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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

Niedermaier v. Southern Tier Building Trades Benefit Plan

Plaintiff Karl Niedermaier, a natural gas pipeline superintendent, sought health benefits coverage from the Southern Tier Building Trades Plan for his bilateral hearing loss and cochlear implant received in 2011. The Plan, through the Joint Board of Trustees, denied his requests for coverage, citing "artificial implant" and "hearing aid" exclusions. After two internal appeals were denied, Plaintiff commenced an action under ERISA to recover benefits. Both parties moved for summary judgment. The court found that while a cochlear implant is not a hearing aid, it reasonably falls under the "artificial implant" exclusion of the Plan. Therefore, the court granted the Defendants' motion for summary judgment and denied the Plaintiff's motion.

ERISAhealth benefitscochlear implanthearing lossartificial implant exclusionhearing aid exclusionsummary judgmentplan interpretationbenefits denialprocedural irregularities
References
24
Case No. ADJ5827846
Regular
May 29, 2013

TSHEA PARTNER vs. SOUTHERN CALIFORNIA EDISON

This Workers' Compensation Appeals Board case denied reconsideration of a lien claim by Pinnacle Lien Services on behalf of Access Mediquip. The applicant received spinal stimulator implants, and the lien claimant sought payment for implantable devices. The Appeals Board adopted the judge's report, which found that the charges for the implantable devices were included in the payments made to the surgery center. The court determined that the lien claimant failed to provide sufficient evidence to prove the defendant's liability for these separately itemized devices.

Petition for ReconsiderationWorkers' Compensation Appeals BoardSouthern California EdisonPinnacle Lien ServicesAccess MediquipSpinal stimulatorImplantable devicesCPT codesAmbulatory Surgery CenterDe Anza Ambulatory Surgery Center
References
1
Case No. ADJ367320 (VNO 0476303) ADJ566883 (LAO 0740861)
Regular
Jun 16, 2015

CRISTINA UGARTE vs. FLINKMAN REALTY, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board (Appeals Board) reconsidered a prior decision that denied separate reimbursement for implanted hardware for lien claimant Pacific Hospital of Long Beach. The Appeals Board found that the WCJ misinterpreted regulations regarding hospital billing and reimbursement. Specifically, the Appeals Board determined that implanted hardware is separately reimbursable under section 9789.22(g) regardless of whether the inpatient services qualify as a cost outlier. Therefore, the Board rescinded the WCJ's decision and returned the case for further proceedings to calculate the correct payment for the implanted hardware.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien claimantReimbursementImplanted hardwareOutlier feesRegulationsCost outlierInpatient hospital services
References
0
Case No. ADJ3491952
Regular
Sep 04, 2012

ELISEO CHACON vs. PICO RIVERA PALLETS INCORPORATED, CALIFORNIA INSURANCE COMPANY

This case involves a lien claimant, Access Mediquip, seeking payment for surgical implants. The Workers' Compensation Judge disallowed the lien, finding the claimant not credible regarding the actual costs of the implants, despite acknowledging their provision. Access Mediquip filed a petition for reconsideration, but the Appeals Board dismissed it. The dismissal was based on the petition being untimely filed 26 days after the judge's decision was mailed, exceeding the statutory 20-day period extended by 5 days for mail service.

Workers' Compensation Appeals BoardLien claimantPetition for reconsiderationTimelinessDismissalWCJ decisionLumbar fusion surgeryAccess MediquipPico Rivera PalletsCalifornia Insurance Company
References
4
Case No. MISSING
Regular Panel Decision

Boyle v. 42nd Street Development Project, Inc.

This dissenting opinion argues against the majority's decision regarding a Labor Law § 240 (1) claim. The plaintiff, an ornamental ironworker, was injured when a steel rod fell from an upper floor of a building under construction, striking him two floors below. The dissent contends that Labor Law § 240 (1) is inapplicable because the rod was not being hoisted or secured, and the lack of 'additional bolts' does not constitute the absence of an enumerated safety device. Citing precedents like Roberts and Narducci, the dissent emphasizes that the statute applies only when an object falls while being hoisted or secured due to the inadequacy of a specifically enumerated safety device, rejecting an 'integral and necessary part' test for expanding the statute's scope.

construction site accidentfalling objectLabor Law § 240(1) interpretationenumerated safety deviceshoisting and securingstatutory interpretationappellate dissentworker injurygravity-related hazardscaffold law
References
11
Case No. MISSING
Regular Panel Decision

Claim of Krietsch v. Northport-East Northport UFSD

Kathryn Krietsch (decedent) suffered from scoliosis and had spinal fixation rods. In 2008, she sustained back injuries from a work-related fall, which led to a broken fixation rod eight months later. The Workers’ Compensation Board authorized surgery after overturning a Workers’ Compensation Law Judge’s finding that the surgery was unrelated to the accident. The self-insured employer and its third-party administrator appealed, arguing untimely service of the claimant's application for Board review, which the Board overlooked. The Appellate Division affirmed the Board's decision, finding that the orthopedic surgeon's testimony provided substantial evidence for a causal link between the work accident and the subsequent back surgery, despite conflicting medical evidence. The appeal regarding the denial of reconsideration and/or full Board review was deemed abandoned.

Workers' CompensationBack InjurySpinal SurgeryCausal RelationshipMedical EvidenceSubstantial EvidenceBoard ReviewTimeliness of ServiceAppellate ReviewScoliosis
References
6
Case No. MISSING
Regular Panel Decision
Jun 08, 2012

Campbell v. Barbaro Electric Co.

The plaintiff, a sewage treatment worker for the Department of Environmental Protection (DEP), suffered personal injuries after slipping on a threaded rod at a sewage facility. He subsequently commenced an action against Barbaro Electric Co., Inc., an electrical contractor working at the site, alleging common-law negligence for creating a dangerous condition. The Supreme Court, Queens County, granted Barbaro Electric's motion for summary judgment, dismissing the common-law negligence claim. On appeal, the order was reversed. The appellate court concluded that Barbaro Electric failed to make a prima facie showing that it did not create the alleged dangerous condition, noting testimony suggesting they might have used threaded rod in the area and that their equipment was found nearby. This raised a triable issue of fact, necessitating the denial of summary judgment.

Personal InjuryCommon-Law NegligenceSummary JudgmentAppellate ReviewHazardous ConditionContractor LiabilityTriable Issue of FactPrima Facie CaseWorkplace AccidentPremises Liability
References
7
Case No. MISSING
Regular Panel Decision

Cohoes Rod & Gun Club, Inc. v. Firemen's Insurance

Plaintiff commenced an action seeking a declaration that the defendant insurer was obligated to defend and indemnify it in a pending personal injury lawsuit brought by Nicholas J. Kdidnasky, III. The underlying lawsuit alleged negligence by plaintiff and Cali Building Company, Inc., leading to Kdidnasky's injury on December 1, 1981. Defendant denied coverage, asserting that plaintiff failed to provide notice of the incident "as soon as practicable" as required by their insurance policy. The Supreme Court initially granted plaintiff's motion for summary judgment, finding the delay reasonable. On appeal, the court reversed this order, concluding that unresolved questions of fact existed regarding the reasonableness of plaintiff's delay in providing notice, specifically concerning possible earlier contact with an insurance representative.

Insurance Coverage DisputeSummary Judgment AppealTimely NoticeAs Soon As PracticableGood-Faith BeliefReasonableness of DelayDuty to DefendDuty to IndemnifyConstruction AccidentPersonal Injury Liability
References
4
Case No. ADJ12865802
Regular
Sep 22, 2025

JENNIFER CHASE vs. SOUTHERN IMPLANTS OF NORTH AMERICA, TRAVELERS PROPERTY AND CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board (WCAB) granted the applicant's Petition for Reconsideration regarding the denial of a psychiatric injury claim. The WCAB found significant issues with the applicant's attorney's legal citations, including apparent fabrications, prompting a Notice of Intention to impose sanctions of up to $2,500.00. The final decision on the merits of the psychiatric injury claim is deferred pending the resolution of the sanctions issue. Aggrieved parties may seek a writ of review after the WCAB issues its final decision.

Psychiatric injuryAdjudication NumberPetition for ReconsiderationFindings & AwardQualified Medical ExaminerAOE/COESanctionsLabor Code section 5909WCAB Rule 10421Bad faith
References
12
Case No. ADJ13831018
Regular
Apr 21, 2023

Toshi Kuwata vs. Implant Direct, LLC, Ace American Insurance Company, Sedgwick CMS

The Workers' Compensation Appeals Board dismissed the Employment Development Department's (EDD) petition for reconsideration. The Board found the EDD was not aggrieved because its lien claim was not adjudicated and the award for temporary disability expressly excluded periods for which the EDD could assert a credit. The EDD's lien can still be adjudicated separately, and the defendants are advised to resolve the credit to avoid further interest.

Workers' Compensation Appeals BoardPetition for ReconsiderationEmployment Development DepartmentAggrieved PartyLien ClaimantFindings and AwardTemporary DisabilityEDD CreditUnemployment Insurance CodeStipulation
References
0
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