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Case Law Database

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. SAC 0296084
Regular
Sep 26, 2007

SHIRLEY MOERSFELDER vs. SAN JUAN UNIFIED SCHOOL DISTRICT, AMERICAN INSURANCE COMPANY, FIREMAN'S FUND INSURANCE COMPANY

This case involves an applicant seeking reconsideration of a workers' compensation award, primarily challenging the denial of additional self-procured medical treatment costs and attorney's fees for enforcing a prior medical treatment award. The Board granted reconsideration, rescinded the prior award, and returned the case to the trial level pending a California Supreme Court decision on similar attorney's fee issues. The Board deferred ruling on the self-procured medical costs to await the outcome of the Supreme Court's determination on the attorney's fee question.

Self-procured expensesLabor Code section 4607attorney's feesmedical treatment awardpermanent disabilityindustrial injuryinstructional aideSan Juan Unified School DistrictFireman's Fund Insurance Companyrescinded
References
3
Case No. ADJ528481 (FRE 0244364) ADJ602408 (FRE 0247847)
Regular
Sep 09, 2013

PEDRO DE DIOS vs. CARROLL'S TIRE WAREHOUSE, REDWOOD FIRE & CASUALTY INSURANCE COMPANY

The Workers' Compensation Appeals Board granted reconsideration and reversed a finding awarding reimbursement for self-procured medical marijuana. The Board ruled that under Health and Safety Code section 11362.785(d), no insurance provider is liable for reimbursement for the medical use of marijuana. The Court further found the Agreed Medical Examiner's opinion regarding marijuana was based on applicant's statements, not medical expertise. Therefore, the employer is not liable for the cost of the self-procured marijuana.

Workers' Compensation Appeals BoardSelf-Procured Medical TreatmentMarijuana ReimbursementIndustrial InjuryBack InjuryNeck InjuryBilateral ShouldersTemporary DisabilityPermanent DisabilityFuture Medical Treatment
References
0
Case No. ADJ10384863
Regular
Nov 27, 2018

RAMON LOPEZ RAMOS vs. SPECIALTY RESTAURANTS, CORPORATION, SAFETY NATIONAL INSURANCE, YORK RISK SERVICES GROUP

The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration, rescinding the prior award. The Board found that the original Finding #3, awarding reimbursement for self-procured medical treatment, lacked substantial evidence as the applicant presented no proof of incurring such costs. Consequently, the issue of liability for self-procured medical treatment is deferred. The matter is returned to the trial level for further proceedings on this specific issue.

Workers' Compensation Appeals BoardSpecialty Restaurants CorporationSafety National InsuranceYork Risk Services GroupRamon Lopez RamosADJ10384863Petition for ReconsiderationFindings and AwardWCJself-procured medical expenses
References
4
Case No. MISSING
Regular Panel Decision

Equal Employment Opportunity Commission v. Grief Bros.

This employment discrimination case, filed July 1, 2002, involves Michael Sabo (Plaintiff) who alleges constructive discharge based on sexual harassment and claims severe emotional pain and suffering. The Defendant moved for a mental examination of Sabo under Fed.R.Civ.P. 35 and to compel the production of his medical records. Sabo alleged severe humiliation, anxiety, depression, loss of self-esteem, sleeplessness, and weight gain, and admitted to a history of depression, past suicide attempts, and current psychiatric treatment with prescribed medications. The court granted the Defendant's motions, finding that Sabo had placed his mental condition in controversy due to the nature and severity of his claims and his medical history, justifying both the examination and the production of relevant medical records. The court also granted Defendant's request for costs associated with compelling the medical records, but denied the request for costs related to the Rule 35 motion itself, and denied Plaintiff's request for counsel or recording during the examination.

Employment DiscriminationSexual HarassmentConstructive DischargeEmotional DistressMental ExaminationRule 35Medical RecordsDepressionSuicide AttemptsCompensatory Damages
References
11
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. ADJ7942487
Regular
Sep 14, 2012

PEDRO SANCHEZ MARTINEZ vs. STEVENS TRANSPORTATION, INC., TRAVELERS INSURANCE CO.

This case involves an applicant truck driver who sustained industrial injuries and sought self-procured medical treatment outside his employer's Medical Provider Network (MPN). The applicant claimed the employer failed to meet MPN notice requirements, making them liable for his treatment costs. However, the Board affirmed the trial judge's decision, finding the employer provided adequate MPN information via a bilingual letter and signed acknowledgment, despite the applicant's claims of not recalling the notice. Therefore, the employer was not found liable for the applicant's self-procured treatment.

Workers' Compensation Appeals BoardPetition for ReconsiderationIndustrial InjuryMedical Provider Network (MPN)Self-Procured TreatmentPosting and Notice RequirementsLabor Code § 4605Labor Code § 4600(a)Consulting PhysicianAttending Physicians
References
2
Case No. ADJ7957976
Regular
Nov 18, 2013

CHARLES TREJO vs. NORTHRUP GRUMMAN CORPORATION, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

The Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding a prior award. The WCJ improperly relied solely on applicant's self-procured physician's report for findings on cervical and lumbar spine injury and permanent disability. Amended Labor Code section 4605 requires any self-procured medical opinions to be addressed by a Qualified Medical Evaluator (QME) or authorized treating physician, which did not occur. The case is returned for further medical development, specifically requiring the QME to address the self-procured physician's opinions.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardMedical Provider Network (MPN)Self-Procured Medical TreatmentLabor Code Section 4605Qualified Medical Evaluator (QME)Panel Qualified Medical Examiner (PQME)Permanent Disability RatingWhole Person Impairment
References
3
Case No. ADJ1047594 (VNO 0549852)
Regular
Dec 22, 2016

Diane De Los Reyes vs. Mediscan, Zurich American Insurance Company

In this case, the applicant, Diane De Los Reyes, sought reimbursement for self-procured medical treatment related to her work-induced Reactive Airway Disease and Anxiety Disorder. The Appeals Board found that some of the applicant's self-procured treatment was likely industrial and reversed the WCJ's finding that all such treatment was non-industrial. The Board therefore rescinded the original order and returned the matter to the WCJ for further proceedings to determine the extent of reimbursable self-procured medical treatment and associated penalties. The applicant's entitlement to reimbursement for medical mileage and penalties thereon was affirmed.

Workers' Compensation Appeals BoardReconsiderationAgreed Medical EvaluatorReactive Airway DiseaseAnxiety DisorderSelf-procured Medical TreatmentReimbursementPenaltiesMedical MileageLabor Code § 4600(a)
References
9
Case No. ADJ7660641
Regular
Jan 12, 2012

BREANNA CLIFTON vs. SEARS HOLDING CORPORATION (KMART CORPORATION), administered by SEDGWICK CMS, INC.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of an award finding industrial injury to claimant's knee, foot, and ankle, temporary disability, and reimbursement for self-procured medical treatment. Defendant contested the award of temporary disability and self-procured treatment based on claimant's treatment outside the employer's Medical Provider Network (MPN), citing *Valdez*. The WCAB found the original decision lacked sufficient explanation regarding the MPN establishment and notice, and the employer's liability for self-procured treatment. Therefore, the WCAB amended the award to defer issues of temporary disability, self-procured treatment, and attorney's fees for further proceedings at the trial level.

MPNValdezKnightself-procured treatmentprimary treating physicianindustrial injurytemporary disabilityreconsiderationmedical provider networkWCJ
References
5
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