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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
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
Case No. ADJ2593762 (SAC 0363364)
Regular
Jul 13, 2012

RICHARD HODGE vs. DEPENDABLE HIGHWAY EXPRESS, ZURICH NORTH AMERICA INSURANCE

The Workers' Compensation Appeals Board denied reconsideration, upholding the WCJ's decision to provide psychiatric treatment. Even if the need for psychiatric treatment stems from a potentially non-compensable psychiatric injury, the employer remains liable if the treatment is reasonably required to cure or relieve the effects of a compensable industrial injury. In this case, the applicant's psychiatric treatment was deemed necessary to address cognitive impairment caused by a compensable traumatic brain injury. Therefore, the employer is liable for this treatment under established case law, regardless of the nuances of the six-month employment rule.

Labor Code section 3208.3(d)sudden and extraordinary exceptionsix-month employment rulemedical treatmentLabor Code section 4600reasonably requiredcure or relievenon-compensable injurypsychiatric treatmenttraumatic brain injury
References
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
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
Case No. ADJ78 10538
Regular
Apr 28, 2016

VALENTE MARTINEZ vs. MESA VERDE PARTNERS DBA COSTA MESA COUNTRY CLUB, AMERICAN CLAIMS MANAGEMENT

This case concerns a lien claimant seeking payment for chiropractic services provided to an injured worker. The Workers' Compensation Appeals Board granted reconsideration and returned the case for further development of the record. The Board found that the lien claimant failed to meet its burden of proof to establish that the treatment was reasonably required to cure or relieve the effects of an industrial injury. Specifically, there was insufficient evidence to determine if an industrial injury occurred or if the treatment addressed injured body parts.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and AwardOfficial Medical Fee ScheduleLabor Code section 4603.2Burden of ProofIndustrial InjuryReasonably Required TreatmentCompromise and Release Agreement
References
Case No. ADJ3133261 (VNO 0400017)
Regular
Aug 17, 2010

FELIPE TOLENTINO vs. CONCO CEMENT, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, XCHANGING INC., FREMONT COMPENSATION

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's petition for reconsideration as premature. The WCAB granted the defendant's petition for reconsideration regarding the temporary disability overpayment issue, deferring it for further proceedings. The Board affirmed the WCJ's findings on injury causation and permanent disability but amended the decision to clarify the overpayment issue. Finally, the WCAB issued a notice of intention to sanction defendant's counsel for attaching and citing unadmitted evidence.

Workers' Compensation Appeals BoardFELIPE TOLENTINOCONCO CEMENTCALIFORNIA INSURANCE GUARANTEE ASSOCIATIONXCHANGING INC.FREMONT COMPENSATIONliquidationADJ3133261VNO 0400017OPINION AND ORDERS DISMISSING PETITION FOR RECONSIDERATION AND GRANTING PETITION FOR RECONSIDERATION
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. ADJ4028210 (SJO 0251585)
Regular
Apr 06, 2009

JENNY PHAM vs. SANMINA-SCI CORPORATION, SENTRY CLAIMS SERVICE

This case concerns a dispute over the reasonableness and necessity of chiropractic and acupuncture treatment provided to an applicant for an industrial injury. The defendant argues the treatment exceeded the ACOEM Guidelines and was not evidence-based. The Appeals Board granted reconsideration, finding the WCJ's prior decision allowing the lien premature. The Board rescinded the decision and returned the case for further development of the medical record to determine if the treatment complied with the ACOEM Guidelines. The defendant's petition for removal was dismissed as moot.

Petition for RemovalPetition for ReconsiderationFindings and OrderCompromise and ReleaseIndustrial InjuryNeck InjuryBilateral ShouldersReasonable and Necessary TreatmentACOEM GuidelinesLabor Code Section 4600
References
Case No. ADJ4454017 (VNO 0518656)
Regular
Aug 11, 2009

SERGIO PLACENCIA vs. ANVIL STEEL CORPORATION, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted defendant's Petition for Reconsideration. The Board found the WCJ erred by issuing a decision on an undeveloped record regarding lien claimant's medical billings. The WCJ identified issues needing further evidence, particularly concerning the reasonableness and necessity of treatment and the adherence to the Official Medical Fee Schedule, but failed to allow parties to supplement the record. Consequently, the May 19, 2009 Findings and Award were rescinded, and the case was returned for further development of the record.

Lien claimantPetition for ReconsiderationOfficial Medical Fee Schedule (OMFS)WCJFindings and AwardFurther development of the recordLabor Code sections 5701 and 5906Reasonably required medical treatmentReasonable expense of treatmentRescinded
References
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