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

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 The WCAB rescinded the decision and returned the case to the trial level, finding the medical opinions of Dr.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. ADJ7897857
Regular
Feb 29, 2012

ALFONSO PONCE DE LEON vs. BARRETT BUSINESS SERVICES, CORVEL INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded a trial judge's order allowing applicant treatment outside the defendant's Medical Provider Network (MPN). The WCAB found the judge improperly investigated the facts himself, violating judicial ethics. The evidence gathered by the judge did not definitively prove MPN non-compliance, and the judge failed to contact all listed physicians. Therefore, the case was returned for a new hearing where parties must present their own evidence regarding MPN physician availability.

MPNMedical Provider NetworkWorkers' Compensation Appeals BoardWCJReconsiderationAccess StandardsRegular PhysicianIndustrial InjuryOrthopedic SpecialistExpedited Hearing
References
Case No. ADJ11314069
Regular
Nov 20, 2018

LUIS TOLENTINO vs. LUKE'S ROOFING, REDWOOD FIRE INSURANCE COMPANY

This case concerns the proper designation of a primary treating physician within a Medical Provider Network (MPN). The applicant selected Dr. Huang, who was employed by Casa Colina. The defendant argued this was improper because Casa Colina was only listed for ancillary services and Dr. Huang was not individually listed in the MPN. The Board affirmed the WCJ's decision, holding that Dr. Huang's designation was proper as long as he acted through Casa Colina, which was included in the MPN without restriction. Regulations permit an entity in the MPN to have its employee physicians considered part of the network, unless specifically excluded.

Workers' Compensation Appeals BoardPetition for ReconsiderationPrimary Treating PhysicianMedical Provider Network (MPN)Ancillary ServicesEmployee PhysicianNon-natural personApplicable RegulationsEntityEmployee
References
Case No. ADJ7048296
En Banc
Apr 20, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America

The Appeals Board held that if an applicant has improperly obtained medical treatment outside the employer’s validly established and properly noticed Medical Provider Network (MPN), the reports of the non-MPN treating physicians are inadmissible and may not be relied upon to award compensation.

MPNnon-MPNinadmissibilitymedical reportstemporary disability indemnityen banc decisionWorkers' Compensation Appeals Boardreconsiderationmedical provider networkself-procured 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
Case No. ADJ7048296
Significant
Apr 20, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America, Adjusted by ESIS

The Appeals Board holds that medical reports from unauthorized, non-MPN (medical provider network) physicians are inadmissible and cannot be relied upon to award compensation; consequently, the employer is not liable for the cost of such reports.

MPNnon-MPNadmissibilitymedical provider networkunauthorized treatmentprimary treating physicianen bancWorkers' Compensation Appeals BoardLabor Codetemporary disability
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. ADJ8128282
Regular
Jan 23, 2014

ANGELA EGBIKUADJE vs. CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATIONS, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, returning the case for further proceedings. The defendant, California Department of Corrections and Rehabilitation, argued that the applicant's psychiatric injury claim was preempted by the ADA and not proven under Labor Code section 3208.3. The Board found the original decision lacked proper analysis regarding predominant industrial causation and the good faith personnel action defense. Therefore, the case was remanded for further development of the record, including expert medical opinion on these issues.

Workers' Compensation Appeals BoardAngela EgbikuadjeCalifornia Department of Corrections and RehabilitationLegally UninsuredState Compensation Insurance FundADJ8128282Van Nuys District OfficeReconsiderationFindings and AwardIndustrial cumulative trauma injury
References
Case No. SAC 342547
Regular
Jun 06, 2008

CLIFFORD J. FARIA vs. BEST BUY COMPANY, ACE AMERICAN INSURANCE COMPANY

The Appeals Board granted reconsideration and rescinded the prior order, returning the case to the trial level for further proceedings. This decision addresses disputes regarding the applicant's right to change treating physicians, the defendant's Medical Provider Network (MPN) obligations, and the calculation of the applicant's average weekly earnings. The Board requires further development of the record on these key issues.

Workers' Compensation Appeals BoardBest Buy CompanyAce American Insurance CompanyClifford FariaOpinion and Order Granting ReconsiderationDecision After ReconsiderationAdministrative Law Judge (WCJ)Treating PhysicianMedical Provider Network (MPN)Temporary Disability Indemnity
References
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
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