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

Case No. ADJ9438610
Regular
Sep 26, 2014

LUIS MENDIZABAL vs. C. E. LIMITED, INC., dba CENTRAL ENTERPRISES, ZENITH NORTH AMERICAN COMMERCIAL INSURANCE

The Workers' Compensation Appeals Board granted reconsideration, rescinding prior findings that the defendant failed to provide MPN information and that the applicant properly self-procured care. The Board found the defendant timely provided MPN notice in May 2014, not May 2013 as initially determined. Consequently, the defendant is not liable for self-procured treatment, and the case is returned to the trial level.

Medical Provider NetworkMPN transfer of careself-procured medical treatmentreconsiderationFindings of FactWCJadministrative law judgeindustrial injuryright kneenotice of transfer
References
Case No. ADJ3910048 (VNO 0417016)
Regular
Jul 30, 2010

NAHID JAVADI vs. SIMI VALLEY HOSPITAL, ADVENTIST HEALTH SYSTEMS WEST

This case involves an employer, Simi Valley Hospital/Adventist Health Systems West, seeking to prevent the joinder of AIG as a defendant in a workers' compensation claim. The employer argues it is permissibly self-insured and self-administered, and joining AIG, an excess carrier, would cause irreparable harm. The Appeals Board found that since there is no third-party administrator involved, the precedent relied upon for joinder is inapplicable. Consequently, the Board rescinded all orders joining AIG and returned the case to the trial level.

Workers' Compensation Appeals BoardPetition for RemovalJoinder of DefendantReinsurance CarrierExcess CarrierPermissibly Self-InsuredSelf-AdministeredIndustrial InjuryFindings and AwardPetition to Reopen
References
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
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
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
Case No. LBO 0375714
Regular
Jul 09, 2008

VICENTE CARMEN vs. SKB CORPORATION

This case involves a lien claim by California Pharmacy Management for medication provided to an injured worker, Vicente Carmen. The Workers' Compensation Appeals Board denied reconsideration, upholding the finding that the pharmacy's lien was invalid because the medication was not prescribed by a physician within the defendant employer's Medical Provider Network (MPN). The Board reiterated that once an employer provides a MPN, an employee's self-procured treatment outside that network is not compensable, and the pharmacy's reliance on Labor Code section 4600.2 was misplaced as there was no evidence of a contract with the employer.

MPNLien claimMedical treatmentSelf-procuredPharmacy benefit networkLabor Code section 4600.2Treating physicianWorkers' Compensation Appeals BoardFindings and OrderReconsideration
References
Case No. ADJ2060741 (RJV 0068035)
Regular
Apr 13, 2009

GAIL ARITA vs. STATE OF CALIFORNIA, CDCR-CALIFORNIA REHABILITATION CENTER, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration to address petitions from both the applicant and defendant concerning the WCJ's decision. The applicant disputed the finding that she failed to prove entitlement to self-procured medical care. The defendant argued the claim was time-barred, but agreed with the applicant on the self-procured treatment issue. The Board affirmed the WCJ's original decision as amended, finding the applicant's self-procured treatment contention moot due to deferral.

Workers' Compensation Appeals BoardReconsiderationSelf-procured medical careBurden of proofAOE/COEStatute of limitationTemporary disabilityWCJ decisionAdministrative law judgeDefendant petition
References
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
Case No. ADJ9203286
Regular
Mar 23, 2018

Hugo Bucio vs. County of Merced

The Workers' Compensation Appeals Board granted reconsideration, reversing a prior decision that denied temporary total disability indemnity. The applicant, a deputy sheriff, underwent self-procured surgery for an admitted industrial back injury after the employer denied authorization. The Board held that an injured worker is entitled to temporary disability indemnity regardless of whether the treatment was employer-authorized or self-procured. The decision clarified that the utilization review process governs medical treatment disputes, not temporary disability indemnity claims arising from self-procured treatment.

BucioCounty of MercedDeputy Sheriff/Coronerbilateral sacroiliac joint fusiontemporary total disability indemnityself-procured medical treatmentutilization review (UR)denial of authorizationphysician depositionpermanent and stationary status
References
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
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