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

Case No. ADJ8331259
Regular
Dec 21, 2012

MARIELA GOMEZ vs. PROVIDENCE FARMS, LLC, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The Board adopted the WCJ's report, emphasizing that the defendant's failure to properly notify the applicant about changing treating physicians within the Medical Provider Network (MPN) resulted in a denial of necessary medical treatment. This failure to inform the applicant of her rights, particularly regarding physician selection and dispute resolution processes within the MPN, constituted a neglect or refusal to provide reasonable medical treatment, as established by precedent. Consequently, the applicant was permitted to continue receiving treatment outside the MPN until she could begin care with a designated physician within the network.

Workers' Compensation Appeals BoardProvidence FarmsLLCZenith Insurance CompanyMariela GomezADJ8331259Order Denying ReconsiderationPetition for ReconsiderationMedical TreatmentMedical Provider Network
References
2
Case No. ADJ7555799 (MF) ADJ7561888
Regular
Sep 08, 2017

REYNA PANIAGUA vs. T & R BANGI'S AGRICULTURAL SERVICES, INC., SEABRIGHT INSURANCE, administered by ENSTAR GROUP, STATE COMPENSATION INSURANCE FUND

This case involves an applicant seeking reconsideration of a finding that her employer did not refuse to provide medical treatment. The applicant's designated Medical Provider Network (MPN) physicians were unable to treat her, leading to delays and her eventual notification that a provider was no longer accepting new patients. Despite the applicant's frustration and inability to secure treatment within the MPN, the Board affirmed the original finding. The Board concluded there was insufficient evidence that the defendant neglected or refused to provide the requested medical treatment.

Workers Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)Self-Procured TreatmentNeglect or Refusal to Provide TreatmentStipulations With Request for AwardCompromise and ReleaseExpedited HearingDeclaration of David KestnerCentral Valley Occupational Medical Group (CVO)
References
2
Case No. ADJ1148042 (RIV 0079139)
Regular
Apr 24, 2012

SARA OCHOA vs. BEL AIRE WINDOW COVERINGS, ZENITH INSURANCE COMPANY

The Appeals Board affirmed the WCJ's decision disallowing a medical lien from Aspen Medical Resources (AMR). AMR failed to prove that the durable medical equipment it provided was reasonably necessary to cure or relieve the applicant's industrial injury, lacking a report from the primary treating physician requesting such equipment. Furthermore, the applicant's treatment occurred outside the defendant's Medical Provider Network (MPN) after proper notification was given, and AMR's argument regarding defective MPN notice was rejected as defects can be cured. The Board also found no error in the admission of defendant's exhibits, as any objection to the proof of service was waived by AMR's failure to timely object.

Medical Provider NetworkMPNLien ClaimantDurable Medical EquipmentReasonable and NecessaryBurden of ProofUtilization ReviewProof of ServiceTimely ObjectionWaiver
References
14
Case No. ADJ3425466 (FRE 0244904)
Regular
Mar 21, 2013

IMELDA SANCHEZ vs. COUNTY OF FRESNO

The Workers' Compensation Appeals Board affirmed the WCJ's finding that the County of Fresno neglected to provide adequate notice of the applicant's rights under its Medical Provider Network (MPN). This failure resulted in liability for the applicant's self-procured medical treatment from San Joaquin Accident and Medical Group. The Board found the defendant failed to prove proper initial MPN notification and subsequent transfer of care into the MPN. Therefore, the defendant is responsible for the reasonable costs of that treatment.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNSelf-procured medical treatmentNeglect or refusalReasonable medical treatmentLabor Code section 4600Administrative Director Rule 9767.6Knight v. United Parcel ServiceBabbitt v. Ow Jing
References
4
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. ADJ7431195 ADJ7431206
Regular
Oct 14, 2011

MARICELA SANCHEZ vs. AMERICAN PRINTWORKS / P & Y T-SHIRTS AND SILK SCREENINGS COMPANY, INC., ZENITH INSURANCE COMPANY

This case involves a workers' compensation applicant seeking reconsideration of a prior Appeals Board decision. The Board denied reconsideration, upholding its prior ruling that the defendant provided proper notice of its Medical Provider Network (MPN) and that the applicant was not entitled to payment for self-procured medical treatment outside the MPN. The Board found that the defendant cured any initial notification defects and that the applicant continued self-procuring treatment after being properly notified. Therefore, the defendant is not liable for the applicant's unauthorized medical expenses.

Medical Provider NetworkMPNPetition for ReconsiderationAdministrative Director's RulesNotice of RightsSelf-Procured TreatmentTimely NoticeReasonable Medical TreatmentInadmissible TreatmentAppeals Board en banc
References
3
Case No. MISSING
Regular Panel Decision

Queens Blvd. Medical, P.C. v. Travelers Indemnity Co.

The plaintiff, Queens Blvd. Medical, P.C., sought $950 in first-party no-fault benefits for biofeedback medical services provided to its assignor for lower back and chronic pain syndrome. The central issue at trial was the medical necessity of these services under Insurance Law § 5102 (a) (1). The plaintiff established a prima facie case with expert testimony from a board-certified neurologist affirming the medical appropriateness of biofeedback. The defendant insurance company failed to present admissible evidence to disprove medical necessity, as its expert was deemed incompetent to testify on biofeedback for back pain. Consequently, the court granted the plaintiff's motion for a directed verdict, awarding judgment for $950 along with statutory costs, interest, and attorney's fees.

No-fault benefitsMedical necessityBiofeedback treatmentExpert testimonyDirected verdictInsurance lawChronic pain syndromeBack injuryCPT codesBurden of proof
References
9
Case No. ADJ3158190
Regular
Jan 17, 2012

RICK OSEGUERA vs. MITSUMI NAKAMURA, ZENITH INSURANCE COMPANY

In this workers' compensation case, the defendant insurer sought reconsideration of an award for lien claimants' medical services provided outside their Medical Provider Network (MPN). The Appeals Board granted reconsideration, reversing the original award. The Board found that the defendant provided timely MPN notice to the applicant and consistently offered necessary medical treatment within the network. Therefore, the Board concluded the defendant was not liable for treatment obtained outside the MPN and disallowed the lien claimants' claims.

MPNMedical Provider NetworkLien ClaimantsReconsiderationFindings and AwardWCJPenaltiesInterestCompromise and Release AgreementStipulations
References
5
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
1
Case No. ADJ10064259
Regular
Nov 19, 2015

, Applicant, CHARLES WAGNER, vs. , Defendants. BARRETT BUSINESS SERVICES; ACE AMERICAN INS. CO.; CORVEL ADMINSTRATOR

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior order allowing the applicant to treat outside the defendant's Medical Provider Network (MPN). The Board found that while MPN notice requirements are crucial, an employee can only treat outside the network at the employer's expense if a failure to provide notice resulted in a denial of medical care. In this case, the applicant received timely medical treatment, and the defendant presented evidence of providing MPN notices, thus, the applicant was not entitled to self-procured treatment outside the MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)ReconsiderationFindings and OrderAdministrative Law Judge (WCJ)Labor CodeRule 9767.12Medical TreatmentExpedited HearingForklift Operator
References
1
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