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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

Abreo v. URS Greiner Woodward Clyde

A plaintiff sustained personal injuries while working on a scaffold during a renovation project, alleging violations of Labor Law §§ 200, 240 (1), and 241 (6). Defendants Colgate Scaffolding and URS Greiner Woodward Clyde (now URS Corporation-New York), the alleged general contractor and scaffolding provider, respectively, moved for summary judgment to dismiss the complaint. The Supreme Court denied their motions in part. On appeal, the denial of summary judgment for URS concerning Labor Law § 240 (1) and § 241 (6) claims was affirmed, as triable issues of fact existed and the cited Industrial Code provisions were deemed specific. Colgate's appeal from one order was dismissed as they were not aggrieved, and their motion for summary judgment was also found to lack a prima facie case. The plaintiff was awarded costs.

Personal InjuryLabor LawScaffolding AccidentSummary JudgmentAppellate DecisionConstruction AccidentElevation-Related RiskIndustrial Code ViolationsNegligenceWorkers' Safety
References
14
Case No. 2022 NY Slip Op 00941 [202 AD3d 505]
Regular Panel Decision
Feb 10, 2022

Locke v. URS Architecture & Eng'g-N.Y., P.C.

Plaintiff Michael Locke sustained injuries after slipping on soapy water in a designated restroom at a construction site managed by URS. Locke had repeatedly notified URS of an overflowing sink causing water to pool, but URS attributed responsibility to prime general contractor Tri-Rail. The Supreme Court granted summary judgment to plaintiffs on common-law negligence and Labor Law claims against URS, while denying URS's motion to dismiss and for contractual indemnification against Tri-Rail, and denying Crescent's motion to dismiss. The Appellate Division modified the Supreme Court's order, dismissing the common-law negligence and Labor Law § 200 claims against Crescent and granting URS conditional contractual indemnification against Tri-Rail, pending liability apportionment. The court found URS liable under Labor Law §§ 241(6) and 200 due to its control over the injury-producing activity and notice of the dangerous condition.

Workers' CompensationConstruction Site AccidentSlip and FallPremises LiabilityLabor Law §200Labor Law §241(6)Industrial Code ViolationSummary JudgmentContractual IndemnificationCommon-Law Negligence
References
9
Case No. ADJ9893989
Regular
Oct 10, 2017

DAMIAN SANCHEZ vs. MICHAEL SIMMS dba SIMMS PAINTING AND DECORATING, TRUMBULL INSURANCE COMPANY

This case concerns the timeliness of a utilization review (UR) determination regarding a request for home health care. The defendant argued its UR denial was timely because it requested additional information, thereby extending the review period under Labor Code section 4610(g)(1). The WCJ initially found the UR determination untimely for prospective and concurrent review, but timely for retrospective review, citing a narrow interpretation of who can request further information. The Appeals Board granted reconsideration, rescinded the WCJ's decision, and found the UR denial timely. The Board held that the defendant's attorney, acting as an agent for the claims administrator, could validly request additional information, extending the UR deadline to 14 days.

Utilization ReviewRequest For AuthorizationIndependent Medical ReviewProspective ReviewConcurrent ReviewRetrospective ReviewTimelinessLabor Code Section 4610Administrative Director Rule 9792.9.1Findings Of Fact And Order
References
6
Case No. ADJ8454101
Regular
Dec 18, 2014

Joshua Desmarias vs. California Highway Patrol

The Appeals Board rescinded the original WCJ's decision, finding the applicant's appeal of the UR denial for spinal surgery is denied. The Board clarified that a procedural defect in a UR report, such as an illegible signature, does not invalidate the UR determination unless the UR itself was untimely. Since the parties stipulated the UR was timely, the Board lacked jurisdiction to determine the medical necessity of the surgery. Therefore, the IMR decision upholding the UR denial stands, and the applicant's request for surgery is denied.

Workers' Compensation Appeals BoardCalifornia Highway Patrollegally uninsuredState Compensation Insurance FundFindings of Fact and Orderindustrial injuryutilization reviewUR denialspinal surgeryorthopedic surgeon
References
3
Case No. ADJ896085
Regular
Nov 07, 2014

VALERIO FLORES vs. HVOLVOLL-JOHNSON CONSTRUCTION, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for FREMONT INDEMNITY COMPANY

This case involves a workers' compensation applicant seeking authorization for analgesic medications. The applicant's physician submitted requests, which the employer's utilization reviews (URs) denied as untimely. The Administrative Law Judge found the URs untimely and ordered authorization, disallowing the employer's UR denial documents as evidence. The employer sought reconsideration, arguing the Appeals Board lacked authority over UR timeliness and medical necessity. The Board affirmed the ALJ's decision, citing precedent that the Board retains authority over untimely URs and can determine medical necessity based on evidence when URs are invalid. The employer waived their right to challenge the timeliness finding or the medical evidence by not raising these points in their petition.

Workers' Compensation Appeals BoardUtilization ReviewRequest For AuthorizationUntimelyIndependent Medical ReviewMedical NecessityFindings And AwardPetition For ReconsiderationEn Banc DecisionDubon v. World Restoration
References
4
Case No. ADJ795505 (LAO 0794863)
Regular
Feb 13, 2014

VICTORIA SHANLEY vs. HENRY MAYO NEWHALL MEMORIAL HOSPITAL, TRAVELERS INSURANCE CO.

The Appeals Board reconsidered a WCJ's decision upholding utilization review (UR) denials for an MRI and EMG. While other contentions regarding the UR physician's qualifications and licensing were dismissed based on precedent, the Board found the UR decisions invalid due to untimely communication. Specifically, the defendant failed to prove by substantial evidence that the UR decisions were communicated by phone, fax, or email within 24 hours of being made. The matter is returned to the trial level to determine medical necessity, as the UR denials are void.

Utilization ReviewLabor Code Section 4610Administrative Director Rule 9792.9Physician QualificationLicensing RequirementsCommunication TimeframesTimely CommunicationMedical NecessityIndependent Medical ReviewInvalid UR Decision
References
2
Case No. ADJ2426407 (VEN 0086297)
Regular
Sep 12, 2014

ROCHELLE STOCK vs. CAMARILLO STATE HOSPITAL, STATE COMPENSATION INSURANCE FUND

The applicant challenged the admissibility of a Utilization Review (UR) denial for a hospital bed, arguing that UR is not applicable to requests from an MPN physician. The WCJ admitted the UR denial, finding the applicant's objection lacked merit and that the UR process is mandatory for all treatment requests, even those from MPN physicians. The Appeals Board dismissed the applicant's reconsideration petition as premature. However, treating it as a removal petition, the Board affirmed the WCJ's decision, clarifying that MPN participation does not preclude UR review for treatment authorization.

Workers Compensation Appeals BoardUtilization ReviewMedical Provider NetworkPetition for ReconsiderationRemovalFindings and AwardIndependent Medical ReviewPrimary Treating PhysicianMedical Treatment AuthorizationLabor Code Section 4610
References
1
Case No. 2008 NY Slip Op 50816(U)
Regular Panel Decision

Regal Construction Corp. v. National Union Fire Insurance

The Insurance Corporation of New York (INSCORP) appealed a Supreme Court order regarding an additional insured clause in a policy issued to Regal Construction Corporation (Regal), naming URS Corporation (URS). The underlying claim involved Ronald LeClair, Regal's project manager, who was injured on a construction site managed by URS. URS sought defense and indemnification from INSCORP. The Supreme Court declared INSCORP obligated to defend and indemnify URS. The appellate court affirmed, finding a causal connection between LeClair’s injury and Regal’s work, and rejecting INSCORP's estoppel argument.

Insurance CoverageAdditional Insured ClauseDeclaratory JudgmentSummary JudgmentConstruction LawPersonal Injury LiabilityDuty to IndemnifyDuty to DefendReservation of RightsWorkers' Compensation
References
3
Case No. ADJ9070770
Regular
Jun 10, 2014

OSCAR GARCIA-PICEN vs. TIGHT QUARTERS, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) rescinded a prior ruling ordering viscosupplementation injections for an applicant's knee injury. The WCAB found the prior ruling, which deemed the defendant's utilization review (UR) denial defective due to a missing signature, to be based on an incorrect premise as the UR physician did sign the report. However, the WCAB noted the UR physician may not have been aware of the applicant's second surgery, potentially rendering the UR defective for other reasons. The case was returned to the trial level for further consideration, with a dissenting opinion arguing the UR was demonstrably defective for omitting key medical history and the treatment should have been affirmed.

Workers' Compensation Appeals BoardOscar Garcia-PicenTight QuartersInc.California Insurance CompanyADJ9070770Opinion and Decision After ReconsiderationViscosupplementation injectionsUtilization Review (UR) denialDefective UR
References
4
Case No. ADJ12194461
Regular
Dec 10, 2020

Antonio Lemus vs. STEVE P. RADOS, INC., STARR INDEMNITY & LIABILITY COMPANY

This case concerns applicant Antonio Lemus's entitlement to home health care following an admitted industrial head injury. Defendant sought reconsideration of a WCJ's award enforcing a Utilization Review (UR) determination that modified but approved home health aide services. The defendant argued the WCJ lacked jurisdiction to enforce the UR determination due to a second, later UR denial of the same request, which they claimed was timely. The Appeals Board affirmed the WCJ's decision, finding jurisdiction to enforce the initial UR approval and deeming the subsequent denial an improper "self-granted appeal." The Board concluded the applicant was entitled to the treatment approved by the first UR determination.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationIndependent Medical ReviewFindings Orders and AwardPetition for ReconsiderationNurse Case ManagerTraumatic Brain InjuryHome Health AideMedical Treatment
References
2
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