CompFox Logo
AboutWorkflowFeaturesPricingCase LawInsights

Updated Daily

Case Law Database

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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. LAO 823855, LAO 823856
Regular
Oct 03, 2007

PEDRO M. RODRIGUEZ vs. RALPHS GROCERY COMPANY

The applicant sought reconsideration of a denial of workers' compensation benefits, which was based on the finding that his claims were filed after notice of termination. The Board affirmed the denial, concluding that the applicant's job abandonment led to a termination prior to the filing of his claims. The Board also determined that the employer properly denied both the specific and cumulative trauma claims, thus negating a presumption of compensability.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderFindings of FactAdministrative Law JudgeApplicantDefendantRalphs Grocery CompanySecurity GuardIndustrial Injury
References
Case No. ADJ7532885
Regular
Aug 01, 2016

DAVID AREVALO vs. THE MILLARD GROUP, AIG/NATIONAL UNION FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the employer's petition for reconsideration, rescinding prior findings. The Board found the initial decision lacked substantial evidence and failed to address crucial issues like the MPN's validity and the employer's loss of medical control. The case is returned to the trial level for further proceedings to determine these issues and whether the employer refused, delayed, or denied medical treatment. The initial finding of denied treatment was based on insufficient evidence to establish liability for self-procured treatment.

MPNMedical Provider NetworkRefusal of TreatmentDelay of TreatmentDenial of TreatmentLoss of Medical ControlPanel Qualified Medical ExaminerPQMELien ClaimantsPrimary Treating Physician
References
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
Case No. ADJ9957492 ADJ9957588 ADJ10160287
Regular
Jul 14, 2017

JULIO NUNEZ vs. BARRETT BUSINESS SERVICES, INC., ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied a petition for reconsideration by Barrett Business Services, Inc. and Ace American Insurance Company. The defendants sought to overturn a finding that the applicant, Julio Nunez, was entitled to choose his own psychotherapy provider due to a delay in treatment authorization. The Board agreed with the WCJ that the defendant's failure to authorize treatment with a chosen MPN provider after receiving proper notification established the applicant's right to seek care outside the MPN. This entitlement arose from specific instances of delayed and denied authorization for psychotherapy.

Workers' Compensation Appeals BoardReconsiderationJoint Findings and OrderPsychotherapy treatmentMedical Provider NetworkMPNProvider of choiceAuthorizationDelay of treatmentDenial of treatment
References
Case No. ADJ10084576
Regular
Oct 06, 2016

ROSE SMITH vs. MEGGITT SENSING SYSTEMS PLC, THE HARTFORD

This case involves Rose Smith's workers' compensation claim where the defendant, Meggit Sensing Systems and its insurer, The Hartford, seek reconsideration of an order allowing Smith to obtain medical treatment outside their Medical Provider Network (MPN). The Appeals Board denied the petition, affirming the WCJ's finding that the defendant's failure to authorize a requested third medical opinion constituted a denial of care. This denial entitled the applicant to seek treatment outside the MPN at the defendant's expense. The defendant argued the request was procedurally deficient and not a request for treatment, but the Board found the failure to respond to the RFA for a third opinion, in context, was a failure to provide reasonable medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Request for Authorization (RFA)Petition for ReconsiderationDenial of Medical TreatmentThird Medical OpinionUtilization Review (UR)Primary Treating PhysicianCumulative TraumaLoss of Control
References
Case No. ADJ8234651 MF ADJ8234652
Regular
Sep 12, 2014

ZULEMA MIRANDA vs. ARAMARK, permissibly self-insured

The Workers' Compensation Appeals Board granted reconsideration and reversed the Administrative Law Judge's (ALJ) order compelling the employer to authorize out-of-network shoulder surgery. The Board found insufficient evidence that the employer denied, refused, or neglected to provide reasonable treatment for the applicant's left shoulder within its Medical Provider Network (MPN). Therefore, the employer is not liable for the self-procured treatment sought by the applicant outside the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNUtilization ReviewURAgreed Medical EvaluatorAMECumulative InjurySpecific InjuryPetition for Reconsideration
References
Case No. ADJ9070770
Regular
Jun 10, 2014

OSCAR GARCIA-PICEN vs. TIGHT QUARTERS, INC., CALIFORNIA INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) rescinded a prior ruling ordering viscosupplementation injections for an applicant's knee injury. The WCAB found the prior ruling, which deemed the defendant's utilization review (UR) denial defective due to a missing signature, to be based on an incorrect premise as the UR physician did sign the report. However, the WCAB noted the UR physician may not have been aware of the applicant's second surgery, potentially rendering the UR defective for other reasons. The case was returned to the trial level for further consideration, with a dissenting opinion arguing the UR was demonstrably defective for omitting key medical history and the treatment should have been affirmed.

Workers' Compensation Appeals BoardOscar Garcia-PicenTight QuartersInc.California Insurance CompanyADJ9070770Opinion and Decision After ReconsiderationViscosupplementation injectionsUtilization Review (UR) denialDefective UR
References
Case No. ADJ6975049
Regular
Jun 05, 2018

CONSUELO VIEYRA vs. COUNTY OF LOS ANGELES

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision and returned the case for further proceedings, finding that the defendant's utilization review denials were not timely communicated to the physician. While the initial WCJ found the UR timely, the WCAB disagreed, asserting jurisdiction to determine medical necessity. Crucially, the WCAB found that the 2009 Medical Treatment Utilization Schedule (MTUS) guideline used for the denial was an invalid regulation. The matter was returned for further development of the record regarding medical necessity, considering the proper legal framework for treatment requests.

Workers' Compensation Appeals BoardConsuelo VieyraCounty of Los AngelesUtilization ReviewRequest for AuthorizationHome Health CareReasonable and Necessary TreatmentMedical TreatmentIndependent Medical ReviewMTUS Chronic Pain Medical Treatment Guidelines
References
Case No. ADJ9438375
Regular
Dec 15, 2016

MARIA FALCON vs. MARRIOTT HOTEL

The Workers' Compensation Appeals Board granted the applicant's Petition for Reconsideration, amending the original decision. The Board found that the defendant's Marriott Hotel failed to provide the applicant with timely medical treatment within their Medical Provider Network (MPN). Applicant attempted to designate five different MPN physicians, but each refused to treat her. This repeated failure constitutes a denial of care, entitling the applicant to seek treatment outside the MPN at the defendant's expense.

Medical Provider NetworkMPN denialOut-of-network treatmentAccess standardsPrimary treating physicianPhysician availabilityLabor Code section 4600Labor Code section 4616Petition for ReconsiderationFindings of Fact and Award
References
Showing 1-10 of 3,899 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.

CompFox Logo

The AI standard for workers' compensation professionals. Faster research, deeper analysis, better outcomes.

Product

  • Platform
  • Workflow
  • Features
  • Pricing

Solutions

  • Defense Firms
  • Applicants' Attorneys
  • Insurance carriers
  • Medical Providers

Company

  • About
  • Insights
  • Case Law

Legal

  • Privacy
  • Terms
  • Trust
  • Cookies
  • Subscription

© 2026 CompFox Inc. All rights reserved.

Systems Operational