Justia California Court of Appeals Opinion Summaries

Under California’s workers’ compensation law, effective in 2013, an injured worker may challenge a decision denying medical treatment by requesting a determination of medical necessity from an independent medical review (IMR) organization. (Labor Code 139.5, 4610.5.1) The IMR organization, which is regulated by the Division of Workers’ Compensation and operates under contract with the Division, designates one or more medical professionals to review pertinent medical records, determine whether the disputed treatment is medically necessary, and prepare a written report including statutorily-required findings. The IMR organization is required to describe the qualifications of the medical professionals who prepare the determination of medical necessity and to keep the names of the reviewers confidential in all communications outside the IMR organization. The determination of the IMR organization is deemed to be the determination of the administrative director and is binding on all parties, subject to appeal on narrow statutory grounds. Zuniga availed himself of the IMR process and then petitioned the Workers’ Compensation Appeals Board to disclose the names of the reviewers. The Board declined to do so. The court of appeal upheld that decision. IMR determinations are not testimonial in character; IMR reviewers are not workers’ adversaries and are not subject to cross-examination. View "Zuniga v. Workers' Compensation Appeals Board" on Justia Law

Under California’s workers’ compensation law, effective in 2013, an injured worker may challenge a decision denying medical treatment by requesting a determination of medical necessity from an independent medical review (IMR) organization. (Labor Code 139.5, 4610.5.1) The IMR organization, which is regulated by the Division of Workers’ Compensation and operates under contract with the Division, designates one or more medical professionals to review pertinent medical records, determine whether the disputed treatment is medically necessary, and prepare a written report including statutorily-required findings. The IMR organization is required to describe the qualifications of the medical professionals who prepare the determination of medical necessity and to keep the names of the reviewers confidential in all communications outside the IMR organization. The determination of the IMR organization is deemed to be the determination of the administrative director and is binding on all parties, subject to appeal on narrow statutory grounds. Zuniga availed himself of the IMR process and then petitioned the Workers’ Compensation Appeals Board to disclose the names of the reviewers. The Board declined to do so. The court of appeal upheld that decision. IMR determinations are not testimonial in character; IMR reviewers are not workers’ adversaries and are not subject to cross-examination. View "Zuniga v. Workers' Compensation Appeals Board" on Justia Law

Christensen, an applicant for aid under the California Work Opportunity and Responsibility to Kids Act (CalWORKs) program, Welf. & Inst. Code, 11200, lives with her husband and her children. Her husband is the noncustodial parent of additional children, and court-ordered child support is garnished from his income for the benefit of these children who do not live in the applicant’s home. Counting the garnished amounts as nonexempt income to the applicant’s family, San Mateo County determined the family’s income was too high to qualify for CalWORKs cash aid and denied the application. The California Department of Social Services affirmed the denial. The trial court granted Christensen’s petition for writ of administrative mandate and request for declaratory relief, finding the Department’s policy of counting child support payments as nonexempt income was invalid on the grounds it was contrary to regulation, and it resulted in improper “double counting” of income among recipients of aid. The court of appeal reversed. No statute or regulation requires the exemption of the husband’s garnished child support from the income of applicant’s family, so the Department properly treated such amounts as income in determining the applicant’s family’s eligibility for CalWORKs cash aid. View "Christensen v. Lightbourne" on Justia Law

Guerrero applied for workers’ compensation benefits after he was injured in the course of his employment as a construction laborer. He received temporary disability benefits: November 18–December 4, 2005, and January 17–June 15, 2006. His entitlement to permanent disability benefits was contested but settled in December 2014. The resulting agreement provided that Guerrero would receive a lump sum in satisfaction of his employer’s obligation to pay permanent disability benefits, less the amount of permanent disability payments his employer had advanced. Guerrero also applied for benefits from the Subsequent Injuries Benefits Trust Fund (SIBTF), the state fund that pays workers’ compensation benefits to certain permanently disabled workers. A Workers’ Compensation ALJ ordered the SIBTF to pay, finding that Guerrero’s preexisting condition combined with the subsequent injury left him totally and permanently disabled. The ALJ fixed the beginning date for SIBTF payments as June 16, 2006, the day after temporary disability payments ceased, rejecting SIBTF’s argument that its obligation should not begin until January 26, 2011 (when Guerrero’s injuries were deemed permanent and stationary). The Workers’ Compensation Appeals Board denied a petition for review. The court of appeal affirmed, finding that under the controlling statutes, SIBTF benefits commence at the time the employer’s obligation to pay permanent disability benefits begins. View "Baker v. Workers Compensation Appeals Board" on Justia Law

David, age 17 years 11 months, was a victim of past gun violence and is a wheelchair-bound diabetic in need of day-to-day medical assistance. He was living in a homeless shelter when a dependency petition was filed, alleging that he was abandoned by his mother and left without means of support. An investigation revealed that David had not been forthcoming about his family. The court dismissed the petition, finding that David had a support system in place but had chosen to leave it behind to be on his own. Had the petition not been dismissed, David would likely have qualified for transitional support as a nonminor dependent until age 21. The court of appeals dismissed an appeal. Dependency jurisdiction may not be initiated in the first instance over someone who is over age 18; it must be initiated before age 18, and by the plain terms of the Juvenile Court Law, may only be “retain[ed],” “continu[ed]” or “resum[ed]” for nonminors in certain circumstances until age 21. David’s case is now moot because he is 18 and any error by the juvenile court in failing to assume dependency jurisdiction is effectively unreviewable. View "In re David B." on Justia Law

The trial court denied appellant's petition for writ of administrative mandamus seeking to overturn the denial of his claim for services under the Lanterman Developmental Disabilities Services Act (Lanterman Act), Welf. & Inst. Code, 4500 et seq. The trial court denied the petition based on the doctrine of res judicata because his ineligibility for services had been previously adjudicated in two prior proceedings. The court agreed, and rejected appellant's claim that res judicata does not apply because the court’s decision in Samantha C. v. State Dept. of Developmental Services and a 2003 amendment to the Lanterman Act constitute an intervening change in the law or a doctrinal change that precludes application of the doctrine. In this case, the court concluded that neither the Samantha C. decision nor the 2003 amendment to section 4512 bars application of res judicata. Accordingly, the court affirmed the judgment. View "Ronald F. v. Department of Developmental Services" on Justia Law

N.S. was placed in foster care when she was 11 years old. After she turned 18 in 2014, she remained under the jurisdiction of the juvenile court as a nonminor dependent. (Welf. & Inst. Code, 11400(v).) N.S. had been diagnosed with posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and depressive disorder. She was participating in therapy and taking medication and would be enrolled in an educational program. In 2015, the Agency took the position that N.S. qualified for extended foster care because her mental health diagnoses prevented her from attending an educational or employment program or working at least half time. In 2016, the Agency recommended that N.S.’s dependency be dismissed because her exact whereabouts were unknown. N.S. was abusing methamphetamines and declined offers of housing, substance abuse treatment support, and options to get back on track with services. The Agency sought to have N.S.’s psychotherapist testify as to confidential communications. The court overruled N.S.’s objection. The court of appeal granted a writ prohibiting any inquiry concerning the psychotherapist’s confidential communications with N.S. N.S. did not put her mental condition at issue by responding to questions posed by the Agency in its case-in-chief with respect to her eligibility or by submitting documentation. View "N.S. v. Superior Court" on Justia Law

W.C. was born in Guatemala in 1997. He lived with his grandparents because his mother was dead and his father missing. W.C. left Guatemala because of threats to his safety and came to the U.S. alone, in 2014. At the border, W.C. was taken into protective custody and placed with a distant relative in Oakland. The relative agreed to sponsor W.C. for asylum, but their relationship deteriorated. W.C. became homeless in October 2014. He started using drugs. Taken to a hospital for assessment after cutting himself at school, he was denied treatment because he lacked insurance. W.C. lived at a youth shelter for a while, then told social services he was living with a friend. Eventually, W.C. was suspended from school because he was under the influence of drugs, possessed a knife, and engaged in theft. W.C. requested protective custody. The court ordered him detained, with temporary placement and care provided by the agency. On May 1, 2015, W.C. turned 18. At a May 26 hearing, the agency recommended the dependency be dismissed because the juvenile court had made no legal determination on dependency. On July 7, the juvenile court dismissed the Welfare and Institutions Code section 300 petition. In February 2016, W.C. filed a Request to Return to Juvenile Court Jurisdiction and Foster Care, hoping to participate in job training. The court denied the request. The court of appeal affirmed, holding that a nonminor who was never found a dependent of the court could not reenter and be subject to juvenile court jurisdiction. View "In re W.C." on Justia Law

Plaintiff filed a class action against United Healthcare, alleging claims of unfair competition, unjust enrichment, and financial elder abuse. Plaintiff had enrolled in a private health plan offering benefits to persons 65 and over as well as disabled persons under the federally funded Medicare Advantage program, 42 U.S.C. 1395w-21 et seq. After he went to an urgent care center outside of the plan's network, he was forced to pay a $50 copayment instead of the $30 copayment for in-network centers. Plaintiff alleged that the plan’s marketing materials misled him (and other enrollees) as to the availability of in-network urgent care centers (and their smaller copayments) and that the absence of any in-network urgent care centers in California rendered the plan’s network inadequate. The court concluded that plaintiff’s misrepresentation and adequacy-of-network based claims was expressly preempted by the preemption clause applicable to Medicare Advantage plans, 42 U.S.C. 1395w-26(b)(3). The court also concluded that plaintiff’s claims, to the extent they challenge a denial of benefits, are subject to dismissal because plaintiff did not first exhaust his administrative remedies under the Medicare Act, 42 U.S.C. 405(g), (h) and 1395ii. Accordingly, the court affirmed the trial court's dismissal of the complaint. View "Roberts v. United Healthcare" on Justia Law

Plaintiff Joseph Tanner sought to overturn a decision of defendant California Public Employees’ Retirement System (CalPERS) that significantly reduced his expected retirement benefit. The Court of Appeal found that Tanner’s argument appeared to be that under contract principles, he and the city made a mutual mistake in entering into a November 2006 agreement because they thought all of his compensation in that agreement could be used to calculate the amount of his retirement benefit, and when CalPERS informed them otherwise, they reformed the agreement to achieve their original intent by folding various miscellaneous items of compensation in the November 2006 agreement into his new, greater base salary in the March 2007 agreement. The Court concluded, however, that Tanner’s appeal was without merit regardless of these contract arguments, or any of the other arguments Tanner made. The Court agreed with the trial court that the greater base salary in the March 2007 agreement did not qualify as Tanner’s payrate for purposes of calculating the amount of his retirement benefit because that salary was not paid pursuant to a publicly available pay schedule. For this reason, Tanner had no right to have his retirement benefit calculated based on that greater base salary. View "Tanner v. CalPERS" on Justia Law