[12/17] Cal. Ins. Guarantee Assn. v. WCAB
In this medical billing dispute, the decision of the Workers’ Compensation Appeals Board (the Board) adopting the Workers’ Compensation Judge’s (WCJ) findings of fact and determinations of the reasonable fee for various arthroscopic knee, shoulder, and epidural injection procedures is affirmed, where: 1) despite the fact that the Legislature created a new administrative independent review process for the resolution of billing disputes in the context of workers’ compensation, and although the text of the relevant medical fee legislation and resulting statutes is ambiguous, the most reasonable interpretation of the legislation is that it does not divest the Board of jurisdiction to decide the dispute at issue in this case; and 2) the WCJ’s findings are supported by substantial evidence.
[11/20] In the Matter of Maureen Kigin v. State of New York Workers' Compensation Board
In this case, claimant was injured on the job and entitled to worker's compensation, but upon receipt of acupuncture treatment, a Workers' Compensation Law Judge determined that claimant's medical provider failed to show that the additional acupuncture treatments were medically necessary. The Workers' Compensation Board affirmed the Judge's determination, arguing that the treatments were not medically necessary within the "Medical Treatment Guidelines." Order of the Appellate Division affirming the Board's decision is affirmed, where: 1) the establishment of the variance procedure was within the Board's broad regulatory powers; 2) it was reasonable for the Board to promulgate uniform guidelines for defining the nature and scope of treatment considered medically necessary; 3) nothing in the Workers' Compensation law precludes the Board from requiring proof of medical necessity from claimant's health care provider; 4) the carrier bears the burden of proffering "substantial evidence"; and 5) the Guidelines provide claimants with a meaningful opportunity to be heard on the denial of any variance request.
[08/06] LeFiell Manufacturing Co. v. Superior Court (Watrous)
In an action brought by plaintiff-employee under Labor Code section 4558, which provides an exception to the exclusivity of the workers' compensation system for employees injured as a result of the employer's knowing removal of, or knowing failure to install, a point of operation guard on a power press, the trial court erred in denying defendant-employer's motion for summary judgment, where: 1) the door that was removed from the Fenn 5F swaging machine operated by plaintiff-employee is not a point of operation guard as a matter of law; and thus, 2) defendant -employer is entitled to summary judgment.
[07/18] Benavides v. WCAB
The decision of the Workers' Compensation Appeals Board rescinding petitioner's disability rating is annulled, where there was good cause for the Workers' Compensation Judge (WCJ) to reopen the case and therefore the appeals board is directed to reinstate the WCJ's award of a 72 percent disability rating. (Opinion after rehearing)