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

Case No. ADJ9145724
Regular
Jun 01, 2015

ARZAGA, JOSE vs. CROWN AUTOMOTIVE, INC., AMTRUST NORTH AMERICA

This case involves an applicant seeking to select a pain management specialist outside his employer's Medical Provider Network (MPN). The applicant argued the MPN failed to provide a qualifying specialist within the required 15-mile/30-minute access standard for a primary treating physician. The Board denied the employer's petition for reconsideration, affirming the applicant's right to choose an out-of-network physician and reimbursement for investigative costs. The majority reasoned that the MPN must meet the closer access standard for a primary treating physician, even if that physician is a specialist. A dissenting opinion argued that a specialist, when chosen as a primary treating physician, should fall under the 30-mile/60-minute access standard for specialists.

Medical Provider NetworkMPNprimary treating physicianpain management specialistaccess standardAdministrative Director's Rule 9767.5investigative costsLabor Code section 5703Lescallett v. Wal-MartMartinez v. New French Bakery
References
Case No. ADJ9052223
Regular
Aug 05, 2016

Joel Rodriguez Luna vs. The Home Depot, Helmsman Management

Here's a summary of the case for a lawyer in a maximum of four sentences: The Workers' Compensation Appeals Board denied Joel Rodriguez Luna's Petition for Removal, affirming the WCJ's finding that Home Depot's Medical Provider Network (MPN) complied with access standards. The WCJ determined that for a specialist, like an orthopedist, the MPN only needed to meet the 30-mile/60-minute access standard, not the stricter 15-mile/30-minute standard for a general primary treating physician. The Board agreed, concluding that since there was at least one orthopedic surgeon within the 30-mile radius, the MPN satisfied its obligations, despite the applicant's preference for a specialist within a closer distance. The dissenting opinion argued the MPN failed by not having at least three specialists readily available to serve as primary treating physicians for the applicant's specific orthopedic injuries.

Workers' Compensation Appeals BoardPetition for RemovalMedical Provider Network (MPN)Access StandardsPrimary Treating PhysicianSpecialistGeographic AreaAdministrative Director's RuleLabor CodeIndustrial Injury
References
Case No. ADJ7422993
Regular
Apr 06, 2015

SHIRLEY LESCALLETT vs. WAL-MART, ACE AMERICAN INSURANCE, YORK RISK SERVICES

In this workers' compensation case, the applicant sought to select a pain management specialist as her primary treating physician. The employer's Medical Provider Network (MPN) did not have any pain management specialists within the 15-mile/30-minute access standard for primary physicians, though it did have specialists within a 30-mile/60-minute radius. The Appeals Board affirmed the WCJ's decision, holding that if an applicant chooses a specialist for their primary care, the MPN must provide at least three physicians of that specialty within a 15-mile/30-minute radius. Since the defendant's MPN failed to meet this standard for pain management specialists, the applicant was permitted to choose one outside the MPN. A dissenting opinion argued that the 30-mile/60-minute standard for specialists should apply, allowing the applicant to select a physician within that broader radius from the MPN.

MPNMedical Provider NetworkPrimary Treating PhysicianSpecialistAccess StandardsAdministrative Director's RulePain Management PhysicianGeographic RadiusLabor CodeWorkers' Compensation Appeals Board
References
Case No. ADJ9798663
Regular
Sep 02, 2015

ALEJANDRO SAUCEDO SAHAGUN vs. TXC LOUTER'S DAIRY, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the applicant's petition for reconsideration, rescinding the previous award. The applicant sought to change treating physicians outside the defendant's Medical Provider Network (MPN), arguing the MPN failed to meet access standards for primary treating physicians within 15 miles or 30 minutes of his home or work. The Board found the trial judge applied an incorrect, less stringent access standard, and remanded the case for application of the proper standard. The applicant's injury and initial treatment within the MPN were admitted.

Workers' Compensation Appeals BoardMedical Provider NetworkMPN access standardsAdministrative Director's Rule 9767.5rural areasprimary treating physicianorthopedic physiciansoccupational health servicesLab. Code § 4600Lab. Code § 4616
References
Case No. ADJ8759396
Regular
Feb 27, 2015

Jose Diaz vs. Timber Works Construction, Berkshire Hathaway

This Workers' Compensation Appeals Board case involves applicant Jose Diaz seeking reconsideration of a prior order regarding his employer's Medical Provider Network (MPN). The primary issue is whether the MPN's physician accessibility standards, which are tied to the "workplace" or residence, are met. The Board granted reconsideration, rescinded the previous order, and remanded the case, finding the MPN may be defective if it doesn't comply with physician access standards relative to the applicant's residence, given the employer's failure to meet the "workplace" standard. The Board also noted that the applicant's inability to travel, while a factor, was not the deciding point in this decision to remand.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNWorkplaceResidencePhysician Access StandardsTitle 8 Section 9767.5Pain ManagementPhysical MedicineCannot Travel Exception
References
Case No. ADJ9627339, ADJ9627342
Regular
Mar 26, 2018

Esteban Escobar vs. PRN AMBULANCE, INSURANCE COMPANY OF THE WEST

This case concerns whether the defendant's Medical Provider Network (MPN) met access standards for a chiropractor as a primary treating physician. The Appeals Board granted the applicant's petition for removal, overturning the WCJ's decision. The Board found the MPN must provide three chiropractors within 30 minutes or 15 miles of the applicant's residence or workplace. Since the MPN did not meet this closer standard, the applicant is authorized to select a chiropractor outside the MPN.

MPNchiropractorsprimary treating physicianaccess standardsreconsiderationremovalWCJAdministrative Director's Ruleexpedited hearingstipulate
References
Case No. ADJ9618682
Regular
Sep 24, 2015

SOLEDAD GARCIA vs. LYONS MAGNUS, INC., AMERICAN ZURICH INSURANCE COMPANY, TRISTAR RISK MANAGEMENT

The applicant sought removal from a Workers' Compensation Appeals Board order that required her to treat within the defendant's Medical Provider Network (MPN). She argued the MPN lacked sufficient physiatrists, violating access standards, and sought to treat outside it. However, the Board denied removal, finding the applicant presented no evidence to support her claim that the MPN failed access standards or caused denial of treatment. The applicant failed to demonstrate significant prejudice or irreparable harm, and a lack of evidence was the primary impediment to her case.

Petition for RemovalMedical Provider Network (MPN)Access StandardsPrimary Treating Physician (PTP)PhysiatristPain ManagementPetition DenialFindings of Fact and Order (F&O)Workers' Compensation Appeals Board (WCAB)Rule 9767.5
References
Case No. ADJ10472000, ADJ104801639
Regular
Feb 07, 2023

MANUEL DE JESUS GALDAMEZ VASQUEZ vs. JAN AL INNERPRIZES, INC., SECURITY NATIONAL INSURANCE COMPANY, INSURANCE COMPANY OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior decision, remanding the case for further development of the medical record. The Board found that the administrative law judge and medical evaluator may have applied an incorrect legal standard regarding industrial causation for the applicant's hypertension and stroke. Specifically, the focus on whether work stress was "unusual" or "severe" was misplaced; the correct standard requires determining if subjectively perceived work stress was a contributing factor to the physical injury. The Board emphasized its duty to ensure substantial justice and develop the record when medical evidence is insufficient.

Workers' Compensation Appeals BoardPetition for ReconsiderationJoint Findings and OrderIndustrial InjuryHypertensionStrokeWork StressCausation StandardQualified Medical EvaluatorMedical Record Development
References
Case No. ADJ11676994
Regular
Aug 28, 2019

CLIFFORD MOORHOUSE vs. ALISAL GUEST RANCH, TRAVELERS DIAMOND BAR

This case concerns the defendant's petition for reconsideration of a workers' compensation award finding the applicant an employee. The applicant, a farrier, claimed cumulative industrial injury while working for the defendant ranch. The Board denied reconsideration, affirming the administrative law judge's finding that the applicant was an employee under the *Borello* standard. The Board found the defendant failed to meet its burden to prove independent contractor status, citing factors like the defendant's control over the work and the applicant's lack of investment. The Board also clarified that the *Dynamex* ABC test, while applicable to wage orders, does not supersede the *Borello* standard for workers' compensation employment determinations.

Workers' Compensation Appeals BoardClifford MoorhouseAlisal Guest RanchTravelers Diamond Barfinding of fact and awardpresumption of employmentsubstantial evidenceS. G. Borello & Sonsindependent contractorright to control
References
Case No. ADJ1040857
Regular
Feb 24, 2014

IRENE CHAVEZ vs. SOUTHERN CALIFORNIA AUTO AUCTION, BROADSPIRE

The Workers' Compensation Appeals Board denied the applicant's Petition for Reconsideration. The Board adopted the Administrative Law Judge's (ALJ) report, which found no violation of Labor Code section 132a. The ALJ credited the testimony of defense witnesses regarding the applicant's attendance issues and the employer's policies. The applicant failed to prove she was treated differently or suffered disadvantages due to her work-related injury.

Workers' Compensation Appeals BoardPetition for ReconsiderationWCJ reportGarza v. Workmen's Comp. Appeals Bd.LC 132a violationcredibility findingattendance policyterminationdepositionsecurity video
References
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