ADJ11644994 · November 22, 2024

The WCJ found that the cost petitioner failed to prove by a preponderance of the evidence that the copy services were done to prove or disprove a contested component of the claim, and that the claim was not contested at the time the services were performed. The WCAB granted reconsideration but deferred final decision pending further review.

From the decision · page 5*** Based on the evidence as a whole, the undersigned finds Citywide has failed to prove, by a preponderance of the evidence that the copying services at Glendale Eye Medical Group, Concentra Urgent Care and Loma Linda University Medical Group were done to prove or disprove a contested component of applicant's claim.

Cost petitioner failed to prove by a preponderance of the evidence that the copy services were done to prove or disprove a contested component of the claim.

Favours Defendant prevailed

This failure led the WCJ to deny reimbursement and the WCAB to grant reconsideration but defer final decision pending further review.

From the decision · page 5*** Based on the evidence as a whole, the undersigned finds Citywide has failed to prove, by a preponderance of the evidence that the copying services at Glendale Eye Medical Group, Concentra Urgent Care and Loma Linda University Medical Group were done to prove or disprove a contested component of applicant's claim.

Authorized to treat applicant's eyes; back injury claim denied.

From the decision · page 3On February 20, 2019, defendant issued a transfer of care/authorization to treat letter authorizing Gordon Booth, M.D., to treat applicant both eyes in ADJ11644994 and that ADJ11951700 is "a denied claim involving a back injury." (Exhibit C, 2/20/2019.)

Evaluation dated 10/10/18 used for permanent disability determination.

From the decision · page 2We will briefly review the relevant facts. On October 30, 2018, applicant filed an Application for Adjudication (Application), claiming injury to the eye while employed on October 6, 2018, by defendant as an auto mechanic. (Case No. ADJ11644994.) On February 13, 2019, applicant filed an Application claiming cumulative injury to his back while employed from January 1, 2018 through November 7, 2018, by defendant as an auto mechanic. (Case No. ADJ11951700.) On October 26, 2018, defendant issued a Notice of Denial of Permanent Disability Benefits for applicant's injury of October 6, 2018. (Case Number ADJ11644994). The determination of permanent disability is based on the evaluation of treating physician Concentra-Dr. Michael Chiang dated 10/10/18. I agree with the results of the evaluation. If you disagree with the results of the evaluation of the treating physician, you may obtain an evaluation by a Qualified Medical Evaluator (QME). You must notify me in writing of your objection to the determination of the treating physician within thirty (30) days of the date you received the treating physician's report.

Evaluation scheduled for 2/18/19 but applicant failed to attend, hindering investigation.

From the decision · page 3After careful consideration of all available information, we are denying all liability for your claim of injury to your spine on or through 11/7/2018 because there is no substantial legal, medical or factual evidence to indicate that your alleged injury resulted from your employment at Pac Auto Group Inc. while insured by Cypress Insurance Company. You failed to attend a properly noticed medical evaluation we scheduled for you with Dr. Ganna Breland, M.D. on 2/18/19. Dr. Breland needed you to attend his evaluation to fully evaluate your condition. As a result of your failure to attend the appointment, BHHC ability to fully investigate your allegations has been hindered. Thus we do not have, and have been prevented from obtaining sufficient information to determine compensability of your condition.

Labor Code sections 4620, 4621, 4622, 5307.9

These statutes govern the reimbursement for medical-legal expenses and copy services in workers' compensation claims.

From the decision · page 7A lien claimant holds the burden of proof to establish all elements necessary to establish its entitlement to payment for a medical-legal expense. (See § 3205.5, 5705.5; Torres v. AJC Sandblasting (2012) 77 Cal.Comp.Cases 1113, 1115 [2012 Cal. Wrk. Comp. LEXIS 160] (Appeals Board en banc).) As we explained in our en banc decision in Colamonico v. Secure Transportation (2019) 84 Cal. Comp. Cases 1059 (Appeals Board en banc), section 4622 provides the framework for reimbursement of medical-legal expenses. Subsection (f) of the statute, however, specifically states that "[t]his section is not applicable unless there has been compliance with Sections 4620 and 4621." (§ 4622(f).)

Applicant failed to attend QME evaluation scheduled for 2/18/19, hindering defendant's ability to investigate claim.

From the decision · page 3After careful consideration of all available information, we are denying all liability for your claim of injury to your spine on or through 11/7/2018 because there is no substantial legal, medical or factual evidence to indicate that your alleged injury resulted from your employment at Pac Auto Group Inc. while insured by Cypress Insurance Company. You failed to attend a properly noticed medical evaluation we scheduled for you with Dr. Ganna Breland, M.D. on 2/18/19. Dr. Breland needed you to attend his evaluation to fully evaluate your condition. As a result of your failure to attend the appointment, BHHC ability to fully investigate your allegations has been hindered. Thus we do not have, and have been prevented from obtaining sufficient information to determine compensability of your condition.