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

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 The Board therefore rescinded the original order and returned the matter to the WCJ for further proceedings to determine the extent of reimbursable self-procured medical treatment and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. 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
4
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. 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. 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
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. 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
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
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