented sufficient evidence of its "surgical clinic" license to meet its initial burden, thereby establishing it as an "outpatient setting" for purposes of the lien claim, and remanded the case for further proceedings on the reasonableness of the fees.

Workers' Compensation Appeals BoardLien claimantOutpatient settingFictitious Business Name permitSurgical clinic licenseDepartment of Health ServicesFacility feeMedical BoardLicensed physicianReasonable fee
References
9
Case No. SBR 0315782
Regular
Jul 30, 2007

GORDON ADAMS vs. SOUTHLAND DRYWALL COMPANY, STATE COMPENSATION INSURANCE FUND

This case concerns a lien claimant, Premier Outpatient Surgery Center, Inc., whose lien was denied because it allegedly did not use its full corporate name or have a fictitious business name permit. The Appeals Board rescinded the denial and returned the case for further proceedings, finding that Premier was properly licensed as an outpatient facility and that the defendant did not timely raise the fictitious business name statement issue. The Board clarified that a facility fee lien claimant is not required to have a Medical Board fictitious-name permit, but may need to file a fictitious business name statement if operating under a name other than its legal corporate name.

Workers Compensation Appeals BoardLien ClaimantFictitious Business Name StatementFictitious-Name PermitBusiness & Professions Code Section 17910Business & Professions Code Section 2415(a)Medical Board of CaliforniaOutpatient SettingFacility FeeCompromise and Release
References
13
Case No. ADJ4409749
Regular
Feb 07, 2011

Jill Johnson vs. Ventura Unified School District, York Oxnard

Lien claimant Access Mediquip sought reimbursement for over $68,000 for durable medical equipment, specifically neurostimulators. The WCJ denied this, finding the defendant school district had already paid for the equipment through the surgical facility's charges. The Appeals Board affirmed this denial, concluding the evidence showed the neurostimulator costs were bundled into the surgery center's facility fees, aligning with Medicare bundling rules for ambulatory surgery centers. The Board distinguished this case from a prior one where the defendant contested the inclusion of costs in the facility bill, emphasizing the defendant here demonstrated payment via the bundled facility charge.

Workers Compensation Appeals BoardLien ClaimantDurable Medical EquipmentNeurostimulatorSurgical ProceduresFacility ChargeBill ReviewCPT CodeMedicare RulesAmbulatory Surgery Center
References
1
Case No. MISSING
Regular Panel Decision
Aug 24, 1999

Town of Hempstead v. Inc. Village of Atlantic Beach

This case involves two related actions arising from inter-municipal agreements for waste disposal services. The defendants appealed from initial court orders concerning their obligations to pay minimum waste commitment tonnage fees and their entitlement to various credits, including those for private carters, recyclable materials, and yard waste. The plaintiffs cross-appealed regarding the methodology for calculating yard waste credits and the fees for using the Town's transfer facility. The Supreme Court, Nassau County, issued an initial order and a subsequent amended order upon reargument, clarifying several points. The Appellate Division affirmed the amended order, holding that the agreements unambiguously required villages to pay minimum tonnage fees regardless of actual waste delivered. The court also determined that the villages were only obligated to pay transfer facility fees based on actual waste delivered and that any ambiguities regarding yard waste credits should be interpreted against the Town as the drafter of the agreements.

Inter-municipal agreementsWaste disposalSummary judgmentContract interpretationMinimum commitment feesYard waste creditTransfer facility feesUnambiguous agreementsExtrinsic evidenceAmbiguity construction
References
10
Case No. ADJ196150 (LAO 0803808)
Regular
Jul 13, 2009

MARICELA ARELLANO vs. TELACU, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration for lien claimant Tarzana Surgery Center regarding the reasonableness of their billed outpatient surgery fees. While the WCJ found the reasonable fee to be $20,181.00, the lien claimant argued the WCJ erred in using a CHSWC study and in reducing the lien without the defendant meeting its burden of proof. The Board affirmed the WCJ's decision on the fee amount but amended the findings to clarify the admissibility of certain lien claimant exhibits and the inadmissibility of others due to lack of foundation or relevance.

Lien claimantPetition for ReconsiderationFindings and OrderWorkers' Compensation Administrative Law JudgeReasonable outpatient surgery feeCompromise and ReleaseCommission on Health and Safety and Workers' CompensationTapia v. Skill Master StaffingKunz v. Patterson Floor CoveringsInc.
References
2
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