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

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
18
Case No. ADJ9415335
Regular
Oct 21, 2014

ALICIA LYNCH vs. COUNTY OF KERN

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior finding that the applicant was entitled to treat outside the defendant's Medical Provider Network (MPN). The Board found that the applicant failed to meet her burden of proving that the defendant neglected or refused to provide medical care within the MPN. Specifically, the applicant's unsubstantiated claim of one failed appointment attempt with an MPN physician and subsequent designation of an out-of-network doctor was insufficient. Therefore, the defendant retains control of the applicant's medical treatment within the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPetition for ReconsiderationPetition for RemovalFindings and OrderPrimary Treating PhysicianPTPKnight v. United Parcel ServiceSB 863
References
2
Case No. ADJ9048259
Regular
Dec 30, 2015

Antonio Avila vs. Barrett Business Services, Inc., Corvel Insurance Company

Here's a summary of the case in four sentences for a lawyer: The Workers' Compensation Appeals Board denied reconsideration, upholding the judge's decision that the applicant must treat within the employer's Medical Provider Network (MPN). The Board found that while there were some informational deficiencies, they did not amount to a denial of medical treatment that would justify treating outside the MPN. Crucially, the applicant admitted he liked his MPN physician and only sought to change doctors based on his attorney's recommendation. Evidence showed the employer promptly provided medical treatment and confirmed the applicant's treating physician was within their MPN.

Workers' Compensation Appeals BoardPetition for ReconsiderationMPNMedical Provider NetworkWCJHealth First Medical GroupDr. Eliasattorney's recommendationBBSI MPNCorvel Insurance Company
References
1
Case No. SAL 0118930
Regular
May 02, 2008

MARIA I. GONZALEZ vs. SAN BENITO FOODS and SAFETY NATIONAL INSURANCE C/O CAMBRIDGE INTEGRATED SERVICES

The applicant sought reconsideration of a WCJ's decision that found she intentionally left the Medical Provider Network (MPN). The applicant argued that Pinnacle Healthcare wasn't a specific physician and her MPN information was insufficient. The Appeals Board granted reconsideration and amended the order to clarify that the applicant must return to the specific doctor treating her at Pinnacle Healthcare in Gilroy, or select a new physician within the MPN.

Medical Provider NetworkMPNPrimary Treating PhysicianIndustrial InjuryPalletizerFindings and OrderPetition for ReconsiderationWCJMedical Provider HandbookIndustrial Injury
References
0
Case No. SAL 96100; 96096
Regular
Jul 03, 2007

JEANNE LAWRENCE vs. CYPRESS URGENT CARE and PREFERRED EMPLOYERS INSURANCE, TENET/DOCTORS HOSPITAL OF MANTECA

This case involves a worker who sustained two industrial injuries, the first in 2001 with Cypress Urgent Care and the second in 2001 with Tenet/Doctors Hospital of Manteca. The defendant, Tenet/Doctors Hospital, sought reconsideration of a joint findings and award that attributed 25% of the worker's temporary disability and vocational rehabilitation costs to their injury. The WCAB granted reconsideration, finding that while the second injury occurred after the first, evidence indicated the first injury contributed to the worker's need for benefits, thus supporting the apportionment.

WCABReconsiderationJoint Findings and AwardPetition for ReconsiderationTemporary Total Disability (TTD)Vocational RehabilitationApportionmentConsecutive InjuriesMedical TreatmentSelf-Insured
References
0
Case No. ADJ6538283
Regular
Jun 03, 2009

SOPHIA CALIX vs. TARGET CORPORATION, Permissibly Self-Insured and Administered By SEDGWICK, CLAIMS MANAGEMENT SERVICES

The Appeals Board granted reconsideration, rescinding the WCJ's finding that the defendant failed to comply with MPN regulations. The applicant received treatment outside the MPN on the date of injury but was transferred to MPN providers shortly thereafter. The Board found that the defendant provided timely notice of MPN rights and that the applicant did not suffer neglect in receiving medical treatment. The matter was returned to the trial level to clarify the record regarding initial MPN notification.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Administrative Director RulesPetition for ReconsiderationFindings and OrderWCJacute conditiontimely notificationClaim FormKnight v. United Parcel Service
References
1
Case No. ADJ9466570
Regular
Dec 24, 2014

ELVIRA HERNANDEZ vs. NEWCO FOODS, INC., Operating As JACK IN THE BOX, SECURITY NATIONAL, Administered By AMTRUST NORTH AMERICA

The Workers' Compensation Appeals Board granted reconsideration to clarify an earlier decision regarding a Medical Provider Network (MPN). The Board affirmed the finding that the defendant failed to prove the existence of a valid MPN. Consequently, findings related to MPN access standards and transfer of care were rescinded, with the applicant permitted to continue treatment outside the invalid MPN with her chosen physician. This decision primarily hinges on the defendant's failure to establish a legally compliant MPN.

Medical Provider NetworkMPNFindings of Fact and AwardPetition for Reconsiderationprimary treating physiciantransfer of careself-procured medical treatmentTitle 8section 9767.5(b)Title 8
References
0
Case No. ADJ8205235
Regular
Feb 06, 2013

HECTOR GOMEZ vs. FASTENAL, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

This case concerns an injured worker, Hector Gomez, who sought medical treatment outside his employer's Medical Provider Network (MPN). The Board overturned the finding that the employer lost control of medical treatment, finding that the employer's technical failure to schedule the initial MPN visit did not deny treatment. The Board also held that the worker could not select a non-MPN specialist simply because an MPN specialist declined to act as a primary treating physician. Therefore, the applicant must obtain treatment through the defendant's MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)SpecialistLabor Code section 4616.3Administrative Director's Rule 9767.6initial medical evaluationchange of physicianforfeiture of medical controlaccess standards
References
1
Case No. ADJ3823114 (MON 0252208)
Regular
Dec 03, 2015

ILANA BENLULU vs. BEVERLY SINAI TOWERS, SEDGWICK CLAIMS MANAGEMENT SERVICES, servicing facility for CIGA for RELIANCE INSURANCE COMPANY, in liquidation

This case concerns the proper transfer of an injured worker into a defendant's Medical Provider Network (MPN). The applicant contended she pre-designated her physician, avoiding MPN requirements, but provided no supporting evidence. The Board found that the defendant's prior attempts to transfer the applicant into the MPN were invalid due to insufficient notice or the MPN's failure to meet minimum access standards. Ultimately, the Board determined that a July 15, 2014 notice, properly served and containing all required information, effectively transferred the applicant into the MPN on August 14, 2014.

MPNMedical Provider NetworkReconsiderationFindings of FactWorkers' Compensation Appeals BoardLabor CodePre-designation of PhysicianContinuity of CareTransfer of CareMinimum Access Standards
References
0
Case No. MISSING
Regular Panel Decision

Stephens v. Cooper

Plaintiffs, a group of chiropractors, medical doctors, and PTS Thermal Imaging, brought an action against the Superintendent of the New York State Department of Insurance. They challenged a regulation establishing a fee schedule for thermography services under New York's no-fault automobile insurance law, alleging violations of the New York Administrative Procedure Act, due process, equal protection, and the Sherman Act. The Superintendent moved to dismiss the Sherman Act claims and for abstention. The court granted the motion to dismiss, abstaining under the Burford doctrine, finding that New York has a comprehensive insurance regulatory scheme and that the case involves a challenge to the Superintendent's implementation of state law, thus warranting federal court abstention.

Abstention DoctrineBurford AbstentionNo-Fault InsuranceFee Schedule RegulationThermography ServicesInsurance LawFederal Court JurisdictionSherman Antitrust ActDue Process ChallengeEqual Protection Challenge
References
9
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