ADJ13323913 — California WCAB decision

What the panel ordered

Petition for Reconsideration granted; Findings and Order amended to find defendant liable for medical treatment costs up to August 6, 2020; otherwise affirmed

Petition for Reconsideration granted by WCAB panel on December 16, 2024, amending the Findings and Order of September 24, 2024

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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.

Medical treatment / UR / IMRApplicant prevailedleft shoulder · left side rib cage · lumbar spine · left sacroiliac joint · right sacroiliac joint

Defendant failed to provide proper notice of MPN and timely medical evaluation, resulting in liability for medical treatment costs up to August 6, 2020; thereafter, treatment was not reasonably required.

From the decision · page 1Lien claimant Optimal Health Medical Center seeks reconsideration of the Findings and Order (F&O) of September 24, 2024, wherein the workers' compensation administrative law judge (WCJ) found that applicant sustained injury arising out of and occurring in the course of employment to his left shoulder, left side rib cage, lumbar spine, and left and right sacroiliac joints while employed as a maintenance repairer for defendant. The WCJ found that defendant maintained a valid MPN and properly exercised control of medical treatment within the network and the services of Optimal Health Institute were not reasonably required to cure or relieve applicant from the effects of the industrial injury.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Defendant's April 9, 2020 letter to Kaiser Permanente limited authorization to pelvis only and lacked appointment details.

Favours Applicant prevailed

This defective notice failed to inform applicant properly of available treatment, leading to denial of care liability.

From the decision · page 6The only pieces of evidence with respect to notice are defendant's letter dated April 9, 2020 to Kaiser Permanente, defendant's letter dated June 30, 2020 to Dr. Shen, and defendant's DOR dated June 30, 2020. However, the June 30, 2020 letter was not sent to applicant and was not faxed to Dr. Shen until July 6, 2020, which was after his July 1, 2020 evaluation, and the DOR was not filed until July 6, 2020. Thus, the issue is whether the April 9, 2020 letter sufficiently arranged for a medical examination under section 4616.3(a) and sufficiently notified applicant of the MPN under section 4616.3(b). In its Petition, lien claimant asserts that while the letter was allegedly copied to applicant, there was no proof of service. It further contends that "the letter did not include an appointment date, time, and facility or a list of doctors" for applicant to see at Kaiser and authorization was limited to treating applicant's pelvis.

Applicant never sought treatment from Kaiser Permanente and was represented by attorneys before notice was sent.

Favours Applicant prevailed

Applicant's failure to seek treatment and lack of notice to attorneys and Dr. Shen until after evaluation showed neglect by defendant.

From the decision · page 6Here it is undisputed that applicant never sought any treatment from Kaiser Permanente, and the record indicates that applicant became represented on April 7, 2020 before the April 9, 2020 letter. Based on the record before us, we cannot discern whether applicant did not understand that care with Kaiser was available, possibly because of defective notice, or whether he failed to seek care because he was represented. The purpose of the notice requirements is so that an injured worker clearly understands that care is available, and applicant's attorneys and the treating physicians understand that defendant will not assume payment for the cost of care outside the MPN. Defendant's failure to clearly provide notice to applicant after he reported the injury was

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code sections 4600(a), 4600(c), 4616 et seq.

An employer with a valid MPN is liable only for treatment within the MPN, but must reimburse for self-procured treatment if employer neglects or refuses to provide necessary care.

Defendant's failure to provide proper notice and timely medical evaluation constituted neglect, making it liable for treatment costs outside the MPN up to August 6, 2020.

From the decision · page 5When a lien claimant litigates the entitlement to payment for industrially related medical treatment, the lien claimant stands in the shoes of the injured employee and the lien claimant must prove by a preponderance of the evidence all elements necessary to the establishment of its lien. (Kunz v. Patterson Floor Coverings, Inc. (2002) 67 Cal.Comp.Cases 1588, 1592 (Appeals Board en banc.) If an employer has established an MPN, the employer is only liable for payment for treatment by a physician from within the employer's MPN, and applicant is generally limited to treating with a physician from within that MPN. (Lab. Code, § 4600(c), 4616 et seq.) However, if the employer neglects or refuses to provide reasonably necessary medical treatment, whether through an MPN or otherwise, then an injured worker may self-procure medical treatment at the employer's expense. (Lab. Code, § 4600(a); see Knight v. United Parcel Service (2006) 71 Cal. Comp. Cases 1423, 1434 [2006 Cal. Wrk. Comp.

Cal. Code Regs., tit. 8, 9767.12(a)(1), 9767.5(f)

Notification requirements for MPN under AD Rule 9767.12 and AD Rule 9767.5(f) require clear notice and timely appointment availability.

Defendant's April 9, 2020 letter failed to meet notification requirements, contributing to liability for treatment costs.

From the decision · page 6AD Rule 9767.12 provides for notification of the MPN as follows: (a) When an injury is reported or an employer has knowledge of an injury that is subject to an MPN or when an employee with an existing injury is required to transfer treatment to an MPN, a complete written MPN employee notification with the information specified in paragraph (2) of this subdivision, shall be provided to the covered employee by the employer or the insurer for the employer. This MPN notification shall be provided to employees in English and also in Spanish if the employee primarily speaks Spanish.

What proof carried it

The evidence the panel weighed, by kind.

Documentary evidencefavours Applicant prevailed

Defendant's April 9, 2020 letter to Kaiser Permanente did not include appointment date, time, facility, or list of doctors; limited authorization to pelvis only; no proof of service to applicant's attorneys.

From the decision · page 6The only pieces of evidence with respect to notice are defendant's letter dated April 9, 2020 to Kaiser Permanente, defendant's letter dated June 30, 2020 to Dr. Shen, and defendant's DOR dated June 30, 2020. However, the June 30, 2020 letter was not sent to applicant and was not faxed to Dr. Shen until July 6, 2020, which was after his July 1, 2020 evaluation, and the DOR was not filed until July 6, 2020. Thus, the issue is whether the April 9, 2020 letter sufficiently arranged for a medical examination under section 4616.3(a) and sufficiently notified applicant of the MPN under section 4616.3(b). In its Petition, lien claimant asserts that while the letter was allegedly copied to applicant, there was no proof of service. It further contends that "the letter did not include an appointment date, time, and facility or a list of doctors" for applicant to see at Kaiser and authorization was limited to treating applicant's pelvis.

treatment coursefavours Applicant prevailed

Applicant never sought treatment from Kaiser Permanente; defendant failed to notify applicant's attorneys and Dr. Shen until after July 1, 2020 evaluation.

From the decision · page 6Here it is undisputed that applicant never sought any treatment from Kaiser Permanente, and the record indicates that applicant became represented on April 7, 2020 before the April 9, 2020 letter. Based on the record before us, we cannot discern whether applicant did not understand that care with Kaiser was available, possibly because of defective notice, or whether he failed to seek care because he was represented. The purpose of the notice requirements is so that an injured worker clearly understands that care is available, and applicant's attorneys and the treating physicians understand that defendant will not assume payment for the cost of care outside the MPN. Defendant's failure to clearly provide notice to applicant after he reported the injury was

ADJ13323913 · December 16, 2024

What the panel ordered

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