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

Case No. AD-J7246984
Regular
Apr 05, 2016

COURDES ESTRADA vs. OXNARD HARVEST COMPANY, LIBERTY MUTUAL INSURANCE COMPANY

This case concerns a lien claimant's petition for reconsideration of a Workers' Compensation Appeals Board decision. The claimant argued the administrative law judge (WCJ) erred in valuing their services at $105,972.59 and denying interest. The Board denied reconsideration, finding the bill reviewer appropriately considered usual and customary charges and relied on a reasonable cost basis per administrative directives. The Board also found the defendant complied with Labor Code section 4603.2 regarding payment and explanation of bill review.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardLien claimantMonrovia Memorial HospitalInnovative Medical Managementreasonable value of servicesinterest on awardindependent bill reviewerusual and customary charges
References
Case No. ADJ1302099 VNO 0428414 ADJ2831520 VNO 0428415 ADJ1428493 VNO 0435244
Regular
Nov 16, 2012

NAVIDAD LOPEZ vs. SUPERBA, INC., STATE COMPENSATION INSURANCE FUND

This case involves a dispute over the amount allowed for Dr. Silver's medical treatment lien. The Workers' Compensation Appeals Board (WCAB) granted reconsideration of the administrative law judge's (WCJ) decision that allowed $1,439.82 of the lien. Dr. Silver argued for payment at his usual and customary charges, not the Official Medical Fee Schedule (OMFS) rates, and requested penalties and interest. The WCAB affirmed the WCJ's decision, finding that Dr. Silver waived his right to contest the OMFS application by failing to object to an independent bill review or cross-examine the reviewer. Therefore, the WCAB amended the award to rescind the award of interest, but otherwise affirmed the $1,439.82 payment to Dr. Silver.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationOfficial Medical Fee ScheduleCompromise and ReleaseBill ReviewIndependent Bill Review ExpertSubstantial EvidenceStatutory PenaltyLabor Code
References
Case No. ADJ10428582
Regular
Jul 19, 2019

MICHAEL GELI vs. CENTER FOR BEHAVIORAL SCIENCES, THE HARTFORD

This case involves a lien claimant, Monrovia Hospital, seeking reconsideration after a Workers' Compensation Appeals Board decision denying their claim for additional payment. The claimant argued a lack of due process due to an unavailable expert witness and that their services were exempt from the Official Medical Fee Schedule (OMFS). The Board denied reconsideration, finding the claimant failed to subpoena their expert and did not provide adequate evidence to demonstrate their charges were reasonable and customary under the "reasonable cost basis" standard for non-OMFS services. Ultimately, the WCJ's finding that the defendant reasonably paid the amount awarded was upheld.

Lien claimantPetition for reconsiderationDue processExpert witnessReschedulingSubpoenaCross-examinationOfficial Medical Fee Schedule (OMFS)Reasonable cost basisLong term care hospital
References
Case No. ADJ3172767
Regular
May 10, 2017

VICTOR GONZALEZ vs. CITISTAFF SOLUTIONS, STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed the WCJ's decision finding the lien claimant, Monrovia Memorial Hospital, was entitled to nothing for its services. The WCJ properly excluded the lien claimant's expert declaration as it was submitted after discovery closed. The lien claimant failed to meet its burden of proving its charges were reasonable and based on a reasonable cost basis, as required by precedent in cases exempt from the Official Medical Fee Schedule. Mere presentation of usual and customary charges, without evidence of reasonableness or comparability, is insufficient.

Workers' Compensation Appeals BoardVictor GonzalezCitistaff SolutionsState Compensation Insurance FundMonrovia Memorial Hospitallien claimantbill review expertdue processreasonableness of chargesOMFS exemption
References
Case No. MON 0267400
Regular
Aug 09, 2007

JOSE VAZQUEZ vs. INTERNATIONAL MEDICATION SYSTEMS, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION By CAMBRIDGE INTEGRATED SERVICES For FREMONT INSURANCE, In Liquidation

The Workers' Compensation Appeals Board dismissed CIGA's Petition for Reconsideration because it was not verified as required by Labor Code section 5902. CIGA sought reconsideration of a decision allowing a lien claim balance, arguing the amount was excessive based on the lien claimant's usual billing practices. The Board also noted CIGA improperly attached existing record exhibits to its petition.

CIGAPetition for ReconsiderationDismissalVerificationLabor Code Section 5902Lien ClaimCompromise and ReleaseExpert WitnessUsual and Customary ChargesBoard Rule 10842
References
Case No. ADJ10713529
Regular
Nov 30, 2017

MARIA SOSA vs. CINTAS CORPORATION, TRAVELERS PROPERTY AND CASUALTY INSURANCE COMPANY OF AMERICA, SEDGWICK

The Workers' Compensation Appeals Board granted reconsideration of a prior award finding applicant entitled to temporary total disability. The Board found insufficient evidence regarding applicant's specific job duties and whether they conflicted with the agreed medical evaluator's work restrictions. Therefore, the case is returned to the trial level for further development of the record, specifically for the AME to review a detailed job analysis. This is to determine if applicant could have continued her usual and customary duties but for her termination for cause.

Temporary total disabilityPetition for ReconsiderationFindings and AwardAgreed Medical Evaluator (AME)Work restrictionsTermination for causeJob dutiesFurther proceedingsDevelop the recordModified work
References
Case No. ADJ638016 (VNO 0518817)
Regular
Mar 22, 2011

Roger Schleifstein vs. Leslie's Pool Supply, ST. PAUL'S TRAVELERS INSURANCE

This case concerns a lien claim by Grossman Medical Group for $188,310.89 in unpaid medical treatment expenses following an industrial injury. The WCAB affirmed the WCJ's decision disallowing the lien, finding Grossman Medical failed to prove its charges exceeded the Official Medical Fee Schedule (OMFS) due to extraordinary circumstances. Applicant's private health insurer, CIGNA, had already paid a significant portion of the bill, and the Appeals Board held that the statutory changes eliminating the exception for billing above OMFS in disputed claims applied. The dissenting opinion argued that Grossman Medical met its burden by demonstrating reasonable and customary fees supported by comparable cases, particularly where treatment was extensive.

Lien claimantGrossman Medical GroupOfficial Medical Fee ScheduleOMFSusual and customary feesextraordinary circumstancesreasonablenesslabor codeappeals boardcompromise and release
References
Case No. LAO 835734
Regular
Nov 19, 2007

MARINA SANCHEZ vs. KEELING PROPERTY, THE ZENITH INSURANCE COMPANY

The Appeals Board granted reconsideration and rescinded the WCJ's decision, finding insufficient evidence to support the award for the lien claimant's services. The Board determined that the WCJ failed to address whether the medical treatment was reasonably required and that neither party presented sufficient evidence regarding the reasonableness of the facility fees according to *Kunz* guidelines. The case was returned to the trial level for further proceedings to develop the record on these issues and for a new decision.

Wilshire Surgical CenterKeeling PropertyZenith Insurance CompanyMarina SanchezKunz v. Patterson Floor CoveringFindings and AwardPetition for Reconsiderationusual and customary feesoutpatient surgery facility feesreasonableness of charges
References
Case No. ADJ3069602
Regular
Jul 08, 2010

RAMON MENDOZA vs. J. BUCKBINDER INDUSTRY, INC., INSURANCE COMPANY OF THE WEST

The Appeals Board dismissed a lien claimant's petition for reconsideration because the prior Board decision was not a final order, as it merely returned the case to the trial level for further proceedings. California Pharmacy Management sought reconsideration, arguing the Board failed to define key terms in its prior decision. However, reconsideration is only permissible for final orders that definitively resolve substantive rights and liabilities. The current order, by sending the matter back for further proceedings, does not meet this criteria, thus the petition was dismissed.

Workers' Compensation Appeals BoardLien claimantPetition for reconsiderationFinal orderLabor Code section 5900Aggrieved personSubstantive rightsLiabilitiesTrial levelFindings of Fact and Order
References
Case No. ANA 0390307
Regular
Jul 24, 2007

MARCIA HOELKER vs. SADDLEBACK VALLEY UNIFIED SCHOOL DISTRICT, KEENAN & ASSOCIATES

The Appeals Board reconsidered the WCJ's award to a lien claimant for surgical facility charges. The Board found the lien claimant's initial billing of $12,225 was not fully reasonable. Consequently, the Board modified the award to $7,440, less amounts already paid by the defendant, and denied penalty and interest.

Workers Compensation Appeals BoardPetition for ReconsiderationLien ClaimantFacility FeesReasonableness of ChargesKunz v. Patterson Floor CoveringsOfficial Medical Fee ScheduleBurden of ProofComparative StudyUsual Fee
References
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