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

Case No. ADJ8577504
Regular
Jun 23, 2015

JESUS PONCE vs. LAFAYETTE TEXTILES, CYPRESS INSURANCE COMPANY

This case concerns a lien claimant, Western Imaging Services, seeking reimbursement for photocopying expenses. The Appeals Board clarified that Western did not need to prove applicant sustained an industrial injury to recover its lien. However, Western must demonstrate that a contested claim existed when the expenses were incurred, that they were for proving or disproving that claim, and that they were reasonable and necessary. The Board rescinded the WCJ's decision and remanded the case to determine which specific expenses meet these criteria.

Workers' Compensation Appeals BoardLien ClaimantMedical-Legal ExpenseContested ClaimBurden of ProofIndustrial InjuryReconsiderationReasonable and Necessary ExpensesSubpoenaed RecordsPhotocopied Records
References
Case No. ADJ9542328
En Banc
Nov 14, 2019

ASHLEY COLAMONICO vs. SECURE TRANSPORTATION, NATIONAL UNION FIRE INSURANCE COMPANY

The Appeals Board held that a medical-legal provider has the initial burden to prove an expense was for a contested claim and was reasonable and necessary per Labor Code §§ 4620-4621, and a defendant does not waive these objections by failing to raise them in an Explanation of Review (EOR) under § 4622.

Med-Legal PhotocopyEn Banc DecisionPetition for ReconsiderationFindings and OrdersLien ClaimantExplanation of ReviewContested ClaimReasonable and Necessary ExpensesBurden of ProofLabor Code Section 4620
References
Case No. ADJ6774605
Regular
Sep 02, 2016

Tammy Tran vs. PROFESSIONAL SERVICE INDUSTRY, ZURICH LOS ANGELES

The Workers' Compensation Appeals Board granted reconsideration of the Administrative Law Judge's (ALJ) decision, which limited reimbursement for self-procured medical treatment. The Board found that the ALJ erred by only allowing reimbursement for treatment from the claim date until the denial date. Citing *McCoy v. Industrial Accident Commission*, the Board determined that the employer is liable for all reasonably necessary self-procured medical expenses incurred after the employer denied the claim, as this denial effectively refused to provide treatment. Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardSelf-Procured Medical TreatmentLabor Code Section 4600McCoy v. Industrial Accident CommissionDenial of ClaimReimbursementIndustrial InjuryReasonably Necessary Treatment
References
Case No. ADJ6984629
Regular
Oct 30, 2013

ROBERTA LYNNE MULLER vs. RIVERSIDE COUNTY HOSPITAL, CITY OF RIVERSIDE WORK COMP DIVISION

The Workers' Compensation Appeals Board denied the lien claimant's petition for reconsideration, upholding the administrative law judge's decision to disallow the lien. The lien claimant failed to meet its burden of proof to establish that the incurred expenses for subpoenas were reasonable and necessary for a contested claim. The Board found that the mere issuance of subpoenas did not demonstrate a contested claim or the necessity of the records, especially since the injury was admitted and records may have already been provided. Therefore, the lien was denied as the claimant did not prove entitlement to payment for valid medical-legal expenses.

Lien claimantPetition for ReconsiderationWorkers' Compensation Appeals Boardmedical-legal expensescontested claimsubpoenas duces tecumburden of proofreasonable and necessaryCompromise and Releaselien trial
References
Case No. ADJ8878834
Regular
Dec 22, 2016

RAMIRO CALDERA vs. CAR SOUND EXHAUST SYSTEM, INC.; COMPWEST

This case involves a dispute over lien claimant Western Imaging's entitlement to reimbursement for subpoenaed records in a workers' compensation claim. The WCJ initially disallowed the lien, finding Western Imaging failed to prove the records' reasonableness and necessity. The Appeals Board granted reconsideration, rescinding the WCJ's decision and returning the case for further proceedings. The Board clarified that medical-legal expenses are recoverable if incurred to prove or disprove a contested claim and that reasonableness is assessed at the time of expense incurrence, regardless of whether the subpoenaed records ultimately proved the claim. The Board also emphasized the defendant's obligation to specifically object to such expenses within a timely manner.

Workers' Compensation Appeals BoardLien ClaimantMedical-Legal ExpensesContested ClaimLabor Code Section 4620Labor Code Section 4621Labor Code Section 4622Reasonable and NecessaryBurden of ProofDiscovery
References
Case No. VNO 0301388
Regular
Sep 05, 2007

JACQUELYN GREEN vs. GENERAL MOTORS CORPORATION, SEDGWICK CLAIMS MANAGEMENT

This case involves an employer's attempt to present non-medical evidence regarding the reasonableness of expenses for an applicant's home elevator. The Appeals Board granted removal, reversing the trial judge's exclusion of these exhibits and witnesses. The Board found that while the medical necessity of the elevator was stipulated, the "reasonable expense" of its installation was a valid issue for which non-medical evidence should be admissible.

removalevidentiary rulingnon-medical exhibitsmedical necessitydue processsubstantial prejudiceirreparable harmpermanent disabilitystipulated awardreasonable expense
References
Case No. ADJ841280 (SDO 0360395)
Regular
Dec 06, 2016

ADRIEL DE LA CRUZ vs. PROTECH PAINTING, ZENITH INSURANCE COMPANY

This case involves a lien claimant's challenge to a prior finding that their services were not reasonable and necessary. The Appeals Board granted reconsideration because the administrative law judge erred in disallowing the lien based on the availability of alternative record retrieval methods. The Board found that a contested claim existed, and the applicant's attorney had broad discretion in choosing to subpoena records for discovery. The case is returned for a new decision on the amount the lien claimant is entitled to, focusing on the reasonableness of expenses incurred at the time.

Workers' Compensation Appeals BoardReconsiderationLien ClaimantMedical-Legal ExpensesContested ClaimLabor Code Section 4622SubpoenaReasonable and Necessary ServicesTemporary DisabilityIndustrial Injury
References
Case No. ADJ9542328
Significant
Nov 14, 2019

Ashley Colamonico vs. Secure Transportation, National Union Fire Insurance Company, Administered by SEDGWICK CMS

This en banc decision clarifies that a medical-legal provider bears the initial burden of proof to show that its expenses were reasonable and necessary at the time they were incurred, and a defendant does not waive these objections by failing to raise them in a timely Explanation of Review (EOR).

En bancPetition for ReconsiderationMed-Legal Photocopylien claimantexplanation of reviewcontested claimreasonable and necessarysubpoena duces tecumburden of proofmedical-legal expenses
References
Case No. ADJ10194913 ADJ10194766 ADJ10194759
Regular
Oct 18, 2019

ABRAHAM ANAYA vs. BO ENTERPRISES, INC., dba SIERRA WEATHERIZATION CO., REDWOOD FIRE & CASUALTY INS. CO., c/o BERKSHIRE HATHAWAY HOMESTATE COMPANIES

The Workers' Compensation Appeals Board (WCAB) granted reconsideration to address a lien claimant's petition regarding reimbursement for copying services. The WCAB reversed the original finding that copying the insurer's claims file was not a medical-legal expense, finding it was valid. However, the Board affirmed the denial of reimbursement for the employer's MSDS and additional reprint charges, remanding the case for further proceedings on the reasonable value of copying the insurer's claims file.

Workers' Compensation Appeals BoardMed-Legal LLCJoint Findings and Ordersmaterial safety data sheetinsurance claims filemedical-legal expensesreprint chargessubpoena duces tecumemployment filesKaiser Hospital records
References
Case No. ADJ9542328
Regular
Nov 14, 2019

ASHLEY COLAMONICO vs. SECURE TRANSPORTATION, NATIONAL UNION FIRE INSURANCE COMPANY, SEDGWICK CMS

This en banc decision clarifies that medical-legal providers, not defendants, bear the initial burden of proving their services were reasonable and necessary pursuant to Labor Code section 4621. Defendants do not waive objections based on sections 4620 or 4621 by failing to raise them in an Explanation of Review. The Appeals Board rescinded the WCJ's findings and remanded the case for further proceedings on the provider's burden of proof. This precedent applies to all future Appeals Board decisions.

Med-Legal PhotocopyExplanation of Review (EOR)Contested ClaimBurden of ProofReasonable and Necessary ExpensesLien ClaimantWaiver of ObjectionsSection 4620Section 4621Section 4622
References
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