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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
References
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
Case No. ADJ1666303
Regular
Oct 21, 2011

ALTHEA RUSSELL vs. SECURITAS SECURITY SERVICES, BROADSPIRE

This case involves a supplemental award of attorney's fees to the applicant's attorneys, Charles Clark and Stuart Barth, following a successful defense against the defendant's petition for writ of review. The Court of Appeal remanded the matter to the Workers' Compensation Appeals Board (WCAB) to make this supplemental award under Labor Code § 5801. The WCAB reviewed the fee requests and, after disallowing fees for a separate sanctions motion, awarded Clark $2,800.00 and Barth $1,207.50 for their appellate services.

Labor Code § 5801supplemental attorney's feeswrit of reviewpetition for writ of reviewreasonable feeattorney servicesWorkers' Compensation Appeals BoardSecuritas Security ServicesBroadspireCourt of Appeal
References
Case No. ADJ7148169
Regular
Nov 05, 2019

MARIA GARCIA vs. ST. JOHN KNITS, TRAVELERS PROPERTY AND CASUALTY COMPANY OF AMERICA

The Appeals Board awarded applicant's attorney $6,700.00 in additional attorney fees for services rendered in responding to the defendant's unsuccessful Petition for Writ of Review. The Court of Appeal had remanded the case specifically for this supplemental fee award. While the hourly rate was deemed reasonable, the Board determined the total fee based on the attorney's time, effort, and the merits of opposing the writ. Despite the case being of average complexity, the attorney's thorough response to the defendant's factually based petition justified the full requested amount.

Writ of ReviewLabor Code § 5801Supplemental AwardAttorney's FeesAppellate ServicesPetition for Writ of ReviewWorkers' Compensation Appeals BoardPetition for Attorney's FeesReasonable Hourly RateTime and Effort
References
Case No. RDG 0115958
Significant
Nov 16, 2004

Brice Sandhagen, Applicant vs. Cox & Cox Construction, Inc.; State Compensation Insurance Fund

The Appeals Board held that the utilization review time deadlines are mandatory; if a defendant fails to meet these deadlines, any utilization review report is inadmissible, and the defendant must use the AME/QME procedure as the objecting party.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Time DeadlinesAdmissibility of EvidenceMedical Treatment RecommendationACOEM GuidelinesAgreed Medical EvaluatorQualified Medical EvaluatorSection 4062
References
Case No. ADJ7803069
Regular
Mar 22, 2016

EDILBERTO CERNA ROMERO vs. STONES AND TRADITIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and reversed the judge's finding regarding a September 14, 2015 utilization review (UR) decision. The Board found this second UR decision, which sought further information on some treatments, to be timely for all requested modalities. Consequently, the Board ruled that the UR decision of September 14, 2015, was timely, and the WCJ lacked jurisdiction to review the medical necessity of the denied treatments. The Board did not disturb the WCJ's finding that the August 12, 2015 UR decision was untimely.

Utilization ReviewTimelinessLabor Code Section 4610Request for AuthorizationDWC Form RFAIndependent Medical ReviewMedical NecessityProspective ReviewConcurrent ReviewAppeals Board
References
Case No. ADJ6766619 (MF) ADJ6766620
Regular
Feb 28, 2018

MARIA DURAN vs. FOREVER 21 RETAIL, INC., CHUBB GROUP

This case involves Maria Duran's request for home health care services, which was initially denied by utilization review (UR) and upheld by Independent Medical Review (IMR). The applicant argued that her need for assistance with household chores and personal hygiene fell outside the scope of the Medical Treatment Utilization Schedule (MTUS) guidelines as applied. While the Board acknowledges that the specific MTUS guideline used in this case was later found to be an invalid regulation in a related case, it affirmed the original decision. This affirmance was based on the finding that the initial request for services was too vague, lacking specific details on the type, frequency, and duration of care, and that a revised request could be made.

Workers' Compensation Appeals BoardMaria DuranForever 21 RetailInc.Chubb GroupOpinion and Decision After ReconsiderationIndependent Medical ReviewIMRUtilization ReviewUR
References
Case No. ADJ 1293553 (VNO 0460149)
Regular
May 12, 2016

CHARLES HOLDER vs. TROY CHRISTIAN dba ADVENTURE LIMOUSINE, THE HARTFORD INSURANCE COMPANY

This case concerns a billing dispute for medical treatment provided to applicant Charles Holder. The Workers' Compensation Appeals Board (WCAB) has remanded the matter for the trial judge to determine if Independent Bill Review (IBR) was properly initiated for services rendered on or after January 1, 2013. The Court of Appeal ordered this remand due to uncertainty regarding whether the defendant provided adequate explanations of review, which is a prerequisite for IBR. If IBR was not properly initiated, the WCAB retains jurisdiction over the dispute.

Workers' Compensation Appeals BoardRemandIndependent Bill ReviewExplanation of ReviewLabor Code section 4603.2Official Medical Fee ScheduleLien ClaimantJurisdictionTrial LevelFindings
References
Case No. ADJ12508080
Regular
Dec 18, 2020

JANE YOVINO-YOUNG vs. AMADOR RESIDENTIAL CARE, STATE NATIONAL INSURANCE COMPANY

This case concerns the timeliness of utilization review (UR) decisions in a workers' compensation claim. The applicant argued that UR decisions were untimely communicated due to discrepancies between proofs of service and postal dates. However, the Workers' Compensation Appeals Board (WCAB) denied reconsideration. The WCAB found that since the UR decisions were communicated via facsimile, the stricter two-business-day rule for written notice did not apply. Furthermore, the WCAB held that it is not bound by Code of Civil Procedure rules regarding the validity of proofs of service in this context. Ultimately, the WCAB affirmed the administrative law judge's finding that the UR decisions were timely communicated.

Utilization ReviewTimely CommunicationProof of ServicePostage Date StampFindings and OrderPetition for ReconsiderationPrimary Treating PhysicianRequest for AuthorizationIndependent Medical ReviewMedical Necessity
References
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