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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. 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 Consequently, the Board rescinded the ALJ's award and remanded the case for further proceedings to determine the reasonableness of all self-procured medical expenses.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. ADJ9522703
Regular
Jul 04, 2018

MAYRA MENDOZA vs. SAFEWAY, INC., ALBERTSONS HOLDINGS

This case concerns whether applicant's medical mileage and self-procured medical expenses were included in a prior Compromise and Release (C&R) agreement. The applicant sought reconsideration of the WCJ's finding that these expenses were resolved by the C&R. The Appeals Board affirmed the WCJ's decision, finding that the plain language of the C&R explicitly included medical mileage and self-procured medical treatment as resolved issues within the settlement amount. Therefore, the applicant's subsequent claims for these expenses were denied.

Workers' Compensation Appeals BoardReconsiderationCompromise and ReleaseWCJLabor Code section 5813medical mileageout-of-pocket medical expensesself-procured medical treatmentindustrial injurychecker/stocker
References
3
Case No. ADJ8460289
Regular
Sep 11, 2013

JUAN LUNA vs. CAPITAL DRYWALL, L.L.P.; SEABRIGHT INSURANCE

This case concerns a dispute over the admissibility of medical reports from physicians outside the defendant's Medical Provider Network (MPN). The Appeals Board rescinded the original findings and award, remanding the case for a new decision. This decision hinges on the employer's failure to provide adequate notice of the MPN and their denial of the employee's claim, entitling the employee to self-procure treatment and rendering those medical reports admissible. The arbitrator must now reconsider the findings regarding self-procured medical expenses and mileage reimbursement.

Workers' Compensation Appeals BoardReconsiderationMedical Provider Network (MPN)Collective Bargaining Agreement (ADR)Admissibility of ReportsSelf-Procured Medical TreatmentLabor Code Section 4600Notice RequirementsDenial of ClaimIndustrial Injury
References
1
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. ADJ2708349 (SBR 0339433)
Regular
Oct 06, 2008

MELVIN LANE vs. BIG LOTS STORES, INC., ZURICH INSURANCE, SEDGWICK CLAIMS MANAGEMENT SERVICES

The applicant sought reconsideration after being ordered to treat within the employer's Medical Provider Network (MPN). The Appeals Board granted reconsideration, finding that while the employer provided adequate notice of its MPN, the applicant has the right under Labor Code section 4605 to self-procure medical treatment at his own expense. Therefore, the applicant cannot be forced to treat within the MPN and the employer is not liable for self-procured treatment.

MPNself-procureLabor Code section 4605Labor Code section 4600Medical Provider Networkworkers' compensationWCJreconsiderationfindings and orderstatutory obligation
References
4
Case No. SBR 0331758
Regular
Apr 21, 2008

MITZI L. THOMAS vs. BAKERS BURGERS, INC., STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed the WCJ's award for self-procured medical treatment due to the defendant's significant delay in authorizing a necessary MRI, which was requested by their own MPN physicians from the outset. The Board found that this delay, combined with other failures in providing timely and adequate treatment, excused the applicant from strictly adhering to MPN dispute resolution procedures. Therefore, the defendant was liable for the applicant's reasonable, self-procured medical expenses.

Workers Compensation Appeals BoardMitzi L. ThomasBakers Burgers Inc.State Compensation Insurance FundSBR 0331758ReconsiderationIndustrial InjuryBilateral WristsBilateral KneesNeck
References
11
Case No. ADJ3745700 (OXN 0128625), APJ6812951
Regular
Dec 24, 2012

PAUL HARBER vs. PGP INC; CNA INSURANCE COMPANY; VARGAS EXCAVATING INC.; STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration of the original award, which found industrial injury but denied reimbursement for self-procured medical treatment. The Board found the applicant's petition for reconsideration was timely filed. The Board amended the award to defer the issue of reimbursement for self-procured medical treatment expenses and returned the matter to the trial level for further proceedings. Otherwise, the original award finding industrial injury to the applicant's bilateral wrists, elbows, cervical spine, and lumbar spine was affirmed.

Workers' Compensation Appeals BoardReconsiderationJoint Findings Award OrderAdministrative Law JudgeCumulative Trauma InjuryIndustrial InjuryBilateral WristsBilateral ElbowsCervical SpineLumbar Spine
References
5
Case No. ADJ10928385
Regular
Mar 05, 2018

MARCO GUERRERO vs. CITISTAFF SOLUTIONS, INC., OLD REPUBLIC INDEMNITY, GALLAGHER BASSETT

In this workers' compensation case, the defendant sought reconsideration of an award finding they failed to provide the applicant with required Medical Provider Network (MPN) notices after an admitted industrial injury. The applicant was found to be entitled to self-procure medical treatment at the defendant's expense due to this failure. The Workers' Compensation Appeals Board affirmed the original decision, holding the defendant failed to meet its burden of proving MPN notice compliance. The Board also agreed that the defendant's inadequate development of the record at trial did not warrant reopening and that the applicant's self-procured treatment was justified.

Medical Provider NetworkMPNpetition for reconsiderationneglect or refusalreasonable medical treatmentself-procured medical treatmentsubstantial medical evidencedue processdevelop the recorddenial of medical care
References
2
Case No. ADJ7957976
Regular
Nov 18, 2013

CHARLES TREJO vs. NORTHRUP GRUMMAN CORPORATION, INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA

The Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding a prior award. The WCJ improperly relied solely on applicant's self-procured physician's report for findings on cervical and lumbar spine injury and permanent disability. Amended Labor Code section 4605 requires any self-procured medical opinions to be addressed by a Qualified Medical Evaluator (QME) or authorized treating physician, which did not occur. The case is returned for further medical development, specifically requiring the QME to address the self-procured physician's opinions.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardMedical Provider Network (MPN)Self-Procured Medical TreatmentLabor Code Section 4605Qualified Medical Evaluator (QME)Panel Qualified Medical Examiner (PQME)Permanent Disability RatingWhole Person Impairment
References
3
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