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

Case No. ADJ11315508
Regular
Sep 12, 2018

SIERRA PRADO vs. PCG HOSPITALITY, TRAVELERS INSURANCE CO.

This case concerns an applicant's request to treat outside her employer's Medical Provider Network (MPN) due to alleged difficulties in scheduling an appointment with an MPN physician. The applicant argued the Medical Access Assistant (MAA) failed to secure an appointment with available MPN doctors, leading to a denial of care. The Workers' Compensation Appeals Board affirmed the WCJ's decision, finding no denial of care because the MPN list is not a guarantee of immediate appointment and the MAA reasonably attempted to find a suitable physician. The majority determined that the applicant did not exhaust reasonable efforts to find an MPN doctor, and a dissenting opinion argued the inaccurate MPN list constituted a failure to provide care, justifying out-of-network treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Medical Access Assistant (MAA)Primary Treating Physician (PTP)Denial of CareOut-of-Network TreatmentLabor Code Section 4600Labor Code Section 4616Cal. Code Regs. tit. 8§ 9767.5
References
18
Case No. ADJ3002639 (LAO 0881928)
Regular
Jun 11, 2012

MIGUEL NAVA vs. BARRETT BUSINESS SERVICES, INC.

This case concerns an applicant's industrial injury to his spine and knees. The defendant sought reconsideration of a decision that allowed reimbursement for non-MPN providers before November 28, 2008. The Appeals Board granted reconsideration, finding the applicant was bound to select an MPN physician as of his March 11, 2008 deposition stipulation. Therefore, non-MPN services rendered after March 11, 2008, are not compensable.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNBarrett Business ServicesCorVel MPNLien ClaimantIndustrial InjurySpine InjuryKnee InjuryReconsideration
References
2
Case No. ADJ3664982
Regular
May 13, 2009

CYNTHIA SALGADO vs. COUNTY OF ORANGE, SOUTHERN CALIFORNIA RISK MANAGEMENT ASSOCIATION

This case concerns whether medical reports from a physician outside the defendant's Medical Provider Network (MPN) were admissible and if the applicant should repay temporary disability benefits. The Appeals Board granted reconsideration, reversing the WCJ's exclusion of the non-MPN physician's reports and reinstating temporary disability benefits. The Board found the WCJ improperly rescinded prior rulings, and restitution was unwarranted as the applicant did not act fraudulently. The matter was remanded to determine the defendant's credit for payments made to the non-MPN physician.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNAdmissibility of Medical ReportsReconsiderationRestitutionTemporary Disability IndemnitySelf-Procured Medical TreatmentLabor Code Section 4605Res Judicata
References
9
Case No. ADJ7048296
Significant
Jul 14, 2011

Elayne Valdez vs. Warehouse Demo Services, Zurich North America

The Appeals Board granted reconsideration of its April 20, 2011 en banc decision to allow for further study of the factual and legal issues regarding the admissibility of reports from non-MPN doctors.

MPNunauthorized treatmenten banc decisionreconsiderationinadmissible reportsliabilitysupplemental pleadingstatutory time constraintsfactual issueslegal issues
References
1
Case No. MISSING
Regular Panel Decision

MTA Bus Non-Union Employees Rank & File Committee ex rel. Simone v. Metropolitan Transportation Authority

The MTA Bus Non-Union Employees Rank and File Committee, along with fourteen individual plaintiffs, brought an action against the Metropolitan Transportation Authority (MTA) and MTA Bus Company (MTA Bus) concerning pension benefits. Plaintiffs asserted claims including violations of the Equal Protection Clauses of the United States and New York State Constitutions, two distinct breaches of contract, a violation of Section 115 of the New York Civil Services Law, and negligent misrepresentation. The court granted the defendants' motion for summary judgment on all claims and denied the plaintiffs' cross-motion for summary judgment. The court found that the pension benefit classifications had a rational basis, the contract claims were defeated by unambiguous plan documents, the Civil Services Law claim lacked jurisdictional basis, and the negligent misrepresentation claim was invalid as it was based on future promises.

Equal Protection ClauseRational Basis ReviewSummary JudgmentPension BenefitsBreach of ContractMTA Bus CompanyMetropolitan Transportation AuthorityNon-Union EmployeesNew York Civil Service LawNegligent Misrepresentation
References
24
Case No. ADJ8205235
Regular
Feb 06, 2013

HECTOR GOMEZ vs. FASTENAL, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

This case concerns an injured worker, Hector Gomez, who sought medical treatment outside his employer's Medical Provider Network (MPN). The Board overturned the finding that the employer lost control of medical treatment, finding that the employer's technical failure to schedule the initial MPN visit did not deny treatment. The Board also held that the worker could not select a non-MPN specialist simply because an MPN specialist declined to act as a primary treating physician. Therefore, the applicant must obtain treatment through the defendant's MPN.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Primary Treating Physician (PTP)SpecialistLabor Code section 4616.3Administrative Director's Rule 9767.6initial medical evaluationchange of physicianforfeiture of medical controlaccess standards
References
1
Case No. ADJ11059073
Regular
Jan 17, 2023

SHERRILL CLAYTOR vs. ALEXANDER R. LATTERI, M.D., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) affirmed a prior decision allowing the applicant to treat with Dr. Spencer outside the defendant's Medical Provider Network (MPN). The WCAB found insufficient evidence that Dr. Spencer, or the applicant's previously selected physician Dr. Small, were definitively part of the defendant's MPN at the time of the request. Therefore, without proper MPN notification and an established denial of care, the applicant retained the right to resume treatment with her non-MPN physician, Dr. Spencer. The defendant may still attempt to transfer the applicant's care into the MPN by following proper statutory procedures.

MPNPTPmedical provider networkprimary treating physicianreconsiderationfindings and ordertransfer of caredenial of caresubstantial evidenceadministrative director rules
References
10
Case No. ADJ7214982
Regular
Jan 06, 2012

JOAQUIN GONZALEZ vs. NFI INDUSTRIES, ZURICH AMERICAN INS. CO.

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration, upholding the WCJ's finding that the applicant received proper notice of the defendant's Medical Provider Network (MPN) and was treated within it initially. The Board also initiated sanctions against the applicant's attorney for misrepresenting witness testimony, threatening a $500 penalty unless good cause is shown otherwise. The applicant's arguments regarding non-MPN treatment non-compensability and inadmissibility of reports were rejected based on established precedent and findings of fact. The Board found the attorney's petition frivolous, demonstrating bad faith tactics.

MPNMedical Provider NetworkReconsiderationOrder of RemovalSanctionsLabor Code § 5813Bad Faith ActionsFrivolousWillful FailureImproper Motive
References
3
Case No. ADJ9415335
Regular
Oct 21, 2014

ALICIA LYNCH vs. COUNTY OF KERN

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior finding that the applicant was entitled to treat outside the defendant's Medical Provider Network (MPN). The Board found that the applicant failed to meet her burden of proving that the defendant neglected or refused to provide medical care within the MPN. Specifically, the applicant's unsubstantiated claim of one failed appointment attempt with an MPN physician and subsequent designation of an out-of-network doctor was insufficient. Therefore, the defendant retains control of the applicant's medical treatment within the MPN.

Workers' Compensation Appeals BoardMedical Provider NetworkMPNPetition for ReconsiderationPetition for RemovalFindings and OrderPrimary Treating PhysicianPTPKnight v. United Parcel ServiceSB 863
References
2
Case No. ADJ9048259
Regular
Dec 30, 2015

Antonio Avila vs. Barrett Business Services, Inc., Corvel Insurance Company

Here's a summary of the case in four sentences for a lawyer: The Workers' Compensation Appeals Board denied reconsideration, upholding the judge's decision that the applicant must treat within the employer's Medical Provider Network (MPN). The Board found that while there were some informational deficiencies, they did not amount to a denial of medical treatment that would justify treating outside the MPN. Crucially, the applicant admitted he liked his MPN physician and only sought to change doctors based on his attorney's recommendation. Evidence showed the employer promptly provided medical treatment and confirmed the applicant's treating physician was within their MPN.

Workers' Compensation Appeals BoardPetition for ReconsiderationMPNMedical Provider NetworkWCJHealth First Medical GroupDr. Eliasattorney's recommendationBBSI MPNCorvel Insurance Company
References
1
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