What the panel ordered
Petition for Reconsideration denied.
Petition for Reconsideration filed by lien claimant RMS Medical Group seeking review of the 02/07/2024 decision denying that defendant Everest National Insurance Company maintained and exercised medical control within its network and that applicant was not free to select RMS as primary treating physician outside the MPN.
What was disputed, and how it came out
Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.
No basis to award costs or impose sanctions on defendant for not paying medical legal expenses as defendant has no liability for those expenses.
From the decision · page 5Costs This issue was not raised at trial. However the pre-trial conference
The designation of RMS as PTP was insufficient to wrest defendant's control of treatment within the MPN because no denial of care was shown and the treatment within the MPN was ongoing and authorized.
From the decision · page 4The designation of RMS as PTP was insufficient to wrest defendant's control of treatment within the MPN. The status of Chrislip Hervatin as applicant's attorney was in question without the statutorily required filing to take over applicant's representation. More importantly, no denial of care has been shown though it is alleged based on Lien Claimant's Exhibit 5, letter of 05/31/2016. This letter appears to only be addressed to applicant, and references a request for authorization dated 05/30/2016 without identifying the requesting party. There is no 05/30/2016 RFA in evidence. The letter refers to 8 Cal. Code of Reg. Sec. 9792.9.1 (b) (1) which relates to the UR deferral process. The letter contains an incomplete sentence stating "This treatment is disputed because" with no words following. Whatever the author of this letter might have intended, it does not demonstrate that defendant was denying care within the MPN. Rather, it appears to be the use of an incorrect template and possibly misdirected. The claim itself was never denied, and the treatment within the MPN was last documented by Defendant's Exhibit V, report of Dr. Aflatoon, 01/05/2016, who recommended further treatment.
Dr. Gottschalk and RMS were never properly elected as the PTP, so defendant has no liability for medical legal services by them.
From the decision · page 4A primary treating physician may perform medical legal services if requested by a party in certain cases. In this case, Dr. Gottschalk and RMS were
The non-IBR petition was not raised at trial or in pre-trial conference and should not be granted in light of the other findings.
From the decision · page 5Non-IBR Petition This issue was neither raised at trial nor in any version of the pre-trial
Defendant was not obligated to provide benefits outside the MPN because no binding determination by PQME or AME was made as to necessity of treatment and defendant provided care within the network without denying the claim.
From the decision · page 5Obligation to Provide Benefits Labor Code Section 4063 requires an employer to commence
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
No denial of care within the MPN was shown; treatment was ongoing and authorized by defendant.
Favours Defendant prevailed
This fact supports the denial of the petition for reconsideration and the finding that applicant was not free to select an out-of-network PTP.
From the decision · page 4The designation of RMS as PTP was insufficient to wrest defendant's control of treatment within the MPN. The status of Chrislip Hervatin as applicant's attorney was in question without the statutorily required filing to take over applicant's representation. More importantly, no denial of care has been shown though it is alleged based on Lien Claimant's Exhibit 5, letter of 05/31/2016. This letter appears to only be addressed to applicant, and references a request for authorization dated 05/30/2016 without identifying the requesting party. There is no 05/30/2016 RFA in evidence. The letter refers to 8 Cal. Code of Reg. Sec. 9792.9.1 (b) (1) which relates to the UR deferral process. The letter contains an incomplete sentence stating "This treatment is disputed because" with no words following. Whatever the author of this letter might have intended, it does not demonstrate that defendant was denying care within the MPN. Rather, it appears to be the use of an incorrect template and possibly misdirected. The claim itself was never denied, and the treatment within the MPN was last documented by Defendant's Exhibit V, report of Dr. Aflatoon, 01/05/2016, who recommended further treatment.
PQME Dr. Kim found AMA impairments requiring permanent disability indemnity, which was resolved by compromise and release.
Favours Defendant prevailed
Supports the finding that defendant met its obligation to provide benefits and no additional liability for out-of-network treatment was required.
From the decision · page 5In this case PQME Dr. Kim found that applicant had AMA impairments, which required defendant to provide permanent disability indemnity, liability for which was resolved by compromise and release approved on 09/25/2017
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Not properly elected as PTP; no liability for medical legal services by him or RMS.
Never properly elected as PTP, so no liability for medical legal services.
From the decision · page 4A primary treating physician may perform medical legal services if requested by a party in certain cases. In this case, Dr. Gottschalk and RMS were
Found AMA impairments requiring permanent disability indemnity, resolved by compromise and release.
PQME determination required defendant to provide permanent disability indemnity.
From the decision · page 5In this case PQME Dr. Kim found that applicant had AMA impairments, which required defendant to provide permanent disability indemnity, liability for which was resolved by compromise and release approved on 09/25/2017
Provided ongoing treatment within the MPN and recommended further treatment.
Treatment within MPN was ongoing and authorized, no denial of care shown.
From the decision · page 4The designation of RMS as PTP was insufficient to wrest defendant's control of treatment within the MPN. The status of Chrislip Hervatin as applicant's attorney was in question without the statutorily required filing to take over applicant's representation. More importantly, no denial of care has been shown though it is alleged based on Lien Claimant's Exhibit 5, letter of 05/31/2016. This letter appears to only be addressed to applicant, and references a request for authorization dated 05/30/2016 without identifying the requesting party. There is no 05/30/2016 RFA in evidence. The letter refers to 8 Cal. Code of Reg. Sec. 9792.9.1 (b) (1) which relates to the UR deferral process. The letter contains an incomplete sentence stating "This treatment is disputed because" with no words following. Whatever the author of this letter might have intended, it does not demonstrate that defendant was denying care within the MPN. Rather, it appears to be the use of an incorrect template and possibly misdirected. The claim itself was never denied, and the treatment within the MPN was last documented by Defendant's Exhibit V, report of Dr. Aflatoon, 01/05/2016, who recommended further treatment.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
California Labor Code
Labor Code Section 4063
Requires employer to commence compensation if PQME or AME makes a medical determination requiring it.
From the decision · page 5Obligation to Provide Benefits Labor Code Section 4063 requires an employer to commence
California Code of Regulations
8 Cal. Code of Reg. Sec. 9792.9.1 (b) (1)
Relates to UR deferral process; referenced in denial of care letter but no denial shown.
From the decision · page 4The designation of RMS as PTP was insufficient to wrest defendant's control of treatment within the MPN. The status of Chrislip Hervatin as applicant's attorney was in question without the statutorily required filing to take over applicant's representation. More importantly, no denial of care has been shown though it is alleged based on Lien Claimant's Exhibit 5, letter of 05/31/2016. This letter appears to only be addressed to applicant, and references a request for authorization dated 05/30/2016 without identifying the requesting party. There is no 05/30/2016 RFA in evidence. The letter refers to 8 Cal. Code of Reg. Sec. 9792.9.1 (b) (1) which relates to the UR deferral process. The letter contains an incomplete sentence stating "This treatment is disputed because" with no words following. Whatever the author of this letter might have intended, it does not demonstrate that defendant was denying care within the MPN. Rather, it appears to be the use of an incorrect template and possibly misdirected. The claim itself was never denied, and the treatment within the MPN was last documented by Defendant's Exhibit V, report of Dr. Aflatoon, 01/05/2016, who recommended further treatment.
California Code of Regulations
Section 10109 of Title 8 of the Code of Regulations
Requires good faith investigation of claim; defendant provided care and did not deny claim.
From the decision · page 5Section 10109 of Title 8 of the Code of Regulations requires defendant to conduct a good faith investigation of a claim. Here defendant never denied the claim and provided medical care commencing the following day of the accident. Nothing suggests a failure to investigate the claim
What proof carried it
The evidence the panel weighed, by kind.
No denial of care within the MPN shown; treatment ongoing and authorized by defendant.
From the decision · page 4The designation of RMS as PTP was insufficient to wrest defendant's control of treatment within the MPN. The status of Chrislip Hervatin as applicant's attorney was in question without the statutorily required filing to take over applicant's representation. More importantly, no denial of care has been shown though it is alleged based on Lien Claimant's Exhibit 5, letter of 05/31/2016. This letter appears to only be addressed to applicant, and references a request for authorization dated 05/30/2016 without identifying the requesting party. There is no 05/30/2016 RFA in evidence. The letter refers to 8 Cal. Code of Reg. Sec. 9792.9.1 (b) (1) which relates to the UR deferral process. The letter contains an incomplete sentence stating "This treatment is disputed because" with no words following. Whatever the author of this letter might have intended, it does not demonstrate that defendant was denying care within the MPN. Rather, it appears to be the use of an incorrect template and possibly misdirected. The claim itself was never denied, and the treatment within the MPN was last documented by Defendant's Exhibit V, report of Dr. Aflatoon, 01/05/2016, who recommended further treatment.
PQME Dr. Kim found AMA impairments requiring permanent disability indemnity, resolved by compromise and release.
From the decision · page 5In this case PQME Dr. Kim found that applicant had AMA impairments, which required defendant to provide permanent disability indemnity, liability for which was resolved by compromise and release approved on 09/25/2017
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About this page
- A published decision of the California Workers' Compensation Appeals Board, taken apart by what it turned on. The Board publishes the decision itself; this page adds the extraction and quotes the passage behind every claim.
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