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

Case No. ADJ10975151
Regular
Jan 06, 2020

RUSSELL CAMARA vs. TESLA, INC., AMERICAN ZURICH INSURANCE COMPANY

In this workers' compensation case, the Applicant sustained an admitted industrial injury to the lumbar spine. The Applicant's primary treating physician (PTP) designated a secondary physician to evaluate permanent and stationary status and impairment, whose report the PTP adopted. The defense challenged the validity of this secondary physician's report, arguing only the Panel Qualified Medical Examiner's (PQME) report was properly obtained. The Workers' Compensation Appeals Board denied the Petition for Reconsideration, affirming that the PTP, or a physician designated by the PTP, is authorized to render opinions on medical issues, provided proper notice and procedural requirements are met. The Board found the designation and subsequent report were compliant with Labor Code and Administrative Director Regulations.

Workers' Compensation Appeals BoardPetition for ReconsiderationPrimary Treating PhysicianQualified Medical ExaminerLabor Code Section 4061.5Permanent and Stationary ReportMedical-Legal EvaluationSecondary PhysicianAdministrative Director Rule 9785Designation of Physician
References
0
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
2
Case No. ADJ7925931, ADJ7925917
Regular
Sep 27, 2017

LUISA SEQUEIRA vs. RANDSTAD PLACEMENT PROS, ACE AMERICAN

This case involved an applicant seeking reconsideration of a workers' compensation award, arguing that the declaration of readiness to proceed was defective due to a lack of a primary treating physician's report on permanent disability. The Appeals Board affirmed the original award, finding that Labor Code section 4061(i) does not require all treating physicians to find maximum medical improvement before proceeding to trial. The Board reasoned that the applicant's Panel Qualified Medical Evaluator (PQME) provided substantial medical evidence sufficient to support the permanent disability award, even though primary treating physicians had not yet found MMI. Therefore, the WCJ correctly relied on the PQME's report.

Declaration of readinessPermanent disabilityPrimary treating physicianQualified Medical EvaluatorMaximum medical improvementLabor Code section 4061(i)Substantial medical evidenceFindings Award and OrderReconsiderationIndustrial injury
References
3
Case No. ADJ2270309 (VNO 0113668) ADJ4503834 (VNO 0113665) ADJ3103605 (VNO 0113666) ADJ2309113 (VNO 0113667)
Regular
Aug 17, 2009

MARIA GARCIA vs. CITY OF LOS ANGELES

This case involves a dispute over whether Dr. Nagelberg is the applicant's primary treating physician (PTP). The Appeals Board granted reconsideration, reversing the trial judge's finding that Dr. Nagelberg was not the PTP. The Board found substantial evidence that Dr. Nagelberg is indeed the PTP, and that the trial judge erred in relying on an unadmitted nurse case manager's report. The matter is returned to the trial level for further proceedings to determine the applicant's entitlement to medical treatment.

Workers' Compensation Appeals BoardMaria GarciaCity of Los AngelesPetition for RemovalPetition for DisqualificationPetition for ReconsiderationFindings and OrderWorkers' Compensation Judge (WCJ)Primary Treating Physician (PTP)Qualified Medical Evaluator (QME)
References
2
Case No. ADJ6439173
Regular
Jan 19, 2017

JULIETA CEBALLOS vs. SUNVIEW VINEYARDS of CALIFORNIA, WAUSAU INSURANCE COMPANIES

The Workers' Compensation Appeals Board (WCAB) rescinded the original award, finding the primary treating physician's (PTP) report insufficient to establish injury to all claimed body parts. The WCAB also raised concerns about the admissibility of a supplemental PTP report obtained after the Mandatory Settlement Conference without a showing of due diligence. The case is returned to the trial level for further proceedings to adequately address the admitted body parts and develop the record. A dissenting opinion argued the PTP's reports constituted substantial evidence and no further development was needed.

WCABReconsiderationPrimary Treating PhysicianQualified Medical Evaluatorsubstantial evidencePetition for ReconsiderationFindings Orders and AwardMandatory Settlement ConferenceLabor Code Section 5502due diligence
References
16
Case No. ADJ19947925
Regular
May 19, 2025

Andres De Jesus Garcia vs. Slater's 50/50, Security National Insurance Company

Applicant, Andres De Jesus Garcia, sought reconsideration of a March 12, 2025 Findings and Award (F&A) which denied his request for a new primary treating physician (PTP) or a second opinion. The workers' compensation administrative law judge (WCJ) had found that the applicant reached maximum medical improvement (MMI) based on reports from his PTP and a panel qualified medical evaluator (PQME). Applicant contended he is entitled to a change of PTP or a second opinion within the medical provider network (MPN) under various Labor Code sections and WCAB Rules. The Appeals Board granted the Petition for Reconsideration, deferring a final decision after reconsideration to allow for further review of the factual and legal issues.

Petition for ReconsiderationMedical Provider Network (MPN)Primary Treating Physician (PTP)Maximum Medical Improvement (MMI)Qualified Medical Evaluator (PQME)Labor Code sections 4616.3 and 4616.4WCAB Rules 9767.6(e) and 9767.7Tenet/Centinela Hospital Medical Center v. Workers' Comp. Appeals Bd. (Rushing)Labor Code section 5909Electronic Adjudication Management System (EAMS)
References
12
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
3
Case No. ADJ7267845
Regular
Feb 21, 2012

JOSE ACEVEDO vs. TREND PERSONNEL, CHARTIS INSURANCE, GALLAGHER BASSETT SERVICES

This case concerns whether medical liens for treatment rendered after December 18, 2008, are valid. The primary treating physician, Dr. Hoegel, released the applicant from care on that date, and the applicant failed to object to this determination under Labor Code sections 4061 and 4062. Therefore, the applicant could not designate a new primary treating physician and any subsequent treatment liens are barred. The Appeals Board granted reconsideration to clarify that the applicant's failure to follow statutory objection procedures invalidates post-release medical liens.

Workers' Compensation Appeals BoardReconsiderationDecision After ReconsiderationFindings of Facts Re: LiensTenet/Centinela Hospital Medical Center v. Workers' Comp. Appeals Bd. (Rushing)Primary Physician's Permanent and Stationary ReportCompromise and ReleaseLien ClaimantsLabor Code section 4061(b)Labor Code section 4062(a)
References
1
Case No. ADJ9724680
Regular
Sep 17, 2018

JAIME RAMIREZ LEON vs. PEOPLEASE/FTU, NATIONAL INTERSTATE INSURANCE

The applicant sought reconsideration of an award denying temporary disability, permanent disability, and further medical care for a right shoulder injury. The applicant argued the primary treating physician's report lacked substantial evidence due to an inadequate history and exam, and the WCJ erred in not relying on the PQME's report. The Appeals Board granted reconsideration to develop the record, specifically regarding whether the primary treating physician reviewed an MRI prior to her report. The original award was rescinded, and the matter was returned for further proceedings and a new decision by the WCJ.

WCABPetition for ReconsiderationFindings of Fact Award and OrderAdministrative Law JudgePrimary Treating PhysicianPQMESubstantial EvidenceMedical ReportInadequate HistoryInadequate Medical Exam
References
12
Case No. ADJ8677592
Regular
Aug 27, 2018

LINDA DAVIES vs. SECURITAS SECURITY SERVICES USA, INC.

This case involves a dispute over reimbursement for medical-legal expenses incurred by a lien claimant, Dr. Kauss, who was designated as the applicant's primary treating physician. The Workers' Compensation Appeals Board (WCAB) rescinded the initial award, finding that the WCJ erred in determining the compensability of Dr. Kauss's reports. The WCAB remanded the case for further proceedings to evaluate compliance with specific statutory requirements regarding objections to medical-legal bills and the distinction between IBR and non-IBR disputes. A dissenting opinion argued Dr. Kauss did not fulfill the duties of a primary treating physician and should not be reimbursed.

Workers' Compensation Appeals BoardReconsiderationMedical-Legal ExpensesPrimary Treating PhysicianLabor Code Section 4060Labor Code Section 4061Lien ClaimantIndependent Bill ReviewExplanation of ReviewDefense Attorney
References
3
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