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

Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
Case No. MISSING
Regular Panel Decision

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
Case No. ADJ1718435 (MON 0341690) ADJ2131482 (MON 0340861)
Regular
May 10, 2017

JEROME MITCHELL vs. COMMUTER EXPRESS, GALLAGHER BASSETT

This case involves a lien claimant, RS Medical, seeking reconsideration after its $6,800.28 lien for medical treatment was disallowed by the WCJ. The WCJ found RS Medical failed to prove the treatment was reasonable and necessary for the admitted industrial injuries. The Appeals Board granted reconsideration, finding the WCJ erred by focusing solely on neck treatment when evidence indicated prescriptions were for multiple body parts, including admitted injuries. The matter is returned to the trial level for the WCJ to re-evaluate the medical evidence and determine the reasonableness and necessity of the treatment.

Lien ClaimReconsiderationWCJUtilization ReviewTENS deviceMedical TreatmentBurden of ProofSubstantial EvidenceReasonableness and NecessityIndustrial Injury
References
5
Case No. ADJ2401554
Regular
Apr 02, 2013

JOSHUA GROSSMAN vs. ARAMARK UNIFORM SERVICE, ACE AMERICAN INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, upholding its prior decision to grant the lien claimant's claim for medical treatment costs. The Board found that the defendant failed to properly notify the applicant of their Medical Provider Network (MPN) and that the applicant's attempts to secure an MPN physician were unsuccessful. Defendant's failure to provide sufficient assistance in transferring care was deemed a neglect to provide reasonable medical treatment, making them liable for self-procured treatment. The Board also found the lien claimant's treatment reasonable and consistent with the Agreed Medical Examiner's recommendations.

MPNMedical Provider NetworkLien ClaimantReconsiderationSelf-Procured Medical TreatmentAgreed Medical ExaminerPrimary Treating PhysicianLabor Code Section 4600Substantial Medical EvidenceIndustrial Injury
References
7
Case No. ADJ1448881 (VNO 0460995)
Regular
Sep 06, 2017

CLEMENTE MEJIA vs. PACIFIC MAT, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision disallowing the balance of a lien for medical treatment provided by Dr. Arroyo. The administrative law judge found Dr. Arroyo failed to prove the reasonableness of services beyond progress and permanent and stationary reports, and that he was adequately compensated for reasonable services. The WCAB held that Labor Code section 4600(b), requiring medical treatment to be consistent with the Medical Treatment Utilization Schedule (MTUS) to be considered reasonably required, applied retrospectively to all open cases, including this one. Therefore, the original decision disallowing the remaining portion of the lien was affirmed.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings of FactOrderMedical treatment lienIndustrial injuryCumulative periodPermanent disabilityReasonableness of services
References
1
Case No. ADJ2401554 (FRE 023126)
Regular
Jan 07, 2013

JOSHUA GROSSMAN vs. ARAMARK UNIFORM SERVICE, ACE AMERICAN INSURANCE COMPANY

The Appeals Board granted reconsideration, reversing the judge's decision and finding the defendant liable for self-procured medical treatment. The defendant failed to prove they properly transferred the applicant into their Medical Provider Network (MPN) and neglected or refused to provide reasonable treatment by failing to ensure MPN physician availability. Consequently, the applicant's self-procured treatment from the lien claimant is deemed reasonable and compensable. The defendant is liable for the reasonable cost of this treatment, plus interest and penalties.

MPNself-procured medical treatmentneglect or refusal to provide medical treatmentprimary treating physicianlien claimantreasonable medical treatmentAramark Uniform ServiceAce American Insurance CompanySan Joaquin Accident & Medical GroupKnight v. Liberty Mut. Ins. Co.
References
16
Case No. MISSING
Regular Panel Decision
Nov 02, 2001

Fonville v. New York City Health & Hospitals Corp.

The plaintiff appealed an order from the Supreme Court, Kings County, which, upon reargument, adhered to a prior decision to dismiss a medical malpractice claim against the New York City Health and Hospitals Corporation (HHC). The claim alleged that HHC's emergency medical services (EMS) improperly treated the decedent. The appellate court reversed the order, reinstating the claim concerning improper treatment by EMS workers. The court reasoned that although municipalities generally have immunity for governmental functions, once an affirmative action is voluntarily undertaken, it must be performed with due care. Consequently, the claim of improper treatment was reinstated, while allegations of nonfeasance remained dismissed.

Medical MalpracticeMunicipal ImmunitySpecial RelationshipVoluntary UndertakingDue CareCPLR 3211(a)(7)Motion to DismissClaim ReinstatementAppellate ReviewEMS Negligence
References
5
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
9
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
5
Case No. ADJ1812869 (SAC 0356491)
Regular
Nov 10, 2010

DIVINA EMANO vs. UC DAVIS MEDICAL CENTER; Permissibly Self-Insured, Adjusted by SEDGWICK, CMS

This case involves applicant Divina Emano claiming a left carpal tunnel injury against UC Davis Medical Center. The Workers' Compensation Appeals Board granted reconsideration and amended the previous decision. Specifically, Finding of Fact No. 8 was modified to clarify that while no further treatment is needed for the left carpal tunnel injury, other industrial injuries will require reasonable and necessary medical treatment. The Board expressed surprise at the defendant's contention regarding the carpal tunnel injury, noting their prior stipulation and a relevant physician's report.

WORKERS' COMPENSATION APPEALS BOARDDIVINA EMANOUC DAVIS MEDICAL CENTERSEDGWICK CMSOPINION AND ORDERGRANTING RECONSIDERATIONDECISION AFTER RECONSIDERATIONleft carpal tunnel injuryindustrial injuriesWCJ report
References
0
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