Author: WorkCompAcademy

Maria Morales filed two claims against her employer. The first was a claim for injury to the left thumb, knees, back, headaches, internal body system, psyche, neck, and “multiples” on September 9, 2000 (ADJ2160716). The second claim was for injury to the internal system, neck, back, knees, upper extremities, psyche, and urinary system through July 31, 2001 (ADJ634371).

On June 13, 2016, the parties entered into a compromise and release in the amount of $118,000.00. Both of applicant’s claims were described in Paragraph One (1 ), but the internal system was not listed as a body part, condition or system being settled in ADJ634371. Below Paragraph Ten (10) of the C&R, the parties drew a star and handwrote, “[r]esolves all liability/claims against American Home Assurance Company/AIG for Lifestyle Furnishings.”

Approximately 26 days later, applicant notified defendant that she did not believe that the compromise and release resolved the claimed injury to her internal system.

On May 22, 2017, the matter proceeded to trial on the issue of whether the compromise and release barred applicant’s claim of injury to her internal system.

The WCJ found that the “Compromise and Release Agreement entered into on June 13, 2016 by AIG Property and Casualty (AIG) resolves applicant’s internal claim of injury in addition to all other claims of injury resolved by that agreement” and that the “claims filed against AIG were fully resolved by the Order Approving Compromise and Release dated June 13, 2016.”

The WCAB granted reconsideration, and reversed, finding that applicant’s claim of internal injury was not resolved as part of the June 13, 2016 Compromise and Release in the panel decision of Morales v. Universal Furniture, AIG.

The parties must clearly identify each injury and list the corresponding body parts in Paragraph One (1) because that section requires that the parties state “with specificity the date(s) of injury(ies) and what part(s) of body, conditions or systems are being settled.” (C&R, Paragraph One (1), p. 3, emphasis added.) Further Paragraph One (1) also states that “[b]ody parts, conditions and systems may not be incorporated by reference to medical reports.” (Id. at pp. 3, 4, 5, emphasis in original.) Paragraph One (1)· allows the parties to clearly identify the settlement of multiple injuries with corresponding body parts by requiring that the parties list the case number, the type of injury, the date of injury and the settled body parts. (Id.)

Therefore, if parties wish to settle multiple injuries to the same body part, the parties must list that body part under the description of each injury, and the parties may not settle multiple injuries to one body part by listing the body part under the description of one injury but not another.

In Jefferson v. Dept. of Youth Authority (2002) 28 Cal.4th 299 [67 Cal.Comp.Cases 727], the Supreme Court held that a general release in a workers’ compensation case will bar other potential claims against the employer that exist at the time of execution of the release unless the employee knows about the claim and expressly excepts it from the release. (Id. at p. 310.) However, approximately six years after the Supreme Court decided that case, the compromise and release form was revised to prevent overbroad releases and thus further the legislative intent of protecting workers who might agree to unfortunate compromises because of economic pressure or lack of competent advice.

The release in Paragraph Two (2) of that form states in relevant part, Upon approval of this compromise agreement . . . and payment in accordance with the provisions hereof, the employee releases and forever discharges the above named employer(s) and insurance carrier(s) from all claims and causes of action, whether now known or ascertained or which may hereafter arise or develop as a result of the above-referenced injury(ies) …

This release does not bar applicant’s claimed internal injury because it is limited to the settlement described in Paragraph One (1), and as discussed above, that paragraph did not settle the claimed internal injury.

Covidien was an Irish-headquartered global health care products company and manufacturer of medical devices and supplies. It was purchased by Medtronic in a transaction that closed in 2015.

Covidien has agreed to pay $17,477,947 to resolve allegations that it violated the False Claims Act by providing free or discounted practice development and market development support to physicians located in California and Florida to induce purchases of Covidien’s vein ablation products.

Under the settlement agreement, Covidien will pay an additional $1,474,892 to California and $1,047,160 to Florida for claims settled by these state Medicaid programs. The Medicaid program is a jointly funded federal and state program.

The United States alleged that Covidien violated the Anti-Kickback Statute and, correspondingly, the False Claims Act by providing practice development and market development support to health care providers located in California and Florida from Jan. 1, 2011, through Sept. 30, 2014, to induce those providers to purchase ClosureFASTTM radiofrequency ablation catheters that were billed to Medicare and to the California and Florida Medicaid programs.

ClosureFastTM catheters are used in procedures that treat venous reflux disease, a disease often marked by the presence of varicose veins.

The practice and market development support Covidien provided included customized marketing plans for specific vein practices; scheduling and conducting “lunch and learn” meetings and dinners with other physicians to drive referrals to specific vein practices; and providing substantial assistance to specific vein practices in connection with planning, promoting, and conducting vein screening events to cultivate new patients for those practices.

The Anti-Kickback Act prohibits the payment of remuneration to induce the referral or use of items or services paid for by federal health care programs. Remuneration includes not only cash payments but also offers or payments made “in kind.”

The settlement resolves allegations contained in lawsuits filed by Erin Hayes and Richard Ponder (former sales managers for Covidien) and Shawnea Howerton (a former employee of one of Covidien’s customers), which are pending in federal court in San Francisco, California.

The lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private individuals to sue on behalf of the United States for false claims and to share in any recovery. Mr. Hayes and Mr. Ponder will receive $3,146,030 as their share of the federal recovery.

Trial proceeded in the case of Ana Villanueva v Teva Foods, Travelers Insurance Company on December 12, 2018 on the issue of whether the lien of Firstline Health, Inc., should be subject to an automatic stay pursuant to Labor Code section 4615.

The WCJ found that applicant claimed an injury arising out of and in the course of her employment on October 11, 2012; that criminally charged providers Munir Uwaydah, M.D., and Paul Turley controlled Firstline pursuant to Labor Code section 139.21(a)(3); and, that Firstline’s Exhibit 73 is not admissible as it was not listed on the pre-trial conference statement.

The WCJ thus ordered that the lien of Firstline in this case is subject to a stay pursuant to section 4615.

Firstline filed a Petition for Reconsideration contending that as of October 11, 2010, David Johnson, M.D., was the sole owner and officer of Firstline and thus “controlled” Firstline pursuant to section 139.21(a)(3); that Dr. Johnson is not currently charged with any crime; and, thus, there are no grounds to impose a section 4615 stay against its lien in this case.

Defendant did not file an answer to Firstline’s Petition for Reconsideration.

The WCJ filed a Report recommending that Firstline’s Petition for Reconsideration be denied because defendant’s evidence indicates that Dr. Uwaydah exercised absolute control over Firstline despite the fraudulent identification of other individuals as owners, officers or directors of Firstline in official documents, which was done in order to hide Dr. Uwaydah’s ownership and control of Firstline from creditors, investigators, government agencies and law enforcement.

Mr. Turley states that Firstline was created to take over the fraudulent activities of Frontline, and that Dr. Uwaydah exercised the same absolute control over Firstline as he had over Frontline, even though others – including Dr. Johnson – were identified as owners, officers or directors:

Uwaydah fled the United States to Lebanon in June of 2010…In the Fall of 2010, Turley traveled to Lebanon to confer with Uwaydah and to discuss how to keep the Frontline Business operating without Uwaydah’s presence, and without his name being connected to the business.

Uwaydah told Turley that there was close to a billion dollars in receivables from Frontline and Firstline

Dr. Uwaydah’s control extends to the current criminal defense in this case. He has paid millions of dollars for the attorneys for the defendants, including defending Turley.

The WCAB on reconsideration said it concurs with the conclusion of the WCJ that defendant’s evidence, namely defendant’s Exhibit C, the “Factual Statement of Paul Turley dated 12/3/18” appears to establish prima facie grounds to impose a section 4615 stay against Firstline’s lien based on Dr. Uwaydah’s de facto ownership and control of Firstline.” The ruling is posted to its website as a “Significant Panel Decision.“

“However, the Turley Statement was produced on the eve of trial and thus, lien claimant did not have sufficient notice or opportunity to rebut the Turley Statement.”

Lien claimant objected that the Turley Statement was part of a plea arrangement in his criminal case wherein he pled guilty and got credit for time-served in exchange for his execution of this statement.

The Petition for Reconsideration, was granted, and the WCAB rescinded the F&O and returned this case to the trial level for further proceedings consistent with this decision. Firstline is thus afforded an opportunity to rebut the Turley Statement.

In a radiation-proof room at the Erasmus Medical Center in Rotterdam, Emar Thomasa sits behind shielded glass as he carefully measures and mixes lutetium octreotate, an intravenous treatment for certain types of cancer.

The Dutch hospital has been offering it to patients for more than a decade at 16,000 euros ($18,000) for one course of treatments. Drug firm Novartis, which in 2018 acquired rights to sell it in Europe, is asking more than five times that for its proprietary version, Lutathera.

Thomasa is part of a protest against high drug prices launched by an unlikely group of rebels: Dutch pharmacies.

Three – Erasmus, Amsterdam’s University Medical Center (UMC) and the Transvaal Pharmacy in The Hague – have vowed to bypass drug company products and make treatments for a handful of rare diseases themselves, exercising their right to “compound” medicines.

The dispute is part of a growing global backlash against high drug prices, from the United States and Canada to Japan, and campaigners said it was being closely watched by health experts elsewhere.

Compounding is the ancient practice of preparing medicines for individual patients. Pharmacists are trained to compound, though nowadays most medicines are made by industrial producers.

UMC received a 5-million-euro grant last month to expand its compounding program. It plans to use the money to set up a center to swap know-how with pharmacies at home and abroad.

The worldwide push against high drug prices has seen the Trump administration in the United States declare bringing down prescription prices a top priority.

The Dutch pharmacies, whose production is on a small scale, acknowledge they may face legal challenges from the drug industry. However, such a case could set a precedent for other European countries.

Pharmacies retain the right under European and American law to prepare medicines for individual patients. Common examples including making lower dosage versions for children or liquid versions for people with difficulty swallowing.

However, in the United States, for-profit compounding pharmacies have tested the limits of what they are allowed to do in recent years, including mixing medicines in large quantities. In some cases, that has prompted legal conflicts with drugmakers.

Official scrutiny of the practice increased after the 2012 deaths in Massachusetts, which led to U.S. lawmakers requiring bulk compounding facilities to register with the Food and Drug Administration (FDA) and meet quality and labeling standards – still not as stringent as full FDA drug approval.

The first two drugs targeted by Dutch pharmacies are Novartis’s Lutathera and a drug called CDCA, registered in Europe by Leadiant.

Novartis boss Narasimhan said he was worried by developments in the Netherlands. “The Netherlands’ characterization that the local medicine that is made in the hospitals is the same as what we’ve done from a regulatory, full-development standpoint, particularly given (the Dutch) will house the European Medicines Agency, I think is troubling,” he told Reuters in an interview.

Paris-based Shift Technology has raised another $60 million funding round, and announced a new contract with CNA. Shift Technology claims to have a 70% hit rate in detecting fraudulent insurance claims.

Bessemer Venture Partners is leading the round and existing investors Accel, General Catalyst, Iris Capital and Elaia Partners are also participating.

This March it announced that it has entered into an agreement with CNA Financial Corporation, one of the largest commercial property and casualty insurance companies in the United States, to automate the carrier’s fraud detection capabilities. CNA is the first commercial insurer based in the United States to partner with Shift Technology to take advantage of FORCE, the company’s AI-native, SaaS-based fraud detection solution.

FORCE uses advanced artificial intelligence (AI) and data science to not only detect potentially fraudulent claims but also provide contextual guidance for investigation and resolution.

Unlike other technologies which rely heavily on the use of static business rules to identify those claims which may be non-meritorious, FORCE uses AI to analyze vast amounts of data from multiple sources. The result is a dynamically generated fraud score for each claim that indicates how suspicious the claim is, contributing factors, and how the claim could be investigated.

“CNA continues to focus on, and invest in, technology and analytics to advance claims,” said Rob Thomas, Senior Vice President of Claim Analytics, Finance and Operations for CNA’s Worldwide P&C Claim unit. “By partnering with Shift Technology, CNA will optimize its special investigations efforts by focusing on the most suspicious cases with pre-identified paths for investigation.”

There are 70 insurance companies around the world relying on its product, such as MACIF in France, Axa in Spain, and CNA and HyreCar in the U.S.

The startup has already grown quite a lot since its previous funding round. They now have 200 employees, and customers all around the globe. In addition to its headquarters in Paris, Shift Technology also has offices in Boston, London, Hong Kong, Madrid, Singapore and Zurich.

With today’s funding round, the company plans to hire more people in Boston, including data scientists and developers. The company is also developing an automated claim-processing solution.