ADJ16590361 · October 16, 2023

The defendant neglected to provide medical treatment within the MPN, failing to arrange initial appointments despite authorizing physicians, thus the applicant is entitled to treat outside the MPN at defendant's expense.

From the decision · page 4The matter proceeded to an expedited hearing on July 10, 2023 on applicant's contention that he was entitled to treat outside defendant's Medical Provider Network ("MPN") as the MPN did not meet the access standards pursuant to Title 8, California Code of Regulations 9767.5. I issued my Finding and Order on August 2, 2023 where I found that applicant had not provided sufficient evidence to establish that defendant's MPN did not meet the access standards, however, I found that the defendants had neglected to provide medical treatment in this case. It was on that basis that I found the applicant was entitled to treat outside the MPN at defendant's expense. It is from this Finding and Order that defendant has filed a petition for reconsideration.

Defendant authorized physicians designated by applicant but did not arrange initial appointments within the MPN despite knowing difficulties in obtaining care.

Favours Applicant prevailed

This failure constituted neglect to provide medical treatment, entitling applicant to treat outside the MPN at defendant's expense.

From the decision · page 6Defendant took no affirmative steps to arrange for the initial medical treatment within their MPN. Although defendants did authorize each physician designated by applicant, they did not arrange for an initial appointment. Defense, by its own admission, knew that there were difficulties in getting a doctor within their MPN who was accepting patients. (Exhibit 1, page 5.) Despite this knowledge, defendant did not arrange for an initial appointment with a physician within the MPN or assist applicant in establishing care. As defendant neglected to provide medical treatment, I found that the applicant is entitled to treat outside the defendant's MPN at defendant's expense.

Applicant designated multiple treating physicians and requested authorization, but defendant delayed or failed to timely authorize or arrange treatment.

Favours Applicant prevailed

This delay and failure to arrange treatment supported the finding of neglect to provide medical treatment.

From the decision · page 5An application for adjudication of claim was filed on the applicant's behalf on August 22, 2022. (EAMS Document ID 42770059.) A DWC-1 claim form was signed by the applicant on December 21, 2021, and filed and served on defendants at the same time as the application. (EAMS Document ID 42770061.) Applicant designated a treating physician, Dr. Goldin, on September 30, 2022 by letter to both defense counsel and the third-party administrator. (Applicant's Exhibit 5.) Defendant belatedly authorized that treatment more than two months later. (Defendant's Exhibit C.) However, defendant apparently did not arrange for the initial appointment. Applicant designated two additional physicians as treating doctors between January and February, 2023. (Applicant's Exhibit 3 and 4.) Defense counsel, in a March 8, 2023 email to applicant's counsel, admitted that they have authorized several doctors that were not accepting patients but it was "not our delay." (Applicant's Exhibit 1, page 5.) Defendant's apparent position was that applicant was not able to receive medical care within their "it was not our delay." (Id.) Knowing that the applicant was having difficulty obtaining medical care within the MPN, defendant took the position that they were under no obligation to assist.

Diagnosed closed head injury with posttraumatic headache and dizziness, cervical and upper back pain post T1-2 decompression and fusion with probable cervical radiculopathy; opined injuries consistent with January 20, 2018 work incident; recommended additional medical care; not at maximum medical improvement.

From the decision · page 8Dr. Gupta evaluated the applicant as a Panel Qualified Medical Evaluator on April 11, 2023. The applicant reported that on January 20, 2028 he was making a panel and using a hammer to pull a nail when he fell backwards into a trench, hitting his upper back and head against some rocks. He had bleeding on the left side of the head and suffered a blow to the upper back. He went to the emergency room on the day of injury and returned to work full duty but was assigned light duty work. He treated with a chiropractor from February 2018 through August, 2021. He was referred to Dr. Behravan for injections and then Dr. Talwar, who performed a one level fusion on January 4, 2023. He was complaining of headaches and has not had any medical care for them. He was taken off work on August 15, 2021. Dr. Gupta noted that he was taken to the emergency room on the date of injury and there was no further treatment.

Labor Code section 4600(a)

Labor Code section 4600(a) requires employers to provide medical treatment reasonably required to cure or relieve the injured worker from the effects of the injury.

Defendant neglected to provide medical treatment within the MPN, entitling applicant to treat outside the MPN at defendant's expense.

From the decision · page 1Labor Code section 4600(a) provides that:

Title 8, California Code of Regulations section 9767.5

Title 8, California Code of Regulations section 9767.5 sets access standards for Medical Provider Networks.

Applicant failed to prove defendant's MPN did not meet access standards, but defendant neglected to provide treatment within the MPN.

From the decision · page 1If an employer has established an MPN, injured workers are generally limited to treating with a physician from within the employer's MPN. (Lab. Code, § 4600(c), 4616 et seq.) However, if the employer neglects or refuses to provide reasonably necessary medical treatment, whether

Employers neglect or refusal to provide medical treatment occurs when they have notice of injury and need for treatment and fail to provide it.

Defendant had notice of injury and need for treatment but failed to arrange initial appointments within the MPN.

Defendant failed to arrange initial medical appointments within the MPN despite authorizing physicians and knowing difficulties in obtaining care.

From the decision · page 6Defendant took no affirmative steps to arrange for the initial medical treatment within their MPN. Although defendants did authorize each physician designated by applicant, they did not arrange for an initial appointment. Defense, by its own admission, knew that there were difficulties in getting a doctor within their MPN who was accepting patients. (Exhibit 1, page 5.) Despite this knowledge, defendant did not arrange for an initial appointment with a physician within the MPN or assist applicant in establishing care. As defendant neglected to provide medical treatment, I found that the applicant is entitled to treat outside the defendant's MPN at defendant's expense.