The Ambiguous Insurer: Cal. Comp. Cases November Advanced Postings (10/27/2011)

The Ambiguous Insurer: Cal. Comp. Cases November Advanced Postings (10/27/2011)

Featured Case of the Week: Insurer’s Ambiguous Acts Estopped It From Denying Insurance Coverage to Employer

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Granite State Insurance Company/Chartis (formerly AIG), Petitioner v. Workers' Compensation Appeals Board, Rose International Market, (Delmys Martinez), Respondents, 2011 Cal. Wrk. Comp. LEXIS 161

Insurance Coverage—Estoppel to Deny Coverage—WCAB held that carrier was estopped from claiming that its workers' compensation insurance policy issued to applicant’s employer had been canceled prior to applicant’s date of injury, thereby denying coverage, when WCAB found that employer met burden of establishing elements of estoppel by showing that carrier acted ambiguously by issuing notices of cancellation for non-payment of premium (although employer had paid proposed premium in full) and subsequently sending employer invoice for additional balance due on premium, which stated that if bill was not paid insurance policy may be canceled, but contained no indication that policy was already canceled, that employer relied on carrier’s conduct and was mislead into believing that coverage would continue if balance was paid, and that employer paid balance and would be detrimentally harmed, i.e., uninsured, if coverage were not allowed.

Here’s the rest of the first batch of advanced postings for the November 2011 issue of Cal. Comp. Cases. Lexis.com subscribers can link to the complete headnotes and summaries.

Jane Dowds, Petitioner v. Workers' Compensation Appeals Board, Long Beach Unified School District, PSI, administered by Tristar Risk Management, Respondents, 2011 Cal. Wrk. Comp. LEXIS 158

Permanent Disability—Application of 1997 Schedule for Rating Permanent Disabilities—WCAB affirmed WCJ's finding that 1997 Schedule for Rating Permanent Disabilities applied to rate permanent disability stemming from applicant counselor's cumulative trauma industrial injuries from 1/83 through 5/2004 to internal and gastrointestinal systems (irritable bowel syndrome) and cardiovascular system (hypertension), when WCAB found that…

Placido Gaspar, Petitioner v. Workers' Compensation Appeals Board, Ingersoll-Rand/Hussman Corporation, PSI, ACE American Insurance Company, administered by ESIS, Respondents, 2011 Cal. Wrk. Comp. LEXIS 160

Injury AOE/COE—WCAB held that applicant punch and brake press operator sustained admitted injury AOE/COE to both knees from 8/3/2002 through 8/3/2004 but…

Permanent Disability—Rating—WCAB awarded applicant 18-percent permanent partial disability for industrial injury to both knees, based on …

Medical Evidence—WCAB held that it did not err in denying applicant's request for re-evaluation by agreed medical evaluator, when WCAB found…

Los Angeles Unified School District, PSI, Sedgwick CMS v. Workers' Compensation Appeals Board, Robert S. Frederick, Respondents, 2011 Cal. Wrk. Comp. LEXIS 163

Temporary Disability—WCAB, awarding temporary total disability from 6/23/2009 to present and continuing for applicant teacher's 5/9/2009 industrial injury to his left shoulder and cervical spine, held that applicant's temporary disability rate should be based on earnings of substitute teachers and remanded for parties to develop record on issue of earnings of substitute teachers, when WCAB found…

James A. Bishop, Petitioner v. Workers' Compensation Appeals Board, Schindler Elevator Company/Schindler Elevator Corporation, Zurich American Insurance Company, administered by Broadspire Services, Respondents, 2011 Cal. Wrk. Comp. LEXIS 156

Medical Treatment—Reasonableness and Necessity—Utilization Review—WCAB panel majority, rescinding WCJ's finding, held that there was not substantial evidence to support WCJ's award of medical treatment, including housekeeping, pool, and gardening services, to applicant with specific and cumulative trauma injuries to back, knees, and gastrointestinal system, which was based on reports of treating physician and agreed medical evaluator and on defendant's alleged failure to conduct timely utilization review of requests for services, when WCAB panel majority found …

Marcus Cazares, Petitioner v. Workers' Compensation Appeals Board, Norman Bell Enterprises, Inc., State Compensation Insurance Fund, Respondents, 2011 Cal. Wrk. Comp. LEXIS 157

Petitions for Writ for Review—Dismissal—Court of Appeal dismissed petition for writ of review because…

Gallo Glass Company, PSI, Petitioner v. Workers' Compensation Appeals Board, James Hernandez, Respondents, 2011 Cal. Wrk. Comp. LEXIS 159

Permanent Disability—Apportionment—Overlap—WCAB affirmed WCJ’s findings that, based on agreed medical evaluator's opinion and parties’ stipulations, applicant incurred 57.5-percent permanent disability after apportionment as result of cumulative industrial injuries to…

Erma Lester, Petitioner v. Workers' Compensation Appeals Board, State of California/Board of Equalization, State Compensation Insurance Fund, adjusting agency, Respondents, 2011 Cal. Wrk. Comp. LEXIS 162

Permanent Disability—Apportionment—Successive Injuries—WCAB panel majority rescinded WCJ's finding that applicant's specific and cumulative trauma injuries to her bilateral upper extremities, back, and in form of fibromyalgia combined to cause 100-percent permanent disability, and held that independent medical evaluator's 2008 deposition testimony justified…