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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. ADJ8026817
Regular
Apr 22, 2013

MARIA OCHOA vs. RANGERS DIE CASTING COMPANY, COMPWEST INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision finding the applicant sustained injury to her respiratory system and psyche AOE/COE. The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr. Lipper and Dr. Curtis lacked substantiality. Specifically, the physicians failed to provide clear diagnoses, quantify exposures, or adequately explain causation. The Board noted contradictory testimony from the applicant's supervisor and insufficient evidence to support the initial findings.

Workers' Compensation Appeals BoardMaria OchoaRangers Die Casting CompanyCOMPWEST INSURANCE COMPANYADJ8026817Los Angeles District OfficeOpinion and Order Granting ReconsiderationDecision After ReconsiderationFindings of FactWorkers' Compensation Administrative Law Judge (WCJ)
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. ADJ8035089, ADJ8033530, ADJ8033513
Regular
Jun 27, 2012

Linda Barajas vs. First Group America, Chartis

The Appeals Board overturned a WCJ's denial of reimbursement for a self-procured gym membership. The applicant's claim was in delay status when her physician prescribed the membership, and she notified the adjuster without objection before purchasing it. The Board found the gym membership reasonable and consistent with ACOEM guidelines for shoulder treatment, though limited to six months. Therefore, the applicant is awarded one-half the cost of her 12-month membership as reasonable self-procured medical treatment.

Workers' Compensation Appeals BoardReconsiderationSelf-procured medical treatmentGym membershipTreating physicianDelay statusACOEM guidelinesLabor Code 5402(c)Utilization reviewIndustrial injury
References
Case No. ADJ8482364
Regular
Jul 07, 2014

LORENA RAMIREZ vs. GUILLERMO GARCIA ZAMUDIO, et. al.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration in the case of *Ramirez v. Zamudio* because the Board believes further study of the factual and legal issues is necessary. Applicant Lorena Ramirez sought reconsideration of a judge's finding that the defendant's Medical Provider Network (MPN) was properly maintained and that treatment authorization was timely. The WCAB needs more time to thoroughly review the record to ensure a just and reasoned decision. All future filings in this matter must be submitted in writing directly to the WCAB Commissioners and not through district offices or e-filing.

Medical Provider NetworkMPNauthorization for treatmentdelay of medical treatmentdenial of medical treatmentPetition for ReconsiderationFindings Of Factworkers' compensation administrative law judgeWCJWorkers' Compensation Appeals Board
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. ADJ9823935, ADJ9088024
Regular
May 20, 2016

LE VAN vs. FEDEX OFFICE AND PRINT SERVICES, GALLAGHER BASSETT

The Workers' Compensation Appeals Board granted FedEx's petition for reconsideration but ultimately affirmed the original order finding treatment by Monrovia Memorial Hospital reasonable and necessary. The Board clarified that even if the cervical spine was not explicitly pled as an injured body part, FedEx authorized the treatment and failed to properly rescind that authorization. Therefore, the lien claimant is entitled to payment for the services rendered.

WCABPetition for ReconsiderationFindings and Orderlien claimantMonrovia Memorial Hospitalcervical spineDr. Wilkercervical surgeryobjection letterprimary treating physician
References
Case No. ADJ10896105
Regular
Mar 22, 2018

MICHAEL GHATTAS vs. O'REILLY AUTO PARTS, SAFETY NATIONAL CASUALTY COMPANY

This case concerns whether an employer must authorize requested medical treatment for a denied workers' compensation claim. The Appeals Board denied the applicant's petition for reconsideration, upholding its prior decision. The Board concluded that the employer's timely denial of the claim under Labor Code section 5402 terminated their responsibility to authorize medical treatment. Therefore, the employer was not obligated to submit the physician's request for authorization (RFA) to utilization review despite it being pending when the denial was issued.

Workers' Compensation Appeals BoardPetition for ReconsiderationOpinion and Order DenyingDecision After ReconsiderationFindings of Fact Award and OrderRequest for AuthorizationUtilization ReviewLabor Code Section 5402Claim DenialMedical Treatment Authorization
References
Case No. ANA 0378959
Regular
May 27, 2000

MAI HO vs. MARRIOTT INTERNATIONAL

The Appeals Board granted reconsideration to reverse a restitution order against chiropractor Vu Phan, D.C., who provided unauthorized treatment. While Phan is not entitled to further payment for treatment not authorized by the employer, the Board found that the employer voluntarily paid $6,500 for past treatment and thus cannot recover it absent fraud, thus denying the employer's restitution claim. The Board otherwise affirmed the original decision denying Phan's lien claim for the unauthorized treatment.

Workers' Compensation Appeals BoardLien claimantRestitutionOverpaymentMedical treatmentUnauthorized treatmentPrimary treating physicianSelf-procured treatmentUnjust enrichmentVoluntary payment
References
Case No. ADJ8917716
Regular
May 03, 2016

INGA CZECH vs. BANK OF AMERICA, ACE AMERICAN INSURANCE COMPANY

Defendant Bank of America sought reconsideration of an award for medical treatment, arguing the Request for Authorization (RFA) was improperly served on their attorney, not the adjuster, thus not triggering utilization review timelines. The Workers' Compensation Appeals Board denied reconsideration, affirming that the applicant's physician's requested treatment was reasonable. The Board held that when an attorney receives an RFA and the defense has objected to its receipt, the attorney has a duty to transmit it to the claims administrator to fulfill the duty of good faith investigation. Therefore, the defendant's failure to process the treatment request after receiving it through their attorney resulted in liability for the awarded medical care.

Workers Compensation Appeals BoardUtilization ReviewLabor Code Section 4610Request for Authorization (RFA)Declaration of Readiness to Proceed (DOR)Expedited HearingAdministrative Law Judge (WCJ)Agency LawAttorney NegligenceGood Faith Investigation
References
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