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

Case No. ADJ1787217
Regular
Jul 27, 2011

OFELIA LLAMAS vs. SUN TEN LABORATORIES INC., ZENITH INSURANCE CO.

The Appeals Board denied a lien claimant's petition for reconsideration, upholding the disallowance of their liens for unauthorized treatment outside the Medical Provider Network (MPN). The lien claimant's arguments regarding defendant's denial of benefits and MPN notification failures were rejected, as the evidence showed timely MPN care was offered and the MPN notification issue was not raised at trial. The Board also initiated sanctions against the lien claimant's representative for filing a frivolous petition citing non-existent documents and outside evidence, finding this constituted bad faith and a waste of Board resources.

Workers' Compensation Appeals BoardLien ClaimantMPN providersunauthorized treatmentself-procure medical treatmentMPN employee notification requirementsCCR 9767.12reasonableness and necessityPetition for ReconsiderationOrder of Removal
References
Case No. ADJ6613592
Regular
Aug 06, 2010

GIRASOL GARCIA vs. EXPEDIA MEDIA, LLC, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration of a prior decision. The Board found that the administrative law judge erred in definitively concluding the employer complied with Medical Provider Network (MPN) notification requirements. Doubts exist regarding whether initial MPN notifications were timely provided at the time of injury. Therefore, the case is returned to the trial level for further development of the evidentiary record and to refine the issues for decision, including the consequences of any improper notice.

MPN notificationTitle 8 California Code of Regulations Section 9767.12Labor Code Section 4616.3Knight v. United Parcel Serviceself-procured medical careadmissibility of medical reportstreatment with physicianreformulate issuesconsequences of failure to give noticecured notice
References
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
Case No. ADJ2743306
Regular
Oct 21, 2010

VALENTIN REYES vs. CALICO BUILDING MATERIALS, INC., INSURANCE COMPANY OF THE WEST

This case involves a lien claimant, California Pharmacy Management (CPM), seeking reconsideration of a decision disallowing its lien for treatment provided outside the employer's Medical Provider Network (MPN). The Appeals Board granted reconsideration, finding the petition was effectively timely filed due to administrative delay. The Board rescinded the original order to defer the issue of CPM's lien for further development of the record. This includes determining if the employer provided proper MPN notice and whether that failure makes them liable for self-procured treatment.

Workers' Compensation Appeals BoardMedical Provider NetworkMPN noticelien claimantpetition for reconsiderationstatutory time perioddue processLabor CodeKnight v. United Parcel Serviceindustrial injury
References
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
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
Case No. ADJ3002639 (LAO 0881928)
Regular
Jun 11, 2012

MIGUEL NAVA vs. BARRETT BUSINESS SERVICES, INC.

This case concerns an applicant's industrial injury to his spine and knees. The defendant sought reconsideration of a decision that allowed reimbursement for non-MPN providers before November 28, 2008. The Appeals Board granted reconsideration, finding the applicant was bound to select an MPN physician as of his March 11, 2008 deposition stipulation. Therefore, non-MPN services rendered after March 11, 2008, are not compensable.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNBarrett Business ServicesCorVel MPNLien ClaimantIndustrial InjurySpine InjuryKnee InjuryReconsideration
References
Case No. ADJ9087890
Regular
Jul 03, 2018

SHERLENE WILLIAMS vs. GOLDEN EMPIRE TRANSIT, RISICO CLAIMS MANAGEMENT

This case concerns a lien claimant's claim for reimbursement following applicant Sherlene Williams' industrial injury as a bus driver. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision denying the lien because the medical provider was not within the defendant's Medical Provider Network (MPN). The majority found the WCJ correctly disallowed the lien due to non-compliance with MPN requirements. A dissenting opinion argued the record was incomplete regarding MPN notice to the applicant and recommended further development of evidence.

Medical Provider NetworkMPNLien ClaimantReconsiderationFindings and OrdersCompromise and ReleaseBurden of ProofMPN NoticeLabor Code Section 4616.3Administrative Director's Rule 9767.12
References
Case No. ADJ2359364 (FRE 0248119) ADJ4245839 (FRE 0248120) ADJ3951771 (FRE 0248121)
Regular
Feb 04, 2010

MARIA SOLANO DE SOTO vs. FOSTER FARMS

Lien claimants sought reconsideration after their claims were denied for providing medical services outside the defendant's Medical Provider Network (MPN). The Board denied reconsideration, affirming the original decision that services provided after the applicant received proper MPN notice were not compensable. Petitioners stipulated to the applicant's MPN notice and their own lack of MPN participation, undermining their claim that the defendant's notice was deficient. Ultimately, the petitioners failed to prove the defendant neglected or refused to provide reasonable medical treatment, a necessary element for self-procured treatment claims under *Knight*.

MPNMedical Provider NetworkKnight v. United Parcel Servicelien claimantsFindings and Awarddisallowed liensproper MPN noticeLabor Code sections 4613.1 and 4613.3Administrative Director Rule 9767.12(a)self-procured medical treatment
References
Case No. ADJ9884969
Regular
Aug 07, 2015

FERNANDO RUIZ-LUCERO vs. GCA SERVICES GROUP, INC.; ACE AMERICAN INSURANCE COMPANY, administered by ESIS FREMONT

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, upholding the finding that the applicant could treat outside the defendant's Medical Provider Network (MPN). The MPN failed to meet access standards by not having three primary treating chiropractors within a 15-mile or 30-minute radius of the applicant's residence. This failure constitutes good cause for the applicant to seek treatment outside the MPN, as required by regulations ensuring timely access to appropriate medical care. The Board agreed with the WCJ's reasoning that the defendant's inadequate MPN access justified the applicant's out-of-network treatment.

MPNAccess StandardsPrimary Treating PhysicianMedical Provider NetworkChiropractorAdministrative Director RuleWCJReconsiderationLabor CodeSpecialty
References
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