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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. 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
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. 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. ADJ2605132 (BAK 0154195)
Regular
Jan 23, 2013

JUAN CARILLO MATANCIAS vs. MILK MAID DAIRY / TONY DRAGT, ZENITH INSURANCE COMPANY

This case involves a workers' compensation claim where the applicant self-procured medical treatment outside the defendant's Medical Provider Network (MPN). The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, affirming the administrative law judge's award of $6,304.87 to the lien claimant for reasonable medical treatment. The Board found the defendant failed to provide adequate notice of the applicant's MPN rights, making them liable for the self-procured treatment. A dissenting opinion argued the defendant had sufficiently established MPN control and notified the applicant, therefore not being liable for outside treatment.

MPNself-procured medical treatmentlien claimantPetition for Reconsiderationworkers' compensation administrative law judgeMedical Provider Networkcompromise and releaseindustrial injuryAgreed Medical ExaminerAdministrative Director
References
2
Case No. ADJ7251439, ADJ9344777
Regular
Jul 09, 2015

JERRY BRYANT vs. POMONA UNIFIED SCHOOL DISTRICT, Permissibly Self-Insured, Administered By CORVEL CORPORATION

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration. The Board affirmed the finding that the applicant could seek medical treatment outside the defendant's Medical Provider Network (MPN). This was due to the defendant's failure to provide timely medical treatment within the MPN. Despite an authorized physician being listed on the MPN, the defendant neglected to send written authorization, thereby allowing the applicant to self-procure treatment.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPetition for ReconsiderationFindings of FactWCJexpedited hearingDeclaration of Readinessself-procure medical treatmentLab. Code
References
2
Case No. ADJ8787215
Regular
Jan 10, 2014

FILIBERTO MARTINEZ vs. VORTEX WHIRLPOOL SYSTEMS, INC.; CYPRESS INSURANCE COMPANY, c/o BERKSHIRE HATHAWAY HOMESTATE COMPANIES

The Workers' Compensation Appeals Board denied Filberto Martinez's petition for reconsideration. Martinez sought reimbursement for self-procured medical treatment outside the defendant's Medical Provider Network (MPN), claiming the defendant failed to provide adequate care. The Board found that the defendant provided timely MPN notice and initial medical treatment. Martinez's claim that the treatment was ineffective or a misdiagnosis did not justify self-procurement, as he failed to utilize available internal MPN dispute resolution processes.

Workers' Compensation Appeals BoardPetition for ReconsiderationMedical Provider Network (MPN)Labor Code section 4616.3Self-procured medical treatmentExpedited HearingLabor Code section 4600Medical utilization treatment scheduleIndependent Medical Review (IMR)Findings and Order
References
0
Case No. ADJ6958632
Regular
Jun 16, 2010

CRUSTINA MEDRANO vs. LOS ALTOS FARMS, LLC, ZENITH

The Appeals Board granted Zenith Insurance's petition for reconsideration, reversing the WCJ's award of self-procured medical treatment. The Board found that the applicant received proper notification of Zenith's Medical Provider Network (MPN) at the time of her injury. Furthermore, the Board determined that the applicant knew or should have known she was being treated within the MPN and that any alleged lack of notice did not result in a neglect or refusal to provide reasonable medical treatment. Therefore, the applicant is not entitled to reimbursement for self-procured treatment outside the MPN.

MPNMedical Provider NetworkreconsiderationFindings Award and OrderZenith Insurance CompanyLabor Code section 4600self-procured medical treatmentKnight v. United Parcel Servicenotice requirementsneglect or refusal
References
2
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. 7476980
Regular
Nov 17, 2011

CANDELARIA GUIZAR vs. MISSION FOODS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

In this workers' compensation case, the Appeals Board dismissed the applicant's Petition for Removal and denied her Petition for Reconsideration. The applicant sought benefits for self-procured medical treatment, arguing the employer failed to properly notify her of its Medical Provider Network (MPN) and provide timely authorized treatment. The Board found the employer met its obligation under Labor Code section 5402(c) by offering treatment on the date of injury, and that the applicant had received proper notice of the MPN. Therefore, the applicant was not entitled to self-procure treatment, and the employer was not liable for it.

MPNLabor Code section 5402(c)self-procured medical treatmentPetition for RemovalPetition for ReconsiderationFindings and OrderMandatory Settlement Conferenceemployer representativeConcentra Medical ClinicKnight v. United Parcel Service
References
1
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