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

Case No. VEN 0118950 VEN 0118949
Regular
Aug 10, 2007

JOSEFINA MARRON vs. WORKRITE UNIFORMS COMPANY, INC., ZENITH INSURANCE COMPANY

The Appeals Board denied the lien claimant's petition for reconsideration of a workers' compensation award, finding the WCJ's report and recommendation persuasive. However, the Board removed the case on its own motion to sanction Norma Hall and CMS Network, Inc. for submitting documents with the petition that were either already in the record or not presented to the trial judge, violating WCAB Rule 10842.

Workers' Compensation Appeals BoardPetition for ReconsiderationOrder of RemovalSanctionsLab. Code § 5813WCJLien ClaimantSB Surgery CenterWorkrite Uniforms CompanyZenith Insurance Company
References
Case No. ADJ6973825
Regular
May 21, 2012

MONICA BENARD vs. JENNY CRAIG, SEDGWICK CMS

This case concerns a penalty imposed on Jenny Craig for unreasonably delaying authorization for applicant Monica Benard's chiropractic treatment. The WCJ found a 25% penalty for the delay, which Jenny Craig appealed, arguing the delay was due to the applicant's choice of a chiropractor outside their Medical Provider Network (MPN). The Appeals Board affirmed the unreasonable delay finding but reduced the penalty to 20% of the delayed treatment's value, citing a failure in case management rather than intentional disregard. Jurisdiction was reserved for the parties to adjust the penalty amount.

Workers Compensation Appeals BoardMonica BenardJenny CraigSedgwick CMSADJ6973825ReconsiderationFindings and AwardLabor Code section 5814Medical Provider Network (MPN)chiropractic treatment
References
Case No. ADJ2622573 (ANA 0351842)
Regular
Nov 14, 2014

JOSE MORGADO vs. POWDERCOAT SERVICES, INC., CIGA, For FREMONT INDEMNITY COMPANY, In Liquidation, Administered By SEDGWICK CMS

This case concerns a workers' compensation applicant who sustained a 100% permanent disability injury. The defendant sought reconsideration of a prior ruling denying its medical provider network (MPN) defense. The Appeals Board granted reconsideration, rescinded the finding regarding the MPN defense, and returned the matter to the trial level. This action allows the trial judge to take judicial notice of the defendant's MPN status from the Division of Workers' Compensation website to achieve substantial justice.

Workers' Compensation Appeals BoardPowdercoat Services Inc.CIGAFremont Indemnity CompanySedgwick CMSADJ2622573ANA 0351842Petition for ReconsiderationFindings and OrderMedical Provider Network (MPN)
References
Case No. ADJ11315508
Regular
Sep 12, 2018

SIERRA PRADO vs. PCG HOSPITALITY, TRAVELERS INSURANCE CO.

This case concerns an applicant's request to treat outside her employer's Medical Provider Network (MPN) due to alleged difficulties in scheduling an appointment with an MPN physician. The applicant argued the Medical Access Assistant (MAA) failed to secure an appointment with available MPN doctors, leading to a denial of care. The Workers' Compensation Appeals Board affirmed the WCJ's decision, finding no denial of care because the MPN list is not a guarantee of immediate appointment and the MAA reasonably attempted to find a suitable physician. The majority determined that the applicant did not exhaust reasonable efforts to find an MPN doctor, and a dissenting opinion argued the inaccurate MPN list constituted a failure to provide care, justifying out-of-network treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Medical Access Assistant (MAA)Primary Treating Physician (PTP)Denial of CareOut-of-Network TreatmentLabor Code Section 4600Labor Code Section 4616Cal. Code Regs. tit. 8§ 9767.5
References
Case No. ADJ724329 (LAO 0863195)
Regular
Jan 28, 2010

BRAMBILA vs. VONS, INC.

The Workers' Compensation Appeals Board denied reconsideration to MH Express Pharmacy. The lien claimant sought additional payment for medications provided to the applicant, arguing they were prescribed by MPN physicians. However, the employer had established a Pharmacy Benefit Network (PBN) before the applicant's injury, and the lien claimant was not part of this network. The Board found the lien claimant misrepresented the record by claiming the PBN contract was not in evidence, and affirmed the denial of further payment for medications dispensed outside the PBN.

Workers' Compensation Appeals BoardLien ClaimantPharmacy Benefit NetworkMedical Provider NetworkFindings and OrderReconsiderationLabor Code section 4600.2(a)Compromise and ReleaseOfficial Medical Fee ScheduleBad Faith Tactics
References
Case No. ADJ9285089
Regular
Aug 24, 2016

ANA RAMIREZ FARIAS vs. ABLE BUILDING MAINTENANCE, ZURICH NORTH AMERICA

The Appeals Board affirmed an arbitrator's decision that applicant Ana Ramirez Farias must transfer medical care to her employer's exclusive provider network, despite her continued treatment with Dr. Arthur Harris. The majority found that the collective bargaining agreement's provisions on medical treatment, negotiated under Labor Code section 3201.5, take precedence over general Medical Provider Network (MPN) statutes like section 4603.2(a)(2). The dissenting opinion argued that the collective bargaining agreement diminishes the applicant's statutory right to treatment and that section 4603.2(a)(2) should apply due to the agreement's silence on transfer of care disputes.

Labor Code section 3201.7Labor Code section 3201.5(b)Alternative Dispute Resolution (ADR)self-procure treatmentmedical controlexclusive provider networkcarve-out agreementMedical Provider Network (MPN)collective bargaining agreementagreed list of providers
References
Case No. ADJ11377591
Regular
Feb 10, 2023

MARIA ANDRADE (Deceased) vs. DELTA AIRLINES, ACE AMERICAN INSURANCE COMPANY, SEDGWICK CMS

This case involved a worker's compensation settlement for Maria Andrade against Delta Airlines, which was submitted for approval shortly before Ms. Andrade's death. The Workers' Compensation Appeals Board (WCAB) denied reconsideration of the administrative law judge's (WCJ) order finding the Compromise and Release (C&R) agreement unenforceable. The WCAB adopted the WCJ's reasoning, which concluded that the applicant's death before the C&R was approved constituted a material change in circumstances, rendering the agreement invalid as liability for future medical care ceased. The Board cited precedent emphasizing their discretion in approving C&Rs and highlighted that the settlement primarily addressed future medical care that would no longer be needed.

Workers Compensation Appeals BoardPetition for ReconsiderationDenying PetitionDelta AirlinesACE AMERICAN INSURANCE COMPANYSEDGWICK CMSAdjudication NumberWorkers' Compensation Administrative Law JudgeOpinion and OrderCompromise and Release
References
Case No. ADJ9915005
Regular
Mar 13, 2023

ALICE RIVERA PASILLAS vs. DURHAM D M, OLD REPUBLIC INSURANCE COMPANY, SEDGWICK CMS

This case involves a worker's claim that she was denied medical care, thus allowing her to seek treatment outside her employer's network. The applicant's attorney argued that the employer failed to provide authorization for treatment with a network physician. However, the Administrative Law Judge (WCJ) found that the employer had provided timely authorization, evidenced by a fax confirmation and proof of service, and that the applicant's claim of non-receipt was insufficient to rebut the presumption of delivery. The Workers' Compensation Appeals Board (WCAB) reviewed the petition for reconsideration, adopted the WCJ's reasoning, and affirmed the original findings. Therefore, the WCAB upheld the decision that the applicant did not prove a denial of care.

Denial of careMedical Provider NetworkMPNAuthorization letterProof of servicePresumption of receiptReconsiderationFindings of FactWCJWorkers' Compensation Appeals Board
References
Case No. ADJ2155279 (RIV 0040729)
Regular
Nov 28, 2012

JACK RAMSEY vs. CALIFORNIA PAVEMENT MAINTENANCE, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, Sedgwick CMS, LEGION INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) amended a previous award to defer the issue of attorney fees for enforcing an award of Labor Code section 5710 fees. The WCAB affirmed the remainder of the award, including a $100 penalty for unreasonable delay in authorizing medical treatment, finding the 100-day delay in authorizing treatment with the applicant's chosen physician was unreasonable. The Board also affirmed the award of attorney fees under Labor Code section 5814.5 for enforcing the medical treatment award. The case was returned to the trial level for further proceedings regarding the amount of section 5814.5 fees, with a dissenting opinion arguing for further proceedings on the unreasonable delay issue due to insufficient evidence.

Workers' Compensation Appeals BoardCIGALegion Insurance CompanySedgwick CMSJack RamseyLabor Code section 5814Labor Code section 5814.5Labor Code section 5710Medical Provider NetworkMPN
References
Case No. ADJ3786424; (BAK 150831) ADJ3979764; (BAK 152134)
Regular
Sep 12, 2008

PAUL COONE vs. PEPSI BOTTLING CENTER, OLD REPUBLIC INSURANCE COMPANY

The Appeals Board rescinded the WCJ's decision that the applicant validly selected an out-of-network physician. The Board found the defendant did not neglect to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMPNMedical Provider NetworkPrimary Treating PhysicianIndustrial InjuryReconsiderationWCJExhibit AdmissibilitySelf-Procured TreatmentPhysician Selection
References
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