ADJ9787530 — California WCAB decision

What the panel ordered

The December 10, 2021 Findings and Order is affirmed, denying the lien claimant's petition for reconsideration.

Petition for Reconsideration filed by lien claimant Moussa Moshfegh, M.D. seeking review of the December 10, 2021 Findings and Order denying injury and self-procured treatment claims.

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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.

AOE/COEDefendant prevailedhernia

The lien claimant failed to prove the existence of the October 30, 2014 hernia injury, and the medical history relied upon was inaccurate and contradicted by the admitted March 28, 2014 hernia injury and related treatment.

From the decision · page 6Here, lien claimant's reporting is premised on a wholly inaccurate medical history and cannot constitute substantial medical evidence. Insofar as the parties contest the existence of an October 30, 2014 injury, the record reflects no supporting evidence beyond the non-substantial reporting of lien claimant. Accordingly, we concur with the WCJ's conclusion that lien claimant, standing in the shoes of applicant, has not met its affirmative burden of establishing industrial injury occurring on October 30, 2014. (Finding of Fact No. 2.)

The facts that decided it

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

Applicant sustained an admitted hernia injury on March 28, 2014, with surgical repair and medical treatment provided within defendant's MPN.

Favours Defendant prevailed

This established the baseline injury and timely medical care, undermining the claim of a separate October 30, 2014 injury and need for self-procured treatment.

From the decision · page 5Clarence R. Petrie, M.D. (Defendant's Exhibit F) treated applicant for an admitted right inguinal hernia industrial injury plead as occurring on 03/28/2014. Treatment was provided by defendants after the injury, and Dr. Petrie ultimately operated on the hernia on 06/12/2014. Applicant treated through 08/11/2014 and thereafter cancelled appointments with the surgeon.

Lien claimant's medical history was inaccurate and inconsistent with the admitted injury and treatment records.

Favours Defendant prevailed

This undermined the lien claimant's claim of a new injury and necessity of self-procured treatment.

From the decision · page 6Here, lien claimant's reporting is premised on a wholly inaccurate medical history and cannot constitute substantial medical evidence. Insofar as the parties contest the existence of an October 30, 2014 injury, the record reflects no supporting evidence beyond the non-substantial reporting of lien claimant. Accordingly, we concur with the WCJ's conclusion that lien claimant, standing in the shoes of applicant, has not met its affirmative burden of establishing industrial injury occurring on October 30, 2014. (Finding of Fact No. 2.)

Defendant provided timely and necessary medical treatment within its MPN, including evaluation, surgery, and follow-up care.

Favours Defendant prevailed

This disproved the lien claimant's assertion that employer failed to provide timely treatment and justified self-procured care.

From the decision · page 6However, as the WCJ's Report observes, following the March 28, 2014 injury date, applicant sought and received treatment from within defendant's MPN including evaluation and diagnosis by Eileen Lee, D.O. (Ex. A, Report of Eileen Lee, D.O., various dates), surgical intervention performed by Clarence Petrie, M.D. (Ex. D, Reports of Clarence Petrie, M.D., various dates), and later, follow-up consultation with Raye Bellinger, M.D. (Ex. E, Reports of Raye Bellinger, M.D., various dates). The evidence thus supports defendant's timely provision of medical treatment in response to applicant's March 28, 2014 injury. Moreover, lien claimant identifies no request for medical treatment submitted by applicant which defendant neglected or refused. (See Knight v. United Parcel Service (2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc).)

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.

PTPRelied upon

Reviewed medical imaging and found applicant's complaints out of proportion to activities; questioned October 30, 2014 re-injury diagnosis.

Supported rejection of October 30, 2014 injury claim and necessity of self-procured treatment.

From the decision · page 6Here, lien claimant's reporting is premised on a wholly inaccurate medical history and cannot constitute substantial medical evidence. Insofar as the parties contest the existence of an October 30, 2014 injury, the record reflects no supporting evidence beyond the non-substantial reporting of lien claimant. Accordingly, we concur with the WCJ's conclusion that lien claimant, standing in the shoes of applicant, has not met its affirmative burden of establishing industrial injury occurring on October 30, 2014. (Finding of Fact No. 2.)

PTPRelied upon

Provided evaluation and diagnosis within defendant's MPN for the admitted injury.

Supported that defendant provided timely and necessary medical care within MPN.

From the decision · page 6However, as the WCJ's Report observes, following the March 28, 2014 injury date, applicant sought and received treatment from within defendant's MPN including evaluation and diagnosis by Eileen Lee, D.O. (Ex. A, Report of Eileen Lee, D.O., various dates), surgical intervention performed by Clarence Petrie, M.D. (Ex. D, Reports of Clarence Petrie, M.D., various dates), and later, follow-up consultation with Raye Bellinger, M.D. (Ex. E, Reports of Raye Bellinger, M.D., various dates). The evidence thus supports defendant's timely provision of medical treatment in response to applicant's March 28, 2014 injury. Moreover, lien claimant identifies no request for medical treatment submitted by applicant which defendant neglected or refused. (See Knight v. United Parcel Service (2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc).)

otherRejected

Reported an alleged hernia injury on October 30, 2014, based on an inaccurate medical history, and claimed necessity of self-procured treatment.

Opinion premised on inaccurate medical history and not substantial evidence.

From the decision · page 6Here, lien claimant's reporting is premised on a wholly inaccurate medical history and cannot constitute substantial medical evidence. Insofar as the parties contest the existence of an October 30, 2014 injury, the record reflects no supporting evidence beyond the non-substantial reporting of lien claimant. Accordingly, we concur with the WCJ's conclusion that lien claimant, standing in the shoes of applicant, has not met its affirmative burden of establishing industrial injury occurring on October 30, 2014. (Finding of Fact No. 2.)

PTPRelied upon

Treated admitted hernia injury of March 28, 2014, including surgery on June 12, 2014, and follow-up care.

Supported that defendant provided timely and necessary medical care within MPN.

From the decision · page 6However, as the WCJ's Report observes, following the March 28, 2014 injury date, applicant sought and received treatment from within defendant's MPN including evaluation and diagnosis by Eileen Lee, D.O. (Ex. A, Report of Eileen Lee, D.O., various dates), surgical intervention performed by Clarence Petrie, M.D. (Ex. D, Reports of Clarence Petrie, M.D., various dates), and later, follow-up consultation with Raye Bellinger, M.D. (Ex. E, Reports of Raye Bellinger, M.D., various dates). The evidence thus supports defendant's timely provision of medical treatment in response to applicant's March 28, 2014 injury. Moreover, lien claimant identifies no request for medical treatment submitted by applicant which defendant neglected or refused. (See Knight v. United Parcel Service (2006) 71 Cal.Comp.Cases 1423 (Appeals Board en banc).)

The rules the panel named

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

Labor Code section 5705; Labor Code section 3202.5

Burden of proof rests on the party or lien claimant holding the affirmative of the issue.

Lien claimant must prove entitlement to benefits and reasonable value of services.

From the decision · page 4In addition to the WCJ's well-reasoned report, we observe the following. In workers' compensation matters, the burden of proof rests on the party or lien claimant holding the affirmative of the issue. (Lab. Code, § 5705; § 3202.5.) "[T]he lien claimant bears the burden of establishing the... entitlement to benefits and the reasonable value of the services." (Zenith Ins. Co. v. Workers' Comp. Appeals Board (Capi) (2006) 138 Cal.App.4th 373, 376-377 [71 Cal.Comp.Cases 374].) There is a "well-established general principle that a lien claimant has the burden of proving all of the elements necessary to the establishment of its lien." (Tapia v. Skill Master Staffing (2008) 73 Cal.Comp.Cases 1338, 1343 (Appeals Board en banc).) Thus, lien claimant must prove all the elements needed to support the lien claim, and this includes the burden of proving that that it was authorized to provide the treatment for which a fee is sought.

California Code of Regulations, title 8, section 9767.6(b)

Employer's obligation to provide treatment within one working day of injury under MPN rules.

Lien claimant argued employer failed to provide timely treatment, but evidence showed timely care was provided.

From the decision · page 6Lien claimant further asserts that defendant refused or neglected medical treatment such that applicant was entitled to seek treatment with a physician of his choosing at employer expense. Lien claimant contends that pursuant to AD Rule 9767.6, the employer is obligated to "provide for all treatment, consistent with guidelines adopted by the Administrative Director pursuant to Labor Code section 5307.27 and as set forth in title 8, California Code of Regulations, section 9792.20 et seq." (Cal. Code Regs., tit. 8, § 9767.6, subd. (b).) Lien claimant asserts, "there is no evidence to suggest that treatment was commenced one working day within the Defendants' MPN." (Petition, at p. 5:9.)

Labor Code section 4616.3(b)

Employer's failure to provide MPN notice does not entitle employee to treat outside network unless denial of care shown.

No evidence of denial of care due to delayed MPN notice; self-procured treatment not justified.

From the decision · page 6Finally, insofar as lien claimant asserts defendant's dilatory MPN notice required applicant to self-procure medical treatment at employer expense, we observe that pursuant to section 4616.3(b), "[t]he employer's failure to provide notice... shall not be a basis for the employee to

ADJ9787530 · March 3, 2026

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

What the panel did with the medical opinions

The rules the panel named

What proof carried it

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