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

Case No. ADJ7673518, ADJ7647749
Regular
Jan 23, 2015

ANA DE AYALA vs. AO-THE UNIVERSITY CORPORATION / CALIFORNIA STATE UNIVERSITY NORTHRIDGE

The Workers' Compensation Appeals Board granted reconsideration and reversed a prior ruling, finding the applicant sustained industrial injury to her neck. While the applicant testified to injuring her neck in a workplace incident and this was partially corroborated, the Board found insufficient evidence for other claimed injuries. The Board specifically disagreed with the administrative law judge's credibility assessment concerning the neck injury itself, relying on medical reports and testimony supporting the neck injury claim. The Board affirmed the denial of claims for all other alleged injuries, finding insufficient medical evidence to link them to the incident.

Petition for ReconsiderationFindings and OrderIndustrial InjuryNeck InjuryBack InjurySpine InjuryUpper ExtremitiesPsycheGastroesophageal SystemInternal System
References
Case No. ANA 0378959
Regular
May 27, 2000

MAI HO vs. MARRIOTT INTERNATIONAL

The Appeals Board granted reconsideration to reverse a restitution order against chiropractor Vu Phan, D.C., who provided unauthorized treatment. While Phan is not entitled to further payment for treatment not authorized by the employer, the Board found that the employer voluntarily paid $6,500 for past treatment and thus cannot recover it absent fraud, thus denying the employer's restitution claim. The Board otherwise affirmed the original decision denying Phan's lien claim for the unauthorized treatment.

Workers' Compensation Appeals BoardLien claimantRestitutionOverpaymentMedical treatmentUnauthorized treatmentPrimary treating physicianSelf-procured treatmentUnjust enrichmentVoluntary payment
References
Case No. ADJ7532885
Regular
Aug 01, 2016

DAVID AREVALO vs. THE MILLARD GROUP, AIG/NATIONAL UNION FIRE INSURANCE COMPANY

The Workers' Compensation Appeals Board granted the employer's petition for reconsideration, rescinding prior findings. The Board found the initial decision lacked substantial evidence and failed to address crucial issues like the MPN's validity and the employer's loss of medical control. The case is returned to the trial level for further proceedings to determine these issues and whether the employer refused, delayed, or denied medical treatment. The initial finding of denied treatment was based on insufficient evidence to establish liability for self-procured treatment.

MPNMedical Provider NetworkRefusal of TreatmentDelay of TreatmentDenial of TreatmentLoss of Medical ControlPanel Qualified Medical ExaminerPQMELien ClaimantsPrimary Treating Physician
References
Case No. ADJ7755811
Regular
Jun 21, 2013

SONIA MILLS vs. COUNTY OF FRESNO, PSI, AMERICAN ALL-RISK LOSS ADMINISTRATORS, INC.

This case involved a worker, Sonia Mills, seeking compensation from the County of Fresno for medical treatment. The Workers' Compensation Appeals Board granted reconsideration of the prior decision. The Board amended the original decision to clarify that Mills' self-procured treatment was unauthorized and not related to her industrial injury. Therefore, the defendant is not liable for this specific treatment.

Workers' Compensation Appeals BoardReconsiderationSelf-procured treatmentUnauthorized treatmentIndustrial injuryLeft trapeziusLiabilityOpinion and OrderDecision After ReconsiderationFindings of Fact
References
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
Case No. ADJ7062572
Regular
Apr 28, 2011

ANA LILIA RODRIGUEZ vs. COUNTRY VILLA HEALTH SERVICES, ZURICH AMERICAN INSURANCE CO. administered by TRISTAR RISK MANAGEMENT

The Workers' Compensation Appeals Board granted reconsideration of an award of temporary disability indemnity to an applicant who received treatment outside a valid Medical Provider Network (MPN). The Board overturned the original award, ruling that reports from physicians outside the MPN are inadmissible under current case law, *Valdez v. Warehouse Demo Services*. Consequently, the applicant is not entitled to temporary disability indemnity, reimbursement to the EDD, or attorney's fees based on those inadmissible reports. However, the applicant's unauthorized departure from the MPN was not deemed an unreasonable refusal of medical treatment.

Workers' Compensation Appeals BoardMedical Provider Network (MPN)Labor Code Section 4616.6Unauthorized Medical TreatmentAdmissibility of Medical ReportsTemporary Disability IndemnityEmployment Development Department (EDD)Attorney's FeesUnreasonable Refusal of Medical TreatmentLabor Code Section 4056
References
Case No. ADJ4634941
Regular
Jan 13, 2011

BERONICA NUNEZ vs. TELCO FOOD PRODUCTS, CNA INSURANCE

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration of an administrative law judge's decision. The judge had previously denied the lien in its entirety, finding that treatment provided outside the approved Medical Provider Network (MPN) was unauthorized. The Board affirmed this, holding that the applicant failed to follow MPN procedures for seeking further opinions before obtaining treatment outside the network. Therefore, the lien claimant was not entitled to payment for the unauthorized treatment.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings and OrderCompromise and ReleasePanel Qualified Medical Evaluator (PQME)Medical Provider Network (MPN)Unauthorized treatmentLabor Code section 4616.3(c)MPN second and third opinions
References
Case No. ADJ1787217
Regular
Jul 27, 2011

OFELIA LLAMAS vs. SUN TEN LABORATORIES INC., ZENITH INSURANCE CO.

The Appeals Board denied a lien claimant's petition for reconsideration, upholding the disallowance of their liens for unauthorized treatment outside the Medical Provider Network (MPN). The lien claimant's arguments regarding defendant's denial of benefits and MPN notification failures were rejected, as the evidence showed timely MPN care was offered and the MPN notification issue was not raised at trial. The Board also initiated sanctions against the lien claimant's representative for filing a frivolous petition citing non-existent documents and outside evidence, finding this constituted bad faith and a waste of Board resources.

Workers' Compensation Appeals BoardLien ClaimantMPN providersunauthorized treatmentself-procure medical treatmentMPN employee notification requirementsCCR 9767.12reasonableness and necessityPetition for ReconsiderationOrder of Removal
References
Case No. ADJ1524412 (RDG 0043469)
Regular
Oct 18, 2011

STEPHEN FLESHMAN vs. MANDINA'S CUSTOM CABINETS, STATE COMPENSATION INSURANCE FUND

This case involves a dispute over ongoing chiropractic treatment for a back injury sustained in 1989. The defendant sought reconsideration of a prior award granting weekly chiropractic visits, arguing the treatment wasn't providing functional restoration after 21 years. The Appeals Board affirmed the award of 90 days of weekly chiropractic treatment, finding it supported by the treating chiropractor's reports and testimony. However, the Board amended the order to require further medical evaluation after the 90 days to determine future treatment needs.

Workers' Compensation Appeals BoardIndustrial InjuryBack and SpineStipulated AwardPermanent DisabilityFurther Medical TreatmentChiropractic TreatmentChronic Pain Medical Treatment GuidelinesFunctional RestorationProgress Report
References
Case No. ADJ4028210 (SJO 0251585)
Regular
Apr 06, 2009

JENNY PHAM vs. SANMINA-SCI CORPORATION, SENTRY CLAIMS SERVICE

This case concerns a dispute over the reasonableness and necessity of chiropractic and acupuncture treatment provided to an applicant for an industrial injury. The defendant argues the treatment exceeded the ACOEM Guidelines and was not evidence-based. The Appeals Board granted reconsideration, finding the WCJ's prior decision allowing the lien premature. The Board rescinded the decision and returned the case for further development of the medical record to determine if the treatment complied with the ACOEM Guidelines. The defendant's petition for removal was dismissed as moot.

Petition for RemovalPetition for ReconsiderationFindings and OrderCompromise and ReleaseIndustrial InjuryNeck InjuryBilateral ShouldersReasonable and Necessary TreatmentACOEM GuidelinesLabor Code Section 4600
References
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