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

Case No. MISSING
Regular Panel Decision

Vam Check Cashing Corp. v. Federal Insurance

Vam Check Cashing Corporation (VAM) sued Federal Insurance Company after experiencing a $120,000 loss due to an elaborate fraud scheme. Imposters tricked a cashier at VAM's Pine Check Cashing location into handing over the money. Federal denied VAM's claim, asserting the incident did not meet the policy's definition of 'Robbery,' specifically concerning the terms 'overt felonious act' and 'cognizance.' The court examined the insurance policy's ambiguous language, particularly the meanings of 'overt' and 'cognizance.' It ruled that the cashier did not need to recognize the act as criminal for coverage, only that the physical act of transferring money occurred in her presence and control. The court found Federal's interpretation would defeat the policy's purpose of protecting check cashing businesses from fraud. Consequently, VAM's motion for summary judgment was granted, and Federal's motion was denied.

Insurance Policy InterpretationRobbery DefinitionSummary JudgmentContract AmbiguityFraud SchemeCheck Cashing BusinessOn Premises ClauseOvert Felonious ActCognizance RequirementNew York Law
References
13
Case No. ADJ4461663 (VNO 0501542)
Regular
Oct 01, 2014

JONATHAN TRASK, vs. BLOOMINGDALE'S, INC., permissibly selfinsured, administered by MACY'S CORPORATE SERVICES

The Workers' Compensation Appeals Board denied lien claimant Dr. Silver's petition for reconsideration. The Board found that Bloomingdale's timely paid the negotiated lien settlement by issuing a check within 30 days, and when it was not received, a stop payment was placed and a replacement check issued promptly. The Board affirmed the administrative law judge's decision to admit bank records supporting timely payment, despite procedural objections regarding disclosure. Therefore, penalties, sanctions, and costs sought by the lien claimant were denied.

Lien claimantPetition for ReconsiderationStipulation and OrderTimely PaymentPenaltiesSanctionsFeesCostsComputer screen shotsSubstantial Evidence
References
0
Case No. MISSING
Regular Panel Decision
Jul 27, 2001

Claim of Losurdo v. Asbestos Free, Inc.

The case involves a claimant appealing a Workers’ Compensation Board decision. The Board ruled that the claimant violated Workers’ Compensation Law § 114-a by failing to disclose prior left and right knee injuries to physicians and under oath, leading to disqualification from future wage replacement benefits. Although a Workers’ Compensation Law Judge initially found no fraud, the Board reversed this determination on administrative appeal, concluding the claimant knowingly made false statements. The Appellate Division affirmed the Board's decision, finding it supported by substantial evidence, emphasizing the Board's authority as the sole arbiter of witness credibility. The court rejected the claimant's explanations of forgetting the prior incidents as not credible.

Workers' Compensation FraudMisrepresentation of Medical HistoryFalse Statements Under OathWage Replacement Benefits DisqualificationWorkers' Compensation Law Section 114-aAppellate Review of Board DecisionWitness CredibilitySubstantial EvidencePrior Knee InjuriesAdministrative Appeal
References
11
Case No. MISSING
Regular Panel Decision

Claim of Jacob v. New York City Transit Authority

Claimant sustained work-related injuries in January 2000 and later sought workers’ compensation benefits alleging recurrence. An issue arose regarding the veracity of the medical history provided to the employer’s independent medical examiners, specifically concerning undisclosed prior similar injuries. A workers’ compensation law judge and subsequently the Workers’ Compensation Board found that the claimant violated Workers’ Compensation Law § 114-a, leading to disqualification from wage replacement benefits. However, the Board authorized medical treatment for the January 2000 injuries. On cross appeals, the Board’s determination was affirmed, finding substantial evidence supported the violation and the appropriateness of the penalties imposed.

Workers' Compensation Law Section 114-aMedical MisrepresentationWage Replacement Benefits DisqualificationMedical Treatment AuthorizationPrior Injuries DisclosureSubstantial Evidence ReviewIndependent Medical ExaminationWorkers' Compensation Board DecisionAppellate ReviewAffirmed Decision
References
4
Case No. ADJ9175444 ADJ9175443 ADJ9182342 ADJ9863288
Regular
Sep 11, 2017

ALEXANDRA MOON (RAMIREZ) vs. LONG BEACH COMMUNITY ACTION PARTNERSHIP, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied the State Compensation Insurance Fund's (SCIF) petition for reconsideration. SCIF sought to overturn penalties and attorney's fees awarded due to an alleged unreasonable delay in issuing settlement proceeds. The Board upheld the administrative law judge's decision, finding that SCIF failed to sufficiently prove that replacement settlement checks were mailed on the dates claimed, thus supporting the applicant's testimony of a delay. The exclusion of SCIF's exhibits for lack of authentication was also deemed proper.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings Award OrdersWCJSCIFSettlement ProceedsPenaltyInterestAttorney's FeesCompromise and Release
References
1
Case No. 2021 NY Slip Op 02582
Regular Panel Decision
Apr 29, 2021

Matter of Young v. Acranom Masonary Inc.

Claimant Timothy Young established a workers' compensation claim for a back injury and received indemnity benefits, despite his treating physician continuously diagnosing a total temporary disability. Young returned to work for a different employer on April 1, 2019, but failed to disclose this information to any party or the Workers' Compensation Board, continuing to cash compensation checks. The employer's carrier subsequently raised a fraud issue under Workers' Compensation Law § 114-a, supported by video surveillance showing Young engaged in physical activity. The Workers' Compensation Board found that Young violated § 114-a through misrepresentation and imposed both mandatory and discretionary penalties, including a lifetime bar of indemnity benefits. On appeal, the Appellate Division affirmed the finding of a § 114-a violation but reversed the discretionary penalty of permanent disqualification from future wage replacement benefits, deeming it disproportionate to the offense given mitigating circumstances.

Workers' Compensation FraudDisability BenefitsMisrepresentationMandatory PenaltyDiscretionary PenaltyIndemnity BenefitsReturn to WorkVideo SurveillanceAppellate ReviewWorkers' Compensation Board Decision
References
10
Case No. ADJ1384238 (SAC 0366460)
Regular
Oct 09, 2017

ROSA VIRGEN vs. MACY'S WEST, MACY'S CORPORATE SERVICES-RISK MANAGEMENT DEPARTMENT

The Workers' Compensation Appeals Board denied Macy's West's petition for removal, upholding the WCJ's decision not to grant a replacement Qualified Medical Evaluator (QME). The Board found that a late supplemental report alone does not mandate a replacement QME under LC 4062.5 or AD Rule 31.5(a)(12). Granting a replacement QME for untimely supplemental reporting is discretionary and requires a showing of good cause, which Macy's failed to demonstrate. The Appeals Board retains exclusive jurisdiction over the validity of replacement panels.

Workers' Compensation Appeals BoardPetition for RemovalQualified Medical EvaluationPQMEReplacement PanelMedical DirectorTimelinessSupplemental ReportGood CausePrejudice
References
4
Case No. ADJ15951486, ADJ15951487
Regular
Aug 25, 2025

JEFF CRAIL vs. AMTRUST NORTH AMERICA, HARTFORD FIRE INSURANCE COMPANY

The defendant, Amtrust North America and Hartford Fire Insurance Company, filed a Petition for Reconsideration of a Joint Findings of Fact and Orders (F&O) issued on May 20, 2025. The F&O had ordered the replacement of Panel Qualified Medical Examiner (PQME) Dr. Wiseman due to his failure to properly serve his report. The defendant argued that the court improperly interpreted Administrative Director Rule 31.5(a)(12) and that a Declaration of Readiness (DOR) does not constitute both an objection and a request for a replacement panel. The Appeals Board denied the Petition for Reconsideration, affirming the WCJ's decision to replace Dr. Wiseman. The Board's decision cited its en banc ruling in Vazquez v. Inocensio Renteria, reinforcing that a QME's failure to timely issue and serve a report, and engaging in ex parte communication by serving only one party, grants a party the right to seek replacement. The Board also emphasized the informal nature of pleadings in workers' compensation proceedings, as established in Perez v. Chicago Dogs, when addressing the applicant's DOR.

PQMEPetition for ReconsiderationJoint Findings of Fact and OrdersAdministrative Director RuleDeclaration of ReadinessIrreparable HarmMandatory Settlement ConferenceOncology PanelQualified Medical ExaminerProof of Service
References
14
Case No. ADJ6794293
Regular
Jul 29, 2011

SHARON HIRONYMOUS vs. CENTRAL ANESTHESIA SERVICE, EMPLOYERS COMPENSATION INSURANCE COMPANY

The Workers' Compensation Appeals Board dismissed the defendant's petition for reconsideration of an order allowing a replacement QME panel. The Board granted removal, rescinded the order, and ruled the applicant was not entitled to a replacement QME. This decision was based on the applicant's failure to object to the QME's conduct during the examination itself, instead waiting until after reviewing the QME's report. Allowing a replacement panel under these circumstances was deemed prejudicial to the defendant.

QMEreplacement panelPetition for ReconsiderationPetition for Removalindustrial injurycarpal tunnel syndromeAdministrative Law JudgeQualified Medical Evaluator Complaint FormTitle 8 California Code of Regulationsinterlocutory procedural order
References
16
Case No. ADJ11802539
Regular
Dec 03, 2019

LA TONYA RIDER vs. PRIDE INDUSTRIES, NORTH RIVER INSURANCE

The Appeals Board granted removal and rescinded the WCJ's order denying a replacement QME panel. Defendant sought a replacement due to the current QME's unavailability for deposition. The Board found the original order lacked an evidentiary basis, necessitating a return to the trial level. Further proceedings will establish an evidentiary record to adjudicate the QME replacement issue, considering relevant Administrative Director Rules.

Petition for RemovalQualified Medical Evaluator paneldeposition unavailabilityevidentiary recordsubstantial evidenceAdministrative Director Rule 31.5(a)Administrative Director Rule 35.5(f)trial levelrescinded orderReturn to trial
References
4
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