What the panel ordered
Petition for Reconsideration denied
Petition for Reconsideration filed by defendant and denied by WCAB panel after review of WCJ report
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.
The WCAB panel adopted the WCJ's report and denied the petition for reconsideration because the defendant failed to comply with its duty to conduct a reasonable and good faith investigation and improperly rejected the medical evidence without clarification attempts.
From the decision · page 1We have considered the allegations of the Petition for Reconsideration and the contents of the report of the workers' compensation administrative law judge (WCJ) with respect thereto. Based on our review of the record, and for the reasons stated in the WCJ's report, which we adopt and incorporate, and for the reasons stated below, we will deny reconsideration.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant failed to conduct a reasonable and good faith investigation as required by WCAB Rule 10109.
Favours Applicant prevailed
This failure led to denial of benefits and was a key reason for denying the petition for reconsideration.
From the decision · page 1Defendants have a regulatory duty to conduct a reasonable and good faith investigation to determine whether benefits are due. We agree with the WCJ that defendant failed to comply with that duty in this case.
Claims examiner rejected medical evidence without attempting to clarify deficiencies in the report.
Favours Applicant prevailed
This improper rejection of medical evidence without clarification attempts supported denial of the petition for reconsideration.
From the decision · page 5The claims examiner testified that in his opinion, the words "adjustment disorder" raise unresolved questions about the diagnosis. He testified that he questions whether being "almost electrocuted" can cause injury. In doing so, the claims examiner is rejecting medical evidence without any attempt to clarify it presumably based on his own understanding of medical science.
Dr. Mark Kimmel's QME report was thorough, reviewed all records provided, and supported the diagnosis and causation of the industrial injury.
Favours Applicant prevailed
The substantial medical evidence in Dr. Kimmel's report supported the applicant's claim and was relied upon by the WCJ and WCAB.
From the decision · page 4The claim was denied and applicant was evaluated by Mark Kimmel, PhD., who reported on July 16, 2020. (Exhibit AA.) Dr. Kimmel diagnosed applicant with an adjustment disorder with mixed anxiety and depressed mood, with elements of PTSD. This diagnosis was stated to derive from the International Classification of Diseases, Tenth Revision (ICD-10). Dr. Kimmel stated that the industrial event was the predominant cause of the injury. Dr. Kimmel reviewed all available records and took a complete history.
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.
Diagnosed applicant with adjustment disorder with mixed anxiety and depressed mood, with elements of PTSD, predominantly caused by the industrial event; reviewed all available records and took a complete history.
The WCJ found Dr. Kimmel's report to be thorough and substantial medical evidence supporting the claim, despite defendant's objections about record review and diagnostic terminology.
From the decision · page 4The claim was denied and applicant was evaluated by Mark Kimmel, PhD., who reported on July 16, 2020. (Exhibit AA.) Dr. Kimmel diagnosed applicant with an adjustment disorder with mixed anxiety and depressed mood, with elements of PTSD. This diagnosis was stated to derive from the International Classification of Diseases, Tenth Revision (ICD-10). Dr. Kimmel stated that the industrial event was the predominant cause of the injury. Dr. Kimmel reviewed all available records and took a complete history.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
WCAB Rule 10109
Claims administrator must conduct a reasonable and timely investigation upon receiving notice or knowledge of an injury or claim for workers' compensation benefits.
Defendant failed to comply with this duty by not conducting a reasonable and good faith investigation and not clarifying medical report deficiencies.
From the decision · page 1Specifically, Workers' Compensation Appeals Board (WCAB) Rule 10109 provides, in relevant part:
Labor Code section 4063
Upon receipt of a report resolving an issue requiring compensation, defendant must provide compensation or file a Declaration of Readiness to Proceed.
Claims examiner incorrectly believed he had no duty to act on the medical report, leading to denial of benefits.
From the decision · page 6Labor Code section 4063 requires that on receipt of a report resolving an issue requiring a defendant to provide compensation, it must do so or file a Declaration of Readiness to Proceed. The claims examiner is incorrect that he has no duty when he makes a unilateral decision to reject the clear and unambiguous opinion of the evaluator. 3. Defendant made no formal attempts to receive additional records Defendant has argued that its discovery attempts were hampered by the failure of applicant to sign an unlimited release. However, it has shown no meaningful attempts to receive an unlimited release. The claims examiner can only recall with any detail one phone call to applicant requesting a second release. (Minutes of Hearing, Summary of Evidence, page 11, liens 1 to 4.) If defendant determined that it needed an unlimited release, it had the ability to seek WCAB intervention. There is no record of any efforts to do so. Instead it chose to unilaterally sit on its hands from the February 20, 2020, receipt of the time-limited release until its October 7, 2020, objection to applicant's DOR. Defendant clearly waived any right to insist on an unlimited release due to its delays.
What proof carried it
The evidence the panel weighed, by kind.
Defendant failed to conduct a reasonable and good faith investigation and did not clarify or follow up on the medical report deficiencies.
From the decision · page 1Defendants have a regulatory duty to conduct a reasonable and good faith investigation to determine whether benefits are due. We agree with the WCJ that defendant failed to comply with that duty in this case.
Claims examiner rejected medical evidence based on personal understanding without clarification attempts.
From the decision · page 5The claims examiner testified that in his opinion, the words "adjustment disorder" raise unresolved questions about the diagnosis. He testified that he questions whether being "almost electrocuted" can cause injury. In doing so, the claims examiner is rejecting medical evidence without any attempt to clarify it presumably based on his own understanding of medical science.
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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.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
- Issues, outcomes and weights were extracted by AI and released only where the source passage checked. Read the official decision before relying on anything here. Not legal advice.
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