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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. ADJ1967938
Regular
Oct 18, 2012

MARITZA RENGIFO vs. MARRIOTT INTERNATIONAL

Defendant Marriott International filed an untimely petition for removal seeking a determination of liability for applicant's self-procured medical treatment outside their alleged Medical Provider Network (MPN). The Appeals Board, while dismissing the petition due to untimeliness, granted removal on its own motion. The Board found the WCJ erred in deeming the MPN and self-procured treatment issues premature lien issues. The Board rescinded the WCJ's order taking the case off calendar and directed the matter be set for trial promptly to adjudicate the MPN and treatment liability.

Removal PetitionMPNSelf-Procured TreatmentLabor Code 4903.6(b)Labor Code 4616WCAB Rule 10843(a)Untimely FilingGrant RemovalOwn MotionDecision After Removal
References
0
Case No. ADJ6949453
Regular
Sep 27, 2012

MARIA LAZARTE vs. AMERICAN HONDA

The Workers' Compensation Appeals Board rescinded an order approving a compromise and release because the judge improperly added a handwritten provision withholding settlement proceeds pending determination of non-MPN lien claimants' liability. The Board clarified that while it has jurisdiction over liens for treatment provided under Labor Code section 4600, treatment procured at the employee's own expense under section 4605 falls outside its jurisdiction and is the employee's personal liability. The case was remanded for further proceedings to determine the adequacy of the settlement and the parties' rights, particularly concerning the applicant's potential personal liability for self-procured medical treatment.

Workers' Compensation Appeals BoardCompromise and ReleaseMedical Provider NetworkLabor Code Section 4605Self-Procured TreatmentLien ClaimantsJurisdictionDue ProcessAdministrative Law JudgePetition for Reconsideration
References
11
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. 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. ADJ6697087
Regular
Jul 26, 2010

MARIA GARCIA vs. SODEXHO INC.; INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA, Administered By GALLAGHER BASSETT SERVICES, INC.

This case involves an industrial injury to applicant Maria Garcia's left knee and lumbar spine. The primary dispute concerns whether applicant was properly notified of the employer's Medical Provider Network (MPN), which affects her right to self-procure medical treatment. The Workers' Compensation Appeals Board granted reconsideration to further develop the record regarding the employer's compliance with MPN notice requirements, particularly at the time of injury. The Board rescinded the prior award and remanded the case for further proceedings and a new decision on these notice issues and their impact on self-procured treatment liability.

Workers' Compensation Appeals BoardMedical Provider NetworkMPN noticesself-procured medical treatmentindustrial injuryleft kneelumbar spinehousekeeperfindings and awardreconsideration
References
1
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
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