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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
Dec 11, 2002

Claim of Speer v. Wackenhut Corp.

The claimant sought workers' compensation benefits for mental depression, alleging it resulted from being removed from a security guard position by their employer. The Workers' Compensation Board initially ruled the injury non-compensable under Workers' Compensation Law § 2 (7), deeming it a direct consequence of lawful personnel decisions. The claimant subsequently filed applications for full Board review and reconsideration, both of which were denied by the Board. This appeal concerns the denials of those applications. The court dismissed the appeal from the May 1, 2002 denial as untimely and affirmed the December 11, 2002 denial, finding that the Board did not abuse its discretion by not requiring transcription of oral arguments before rendering its decision.

Workers' CompensationMental DepressionStress-related InjuryPersonnel DecisionsReconsideration DenialFull Board ReviewAppellate ProcedureTimeliness of AppealOral Argument TranscriptionAdministrative Discretion
References
3
Case No. MISSING
Regular Panel Decision

Claim of Wilkinson v. Bendix Friction Corp.

Claimant filed a workers' compensation claim after being diagnosed with a lung condition, which a Workers' Compensation Law Judge (WCLJ) determined in August 2003 was an occupational disease causally related to 1969 asbestos exposure while working for the employer, though not currently disabling. The claimant sought review. The Workers' Compensation Board, in January 2004, found the employer's rebuttals to be untimely. Subsequently, the employer and its third-party administrator filed an application for Board review in February 2004, which the Board denied as untimely in October 2004. The employer appealed this denial. The appellate court affirmed the Board's decision, finding no abuse of discretion in denying the application as untimely, given that the employer had received proper notice of the WCLJ decision.

Workers' CompensationUntimely ApplicationBoard ReviewOccupational DiseaseAsbestos ExposureCausal RelationDisability ClaimAppellate Decision
References
4
Case No. MISSING
Regular Panel Decision

Cascarano v. DiNapoli

Petitioner, a former sanitation worker, was terminated on June 15, 2012. He applied for disability retirement benefits on May 22, 2013, but his application was denied as untimely by the New York State and Local Employees’ Retirement System. Following a hearing and subsequent review, the respondent sustained the initial denial, prompting the petitioner to commence a CPLR article 78 proceeding. The court confirmed the respondent's determination, finding substantial evidence that the application was untimely, as it was filed beyond the statutory three-month period from the last date the member was paid on the payroll for services rendered. A lump-sum back payment received as a result of an arbitration settlement was not considered 'on the payroll' for purposes of extending the application deadline.

Disability Retirement BenefitsApplication TimelinessStatutory Filing DeadlineRetirement and Social Security LawPayroll DefinitionLump-Sum PaymentCPLR Article 78Administrative ReviewSubstantial EvidenceNew York State Employees Retirement System
References
11
Case No. ADJ3854591 (VNO 0264467)
Regular
Jan 07, 2020

ANDRZEJ WASOWICZ vs. J.L. FISHER, INC., STATE COMPENSATION INSURANCE FUND

This case concerns the timeliness of a Utilization Review (UR) denial for requested medical treatment. The applicant argued the UR denial was untimely because it was issued on the 15th calendar day, exceeding the 14-day statutory limit under Labor Code section 4610(i)(1). The Appeals Board granted reconsideration, rescinding the prior decision that found the UR timely. The Board determined the UR denial was indeed untimely and remanded the case for a new decision on the medical necessity of the treatment.

Utilization ReviewRequest for Authorizationtimelinesscalendar daysworking daysjurisdictionmedical necessityLabor CodeFindings of FactPetition for Reconsideration
References
3
Case No. ADJ4564735 (SFO 0469452)
Regular
Aug 17, 2016

GEORGE FLEET vs. NORTHWEST AIRLINES, LIBERTY MUTUAL INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Northwest Airlines' Petition for Reconsideration, upholding the finding that the utilization review (UR) denial for bilateral knee surgery was untimely. The Board adopted the Judge's report, which found that the initial Request for Authorization (RFA) was faxed on July 23, 2015, making the subsequent UR denial invalid. Because the UR denial was untimely, jurisdiction returned to the Board to determine the medical necessity of the treatment, which was found to be warranted based on substantial medical evidence.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Dubon IIRequest for Authorizationbilateral knee arthroscopic surgerymedical necessityuntimely denialFax Confirmationsubstantial medical evidence
References
1
Case No. ADJ6444600
Regular
Jan 22, 2020

PAUL AGUILAR vs. CITY OF LOS ANGELES

This case involved a dispute over the timeliness of a utilization review (UR) denial for requested medical treatment. The Workers' Compensation Appeals Board (WCAB) granted reconsideration, finding the original WCJ erred by concluding the UR denial was untimely solely due to lack of telephone/fax communication. While the WCAB agreed the UR denial was untimely because it wasn't communicated to the physician as required by law, it found the record incomplete regarding the medical necessity of the treatment. Therefore, the WCAB rescinded the order authorizing treatment and returned the matter to the WCJ for further proceedings to determine medical necessity.

Utilization ReviewRequest for AuthorizationTimelinessCommunicationProspective TreatmentLabor Code Section 4610Administrative Director RuleBodam v. San Bernardino CountyMedical NecessitySubstantial Evidence
References
9
Case No. MISSING
Regular Panel Decision

Truly v. Regan

Petitioner, employed by Brooklyn Developmental Center, sustained a lower back and left leg injury in January 1986. After a period of inactivity, she stopped working in March 1987 due to her injuries and began receiving workers' compensation benefits. In February 1988, her applications for ordinary disability retirement benefits (under Retirement and Social Security Law art 14) and article 15 disability retirement benefits (under art 15) were denied by the respondent. The ordinary disability application was denied because she was not 'in service' at the time of filing, having been terminated in May 1987. The article 15 disability application was deemed untimely, as it was filed in February 1988, beyond the three-month window from her last payroll date of March 27, 1987, and she lacked approved medical leave. The court confirmed the denial and dismissed her petition.

Disability RetirementOrdinary Disability BenefitsArticle 15 Disability BenefitsIn Service RequirementTimely FilingCPLR Article 78 ProceedingEmployment TerminationMedical LeaveNew York State Employees' Retirement SystemAlbany County
References
5
Case No. ADJ9913496
Regular
Aug 05, 2016

Esperanza Sanchez vs. DUNLAP MANUFACTURING INC., TRAVELERS PROPERTY CASUALTY COMPANY

The Appeals Board granted reconsideration, rescinding the original order that found the defendant's utilization review (UR) denial untimely and automatically authorized treatment. While the UR denial was indeed untimely due to failure to serve applicant's attorney, the Board found no evidence of willful suppression of the Request for Authorization (RFA). Therefore, the issue of medical necessity remains undecided, and the case is returned for further proceedings to develop the record on this crucial point.

Workers' Compensation Appeals BoardUtilization ReviewRequest for AuthorizationTimelinessService of DocumentsProcedural Due ProcessAdverse InferenceMedical TreatmentReasonableness and NecessityAdministrative Law Judge
References
7
Case No. ADJ873701 (ANA 0299104) ADJ1741214 (ANA 0299113)
Regular
Sep 04, 2018

SHELLEE SMITH vs. SMITH'S FOOD AND DRUG, a subsidiary of the Kroger Company, permissibly self-insured, administered by SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves an untimely denial of a request for zolpidem by the defendant employer. The Workers' Compensation Appeals Board (WCAB) granted reconsideration because the trial judge's decision on medical necessity lacked substantial evidence due to a missing medical report. The matter is returned to the trial level to determine the reasonableness and necessity of the zolpidem treatment based on the correct evidence. The WCAB clarified that even with an untimely denial, the applicant must still prove the medical necessity of the requested treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardZolpidemUtilization ReviewIndependent Medical ReviewRequest for AuthorizationUntimely DenialMedical NecessityBurden of Proof
References
4
Case No. ADJ11170562
Regular
Dec 02, 2019

NASIR KHAN vs. STAR STAFFING, ZURICH NORTH AMERICA, GALLAGHER BASSETT SERVICES, INC.

Defendant sought removal of a WCJ's order finding their utilization review denial of applicant's medical treatment request untimely. The WCJ determined the denial was late due to the 72-hour window for expedited requests, as the applicant's physician requested "urgent surgery." The Appeals Board denied the petition for removal, finding the defendant failed to show irreparable harm and that reconsideration would be an inadequate remedy. The Board upheld the WCJ's finding of untimely UR, allowing the Board to determine medical necessity.

Petition for RemovalUtilization ReviewExpedited Request for AuthorizationMedical Treatment Utilization StandardsTimelinessAdministrative Director RuleThreshold IssueInterlocutory IssueMedical NecessityPrimary Treating Physician
References
6
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