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

Case No. ADJ17825300
Regular
Sep 22, 2025

BARBARA CRATER vs. CRATE & BARREL HOLDINGS INC, PROPERTY & CASUALTY COMPANY OF HARTFORD

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The defendant challenged the WCJ's findings that they failed to prove an enforceable Medical Provider Network (MPN) for ancillary services and that the applicant had the right to select a family member for home care. The Board affirmed the WCJ's decision, concluding that the defendant did not establish the existence of an enforceable MPN and therefore could not control the selection of the home caregiver, allowing the applicant to choose her daughter.

Medical Provider NetworkAncillary ServicesHome Care ProviderFamily Member SelectionLabor Code Section 5813Petition for ReconsiderationFindings of FactWorkers' Compensation Administrative Law JudgeBurden of ProofUtilization Review
References
Case No. ADJ11059073
Regular
Jan 17, 2023

SHERRILL CLAYTOR vs. ALEXANDER R. LATTERI, M.D., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision allowing the applicant to treat with Dr. Spencer outside the defendant's Medical Provider Network (MPN). The WCAB found insufficient evidence that Dr. Spencer, or the applicant's previously selected physician Dr. Small, were definitively part of the defendant's MPN at the time of the request. Therefore, without proper MPN notification and an established denial of care, the applicant retained the right to resume treatment with her non-MPN physician, Dr. Spencer. The defendant may still attempt to transfer the applicant's care into the MPN by following proper statutory procedures.

MPNPTPmedical provider networkprimary treating physicianreconsiderationfindings and ordertransfer of caredenial of caresubstantial evidenceadministrative director rules
References
Case No. ADJ10954204
Regular
Sep 15, 2022

MARIA FLORES vs. PINNACLE HEALTH CORP., SUMMARY OF EVIDENCE INSURANCE COMPANY OF THE WEST, AFFINITY HOME HEALTH CARE SERVICES, FALLS LAKE FIRE & CASUALTY INSURANCE, SEDGWICK CMS, HOME HEALTH CARE SOLUTIONS, INC.

The Workers' Compensation Appeals Board denied a petition for reconsideration filed by Home Health Care Solutions. The applicant, an LVN, was injured in a car accident while traveling between patients for multiple agencies. The Board adopted the WCJ's report, which found the injury arose out of and occurred in the course of employment for Home Health Care Solutions. This decision was based on the fact that the applicant was required to use her own vehicle, which extended the employer-employee relationship beyond direct service. The WCJ also found the going and coming rule did not bar the claim due to the required use of transportation between patient locations.

Workers' Compensation Appeals BoardPetition for ReconsiderationGoing and Coming RuleAOE/COELVNCar AccidentAutomobile ExceptionTransitEmployment RelationshipRequired Vehicle Use
References
Case No. ADJ11315508
Regular
Sep 12, 2018

SIERRA PRADO vs. PCG HOSPITALITY, TRAVELERS INSURANCE CO.

This case concerns an applicant's request to treat outside her employer's Medical Provider Network (MPN) due to alleged difficulties in scheduling an appointment with an MPN physician. The applicant argued the Medical Access Assistant (MAA) failed to secure an appointment with available MPN doctors, leading to a denial of care. The Workers' Compensation Appeals Board affirmed the WCJ's decision, finding no denial of care because the MPN list is not a guarantee of immediate appointment and the MAA reasonably attempted to find a suitable physician. The majority determined that the applicant did not exhaust reasonable efforts to find an MPN doctor, and a dissenting opinion argued the inaccurate MPN list constituted a failure to provide care, justifying out-of-network treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Medical Access Assistant (MAA)Primary Treating Physician (PTP)Denial of CareOut-of-Network TreatmentLabor Code Section 4600Labor Code Section 4616Cal. Code Regs. tit. 8§ 9767.5
References
Case No. ADJ685961 (VEN 0120428) ADJ3005615 (PAS 0035964)
Regular
Aug 06, 2018

STEPHANIE CURRY vs. PACIFIC CARE BEHAVIORAL HEALTH CARE, INC., THE TRAVELERS INSURANCE COMPANY, ROSEMARY COTTAGE, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, FREMONT INDEMNITY COMPANY, SEDGWICK CLAIMS MANAGEMENT SERVICES

Applicant Stephanie Curry suffered industrial injuries from employment with Pacific Care Behavioral Health Care, Inc. and Rosemary Cottage, leading to disputes regarding the scope of injury and compensation. The Workers' Compensation Appeals Board (WCAB) granted reconsideration of prior awards against CIGA and Travelers Insurance Company. Ultimately, the parties entered into a Compromise and Release agreement, which the WCAB approved, resolving all claims for a settlement payment of $1,363,071.00 from Travelers to applicant, thereby rescinding the prior findings and awards.

Workers' Compensation Appeals BoardStephanie CurryPacific Care Behavioral Health CareInc.Fremont Indemnity CompanyliquidationSedgwick Claims Management Servicesconsequential injurynew and further disabilitytemporary partial disability
References
Case No. ADJ9285089
Regular
Aug 24, 2016

ANA RAMIREZ FARIAS vs. ABLE BUILDING MAINTENANCE, ZURICH NORTH AMERICA

The Appeals Board affirmed an arbitrator's decision that applicant Ana Ramirez Farias must transfer medical care to her employer's exclusive provider network, despite her continued treatment with Dr. Arthur Harris. The majority found that the collective bargaining agreement's provisions on medical treatment, negotiated under Labor Code section 3201.5, take precedence over general Medical Provider Network (MPN) statutes like section 4603.2(a)(2). The dissenting opinion argued that the collective bargaining agreement diminishes the applicant's statutory right to treatment and that section 4603.2(a)(2) should apply due to the agreement's silence on transfer of care disputes.

Labor Code section 3201.7Labor Code section 3201.5(b)Alternative Dispute Resolution (ADR)self-procure treatmentmedical controlexclusive provider networkcarve-out agreementMedical Provider Network (MPN)collective bargaining agreementagreed list of providers
References
Case No. ADJ4446673 (AHM 0130995)
Regular
Oct 13, 2020

OCTAVIO ARTURO ANAYA vs. CARLOS SANDOVAL DBA SANDS TRANSPORT, STATE COMPENSATION INSURANCE FUND

In this workers' compensation case, the applicant sought an increased hourly rate for attendant care services provided since January 1, 2020. The defendant argued the Administrative Law Judge erred by modifying a 2013 stipulation award outside the five-year statutory period under Labor Code section 5804. The Appeals Board granted reconsideration, affirming the increased rate by distinguishing enforcement of awards under section 5803 from modification under section 5804. The Board clarified that the 2013 award's provision for ongoing attendant care allowed for adjustments based on reasonable costs, without violating the five-year limitation.

Workers' Compensation Appeals Boardattendant care serviceshourly rateStipulation Award OrderLabor Code section 5803Labor Code section 5804petition for reconsiderationadministrative law judgehome health carewage analysis report
References
Case No. ADJ 1513511 (LBO 0279490)
Regular
Apr 15, 2016

RIZALINA DERRO vs. KAISER PERMANENTE, WEST ANAHEIM MEDICAL CENTER, TERRACE VIEW CONVALESCENT HOSPITAL, COVENANT CARE, SOUTH GATE CARE CENTER, BROADSPIRE, SUN HEALTH CARE, AIG CLAIM SERVICES, CNA CLAIMS PLUS

The Workers' Compensation Appeals Board (WCAB) is issuing a notice to rescind a prior WCJ decision and remand the case to the WCJ for further record development. This action follows a Court of Appeal order directing the WCAB to address the causation issue regarding the applicant's left wrist injury and employment with Sun Health Care. The WCAB, in its response to the Court, indicated the need for further medical record development on this causation issue. The Court of Appeal dismissed the applicant's petition for review, granting the WCAB's request for remand.

Workers' Compensation Appeals BoardKaiser PermanenteWest Anaheim Medical CenterTerrace View Convalescent HospitalCovenant CareSouth Gate Care CenterBroadsireSun Health CareAIG Claim ServicesCNA Claims Plus
References
Case No. ADJ9915005
Regular
Mar 13, 2023

ALICE RIVERA PASILLAS vs. DURHAM D M, OLD REPUBLIC INSURANCE COMPANY, SEDGWICK CMS

This case involves a worker's claim that she was denied medical care, thus allowing her to seek treatment outside her employer's network. The applicant's attorney argued that the employer failed to provide authorization for treatment with a network physician. However, the Administrative Law Judge (WCJ) found that the employer had provided timely authorization, evidenced by a fax confirmation and proof of service, and that the applicant's claim of non-receipt was insufficient to rebut the presumption of delivery. The Workers' Compensation Appeals Board (WCAB) reviewed the petition for reconsideration, adopted the WCJ's reasoning, and affirmed the original findings. Therefore, the WCAB upheld the decision that the applicant did not prove a denial of care.

Denial of careMedical Provider NetworkMPNAuthorization letterProof of servicePresumption of receiptReconsiderationFindings of FactWCJWorkers' Compensation Appeals Board
References
Case No. MNKOI 0000730458
Regular
Apr 15, 2020

LISA WILLIAMS vs. MAR PIZZA, INC., INSURANCE COMPANY OF THE WEST GROUP

The Workers' Compensation Appeals Board affirmed a prior order finding applicant sustained injury to her left arm and psyche and that defendants did not deny reasonable medical care. The applicant sought removal, arguing delays in psychiatric treatment warranted care outside the Medical Provider Network (MPN). The Board found the applicant did not meet her burden to prove neglect or refusal of treatment by the defendant. Therefore, treatment within the defendant's MPN was affirmed, and the applicant's petition was denied.

Petition for RemovalInjury AOE/COELeft ArmPsycheMedical Provider Network (MPN)Primary Treating Physician (PTP)Denial of CareSelf-Procured TreatmentUtilization Review (UR)Cognitive Behavioral Psychotherapy (CBT)
References
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