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

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 Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.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. ADJ9522703
Regular
Jul 04, 2018

MAYRA MENDOZA vs. SAFEWAY, INC., ALBERTSONS HOLDINGS

This case concerns whether applicant's medical mileage and self-procured medical expenses were included in a prior Compromise and Release (C&R) agreement. The applicant sought reconsideration of the WCJ's finding that these expenses were resolved by the C&R. The Appeals Board affirmed the WCJ's decision, finding that the plain language of the C&R explicitly included medical mileage and self-procured medical treatment as resolved issues within the settlement amount. Therefore, the applicant's subsequent claims for these expenses were denied.

Workers' Compensation Appeals BoardReconsiderationCompromise and ReleaseWCJLabor Code section 5813medical mileageout-of-pocket medical expensesself-procured medical treatmentindustrial injurychecker/stocker
References
3
Case No. ADJ2708349 (SBR 0339433)
Regular
Oct 06, 2008

MELVIN LANE vs. BIG LOTS STORES, INC., ZURICH INSURANCE, SEDGWICK CLAIMS MANAGEMENT SERVICES

The applicant sought reconsideration after being ordered to treat within the employer's Medical Provider Network (MPN). The Appeals Board granted reconsideration, finding that while the employer provided adequate notice of its MPN, the applicant has the right under Labor Code section 4605 to self-procure medical treatment at his own expense. Therefore, the applicant cannot be forced to treat within the MPN and the employer is not liable for self-procured treatment.

MPNself-procureLabor Code section 4605Labor Code section 4600Medical Provider Networkworkers' compensationWCJreconsiderationfindings and orderstatutory obligation
References
4
Case No. SBR 0331758
Regular
Apr 21, 2008

MITZI L. THOMAS vs. BAKERS BURGERS, INC., STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed the WCJ's award for self-procured medical treatment due to the defendant's significant delay in authorizing a necessary MRI, which was requested by their own MPN physicians from the outset. The Board found that this delay, combined with other failures in providing timely and adequate treatment, excused the applicant from strictly adhering to MPN dispute resolution procedures. Therefore, the defendant was liable for the applicant's reasonable, self-procured medical expenses.

Workers Compensation Appeals BoardMitzi L. ThomasBakers Burgers Inc.State Compensation Insurance FundSBR 0331758ReconsiderationIndustrial InjuryBilateral WristsBilateral KneesNeck
References
11
Case No. SRO 0121152
Regular
Dec 12, 2007

GINGER DUNLAP-FENTON vs. EEL RIVER SAWMILLS, SELF-INSURERS' SECURITY FUND

This case involved a defendant's petition for reconsideration of an award for an applicant's industrial neck injury. The appeals board granted reconsideration, amending the original award to reduce the permanent disability rating from 23% to 17% and adjusting the applicant's attorney fees. The board adopted the WCJ's report, which specified the revised permanent disability indemnity, the calculation of attorney fees on remaining temporary disability and self-procured medical expenses, and affirmed other aspects of the original award.

Workers Compensation Appeals BoardEel River SawmillsSelf-Insurers' Security Fundindustrial injuryblock stackerbankruptcytemporary total disabilitypermanent disabilityapportionmentself-procured medical treatment
References
0
Case No. ADJ1116494
Regular
Jun 29, 2009

FAUSTO NORIEGA vs. LA FABRIC IMPORTS, INC., PREFERRED EMPLOYERS INSURANCE COMPANY

The applicant sustained an admitted industrial injury and initially received treatment within the defendant's Medical Provider Network (MPN). The defendant provided initial MPN notices and authorized further specialist treatment for the applicant within the MPN. The applicant later began self-procuring unauthorized treatment outside the MPN against the defendant's objections. The Board found the defendant did not fail to provide or authorize necessary treatment, therefore it is not liable for the self-procured expenses.

Medical Provider NetworkMPNSelf-procured treatmentReconsiderationFindings of FactMedical treatmentIndustrial injuryForklift operatorNotice requirementsWorkers' Compensation Appeals Board
References
3
Case No. ADJ4004824 (OAK 0302288), ADJ3234784 (OAK 0298501)
Regular
Jan 24, 2017

LINDA SALMON vs. HOME DEPOT, permissibly self-insured and administered by HELMSAN MANAGEMENT

The Appeals Board denied Linda Salmon's petition for reconsideration of a Joint Findings and Award. The original award found her eligible for workers' compensation for a head and neuropsychological injury, awarding 19% permanent disability and temporary disability indemnity. However, it denied claims for heart and psyche injuries and allowed the employer a credit for temporary disability overpayment. Salmon sought reconsideration, arguing error in the credit, denial of self-procured medical expenses, and an inadequate permanent disability rating. The Board adopted the judge's report, denying the petition.

Workers' Compensation Appeals BoardJoint Findings and AwardPetition for ReconsiderationNeuropsychological injuryTemporary disability indemnityPermanent disability ratingDiminished future earnings capacityVocational expertReport and RecommendationSupplemental petition
References
0
Case No. ADJ3745700 (OXN 0128625), APJ6812951
Regular
Dec 24, 2012

PAUL HARBER vs. PGP INC; CNA INSURANCE COMPANY; VARGAS EXCAVATING INC.; STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration of the original award, which found industrial injury but denied reimbursement for self-procured medical treatment. The Board found the applicant's petition for reconsideration was timely filed. The Board amended the award to defer the issue of reimbursement for self-procured medical treatment expenses and returned the matter to the trial level for further proceedings. Otherwise, the original award finding industrial injury to the applicant's bilateral wrists, elbows, cervical spine, and lumbar spine was affirmed.

Workers' Compensation Appeals BoardReconsiderationJoint Findings Award OrderAdministrative Law JudgeCumulative Trauma InjuryIndustrial InjuryBilateral WristsBilateral ElbowsCervical SpineLumbar Spine
References
5
Case No. ADJ8460289
Regular
Sep 11, 2013

JUAN LUNA vs. CAPITAL DRYWALL, L.L.P.; SEABRIGHT INSURANCE

This case concerns a dispute over the admissibility of medical reports from physicians outside the defendant's Medical Provider Network (MPN). The Appeals Board rescinded the original findings and award, remanding the case for a new decision. This decision hinges on the employer's failure to provide adequate notice of the MPN and their denial of the employee's claim, entitling the employee to self-procure treatment and rendering those medical reports admissible. The arbitrator must now reconsider the findings regarding self-procured medical expenses and mileage reimbursement.

Workers' Compensation Appeals BoardReconsiderationMedical Provider Network (MPN)Collective Bargaining Agreement (ADR)Admissibility of ReportsSelf-Procured Medical TreatmentLabor Code Section 4600Notice RequirementsDenial of ClaimIndustrial Injury
References
1
Case No. ADJ7431195 ADJ7431206
Regular
Oct 14, 2011

MARICELA SANCHEZ vs. AMERICAN PRINTWORKS / P & Y T-SHIRTS AND SILK SCREENINGS COMPANY, INC., ZENITH INSURANCE COMPANY

This case involves a workers' compensation applicant seeking reconsideration of a prior Appeals Board decision. The Board denied reconsideration, upholding its prior ruling that the defendant provided proper notice of its Medical Provider Network (MPN) and that the applicant was not entitled to payment for self-procured medical treatment outside the MPN. The Board found that the defendant cured any initial notification defects and that the applicant continued self-procuring treatment after being properly notified. Therefore, the defendant is not liable for the applicant's unauthorized medical expenses.

Medical Provider NetworkMPNPetition for ReconsiderationAdministrative Director's RulesNotice of RightsSelf-Procured TreatmentTimely NoticeReasonable Medical TreatmentInadmissible TreatmentAppeals Board en banc
References
3
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