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

Case No. ADJ10369582
Regular
Nov 05, 2018

Barbara Riggs vs. Sears Holdings Corporation, ACE American Insurance Company

This case involves an applicant seeking workers' compensation benefits who claims she cannot find a physician within the defendant's Medical Provider Network (MPN) due to her deafness and past negative experiences. The Administrative Law Judge initially allowed out-of-network treatment based on "exceptional circumstances." However, the Appeals Board granted reconsideration to develop the record, finding that the primary issue is whether the defendant neglected or refused to provide reasonably necessary treatment within its MPN. The Board rescinded the prior order and returned the case for further proceedings to determine if the MPN physician can accommodate the applicant's needs and if the defendant's prior actions constituted neglect or refusal.

Workers' Compensation Appeals BoardSears Holdings CorporationACE American Insurance CompanyESISPetition for ReconsiderationFindings and OrdersMedical Provider Network (MPN)exceptional circumstancesself-procure medical treatmentLabor Code section 4600
References
Case No. ADJ7555799 (MF) ADJ7561888
Regular
Sep 08, 2017

REYNA PANIAGUA vs. T & R BANGI'S AGRICULTURAL SERVICES, INC., SEABRIGHT INSURANCE, administered by ENSTAR GROUP, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking reconsideration of a finding that her employer did not refuse to provide medical treatment. The applicant's designated Medical Provider Network (MPN) physicians were unable to treat her, leading to delays and her eventual notification that a provider was no longer accepting new patients. Despite the applicant's frustration and inability to secure treatment within the MPN, the Board affirmed the original finding. The Board concluded there was insufficient evidence that the defendant neglected or refused to provide the requested medical treatment.

Workers Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)Self-Procured TreatmentNeglect or Refusal to Provide TreatmentStipulations With Request for AwardCompromise and ReleaseExpedited HearingDeclaration of David KestnerCentral Valley Occupational Medical Group (CVO)
References
Case No. AHM 127807
Significant
Oct 10, 2006

Bruce Knight, Applicant vs. United Parcel Service, Liberty Mutual Insurance Company

An employer's failure to provide an employee with the required notice of their rights under a Medical Provider Network (MPN) constitutes a neglect or refusal to provide reasonable medical treatment, thereby making the employer liable for reasonable medical treatment self-procured by the employee.

Medical Provider NetworkMPN noticeself-procured treatmentemployer liabilityduty to notifyLabor Code section 4600neglect or refusalreasonable medical treatmenten banc decisionworkers' compensation
References
Case No. AHM 127807, AHM 129147
En Banc
Oct 10, 2006

Bruce Knight vs. United Parcel Service, Liberty Mutual Insurance Company

The Appeals Board holds that an employer's failure to provide required notice of rights under a Medical Provider Network (MPN) constitutes a neglect or refusal to provide reasonable medical treatment, making the employer liable for reasonable medical treatment self-procured by the employee.

Medical Provider NetworkMPN noticeself-procured treatmentLabor Code 4600Labor Code 4616employer liabilityinsurer liabilityneglect or refusalreasonable medical treatmentemployee rights
References
Case No. ADJ10581300
Regular
Dec 14, 2018

LESLIE HYNES vs. GREAT CLIPS, THE HARTFORD INSURANCE GROUP

The Workers' Compensation Appeals Board affirmed a prior order denying an employee's request to treat outside her employer's Medical Provider Network (MPN) at the employer's expense. The Board found no evidence that the employer neglected or refused to provide medical treatment. Therefore, the employee is not entitled to select a physician outside the MPN at the defendant's expense. However, the employee retains the right to self-procure treatment outside the MPN at her own cost.

Workers' Compensation Appeals BoardReconsiderationFindings of Fact and OrderMedical Provider NetworkMPNSelf-procure treatmentNeglect or refusalIndustrial injuryPrimary treating physicianWCJ
References
Case No. SRO 0139219
Regular
Aug 11, 2008

JENNIFER BALKOWITSCH vs. HOME DEPOT

This case involves an applicant denied self-procured medical treatment by her employer, Home Depot, after failing to secure an MPN physician within reasonable proximity who would accept her. The Appeals Board reversed the initial finding, holding Home Depot liable for self-procured treatment. This decision was based on Home Depot's failure to prove it reasonably provided an MPN physician in accordance with accessibility standards, constituting a neglect or refusal to provide reasonable medical treatment.

Medical Provider NetworkMPN access standardsself-procured medical treatmentreasonable medical treatmentneglect or refusalapplicant's residenceemployment dutiesadministrative regulationemployer's obligationphysician availability
References
Case No. GRO 0032684
Regular
Aug 28, 2007

LUIS CONTRERAS vs. NORTH AMERICAN FIRE HOSE, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board affirmed the WCJ's decision finding an industrial injury and a penalty for unreasonable delay in medical treatment, but denied the applicant's request to go outside the Medical Provider Network (MPN). Although a four-month delay occurred, the Board found that the employer's good-faith efforts to secure treatment within the MPN meant there was no "neglect or refusal" to justify going outside the network. Therefore, the applicant remains within the MPN for treatment.

Workers' Compensation Appeals BoardReconsiderationMedical Provider Network (MPN)Unreasonable DelayLabor Code Section 5814Self-Procured TreatmentNeglect or RefusalKnight v. United Parcel ServiceAndrade v. State Comp. Ins. FundPhysician Choice
References
Case No. ADJ6635537
Regular
May 06, 2011

EDDIE ESPINOZA vs. BARRETT BUSINESS SERVICES, INC.

This case involves a dispute over medical treatment network (MPN) compliance for an industrial back injury. The WCAB granted reconsideration to address whether the defendant's inadequate MPN notices led to a neglect or refusal to provide reasonable medical treatment, impacting the admissibility of outside medical reports. The Board will require the WCJ to re-evaluate MPN compliance and the propriety of further medical development. The case is returned to the trial level for further proceedings and a new decision consistent with the Board's opinion.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)ReconsiderationFindings Award and OrderIndustrial InjuryMedical TreatmentTemporary DisabilityPermanent DisabilityApportionmentMedical Legal Process
References
Case No. ADJ6958632
Regular
Jun 16, 2010

CRUSTINA MEDRANO vs. LOS ALTOS FARMS, LLC, ZENITH

The Appeals Board granted Zenith Insurance's petition for reconsideration, reversing the WCJ's award of self-procured medical treatment. The Board found that the applicant received proper notification of Zenith's Medical Provider Network (MPN) at the time of her injury. Furthermore, the Board determined that the applicant knew or should have known she was being treated within the MPN and that any alleged lack of notice did not result in a neglect or refusal to provide reasonable medical treatment. Therefore, the applicant is not entitled to reimbursement for self-procured treatment outside the MPN.

MPNMedical Provider NetworkreconsiderationFindings Award and OrderZenith Insurance CompanyLabor Code section 4600self-procured medical treatmentKnight v. United Parcel Servicenotice requirementsneglect or refusal
References
Case No. ADJ6490669
Regular
Sep 05, 2012

FELIX CHAVEZ vs. T.D. HAYES COMMUNICATIONS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied reconsideration of a decision concerning applicant Felix Chavez's claim. The Board upheld the judge's credibility findings and admonished lien claimants for procedural missteps. Importantly, the Board clarified that an employer's alleged failure to properly notice their Medical Provider Network (MPN) does not automatically obligate them to reimburse self-procured treatment outside the MPN if reasonable treatment was not neglected or refused. Furthermore, the lien claimants failed to prove the necessity and reasonableness of the claimed medical services and costs.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeMedical Provider Network (MPN)Self-Procured TreatmentNotice RequirementsNeglect or RefusalReasonable Medical TreatmentBurden of ProofReasonably Required Treatment
References
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