Sedgwick Claims Management Services

What they litigate

Disputed issues across the decisions this claims administrator is named in. Every row opens the decisions it counts.

Where they appear

• Van Nuys 131
• Los Angeles 71
• Oakland 65
• Marina del Rey 62
• Santa Ana 51
• Anaheim 35
• Long Beach 27
• Pomona 26
• Sacramento 25
• San Francisco 25
• Oxnard 22
• Riverside 22

How the appealed decisions came out

These are decisions that were appealed and published — the tail of a system that mostly settles. Most claims end in a compromise and release or a stipulation and never reach a panel, so nothing below describes how this claims administrator does its work. It describes how a set of appealed disputes came out.

• 297 for the defense
• 255 for the applicant
• 106 returned for more record

Counted over 628 appealed decisions. Not this claims administrator’s book of work. A decision that went one way on one issue and the other way on another is counted in both columns, so the figures add up to more than the total.

Decisions

Newest decisions this claims administrator is named in, each with the passage the panel turned on and a link to the official PDF.

• ADJ292246 · 2026-07-01 · San Francisco District OfficeJurisdiction / venuedefendant prevailed

  Determinative passage · p.4Under California's workers' compensation system, questions relating to the medical necessity of a treatment requested by a physician are decided through a compulsory UR process. Section 4610 requires that employers establish a UR process and once a treating physician submits an RFA to an employer, the employer must either approve the treatment request or dispute the treatment request and submit the matter for review by a UR physician who then must determine, based on "medical necessity," whether to approve, modify, or deny the requested treatment. (§ 4610; State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 241.)

  The WCAB concluded that the request for a motorized wheelchair is a new and different treatment subject to utilization review, so the WCAB lacks jurisdiction to decide its medical necessity at this time.

  Official decision · page 4 →
• ADJ15211632 · 2026-06-25 · San Diego District OfficeMedical treatment / UR / IMRapplicant prevailed

  Determinative passage · p.1Applicant seeks reconsideration of the April 14, 2026 Findings and Order (F&O), wherein the workers' compensation administrative law judge (WCJ) found that a prior utilization review (UR) decision denying authorization for a requested treatment barred a subsequent request for authorization (RFA) for the same treatment submitted on December 4, 2025. The WCJ further determined that the UR decision issued on December 8, 2025 regarding authorization for a wheelchair accessible hotel room was untimely but that the requested services were not medically necessary.

  The Appeals Board found that the WCJ erred in concluding the prior UR decision barred the subsequent request and that the December 8, 2025 UR decision was untimely but the requested treatment was medically necessary, warranting reconsideration.

  Official decision · page 1 →
• ADJ10896001 · 2026-06-18 · Oxnard District OfficePermanent disability ratingapplicant prevailed

  Determinative passage · p.14Here, a careful review of the medical reporting in this matter reveals that the apportionment opinions provided by both PQME Dr. Brooks and PQME Dr. Tirmizi fail to meet this rigorous evidentiary standard. The apportionment analysis proffered by PQME Dr. Brooks regarding applicant's thoracic and lumbar spine relies upon generalized factors rather than a precise medical explanation of causation. PQME Dr. Brooks assigned 75% nonindustrial apportionment to both spinal regions, attributing this allocation to applicant's mild degenerative MRI findings, his 16 years of previous employment in the construction industry, his participation in sports activities, and his limited 60-day tenure with defendant. PQME Dr. Brooks justified this determination by concluding that a single specific injury likely did not cause the total impairment and positing that applicant likely would have developed 75% of the impairment even absent the October 28, 2016 injury. This rationale is fundamentally speculative. The mere fact that a medical report assigns approximate percentages of industrial and nonindustrial causation does not make the report reliable medical evidence by itself. By relying on applicant's prior work history and sports activities

  The apportionment opinions by PQME Dr. Brooks and Dr. Tirmizi lacked sufficient medical explanation and were speculative, so no apportionment was found. The permanent disability was found to be 27%.

  Official decision · page 14 →
• ADJ931866 · 2026-06-15 · San Bernardino District OfficePermanent total disabilityremanded

  Determinative passage · p.1Defendant seeks reconsideration of the Findings, Award, and Order issued on March 16, 2026. The workers' compensation administrative law judge (WCJ) found, in relevant part, that applicant sustained an injury to the lumbar spine, right shoulder, right wrist, ribs, thoracic spine, head, teeth, jaw (clenching), nose, right clavicle, left lung, sexual dysfunction, bowel dysfunction, urinary dysfunction, sleep, hearing, nervous system, psyche and esophagus (upper GI); and that applicant's injury caused permanent total disability of 100%.

  The Appeals Board found that the vocational expert's opinion on permanent total disability was not supported by substantial medical evidence, particularly regarding work restrictions and pain condition. The Board granted reconsideration to further develop the record and review the merits of the petition.

  Official decision · page 1 →
• ADJ12308686 · 2026-06-11 · Los Angeles District OfficeMedical treatment / UR / IMRdefendant prevailed

  Determinative passage · p.5In the present case, applicant designated Casa Colina rather than any individual physician as her primary treating physician. This designation violates AD Rule 9785(a)(1), which defines the primary treating physician as an actual physician and not a facility or other entity.

  Applicant designated a facility, not an individual physician, as primary treating physician, contrary to regulations; defendant provided access to three neurologists within the MPN, meeting statutory and regulatory requirements for access to care; applicant did not meet burden to show neglect or refusal to provide care.

  Official decision · page 5 →
• ADJ13797705 · 2026-06-09 · Santa Ana District OfficeJurisdiction / venuedeferred

  Determinative passage · p.1We granted reconsideration1 to further study the factual and legal issues in this case. Applicant sought reconsideration of the May 26, 2022 Findings and Order, wherein the workers' compensation administrative law judge (WCJ) found that the Workers' Compensation Appeals Board ("WCAB") cannot exercise subject matter jurisdiction over applicant's claim because he was not hired in California, did not regularly work here, and because California has no legitimate interest in his cumulative injury claim. Applicant contends that the WCJ erred because he was in fact hired in California and/or regularly employed here, thereby establishing subject matter jurisdiction pursuant to Labor Code section 3600.5, subdivisions (a). 2 We received an Answer. The WCJ prepared a Report and Recommendation on Petition for Reconsideration ("Report"), recommending that the Petition be denied. Subsequent to the grant of reconsideration, the Court of Appeal issued Atlanta Falcons v. Workers' Comp. Appeals Bd. (Gandy) (2025) 114 Cal.App.5th 1268 [90 Cal.Comp.Cases 997] ("Gandy"), a decision interpreting section 3600.5, subdivisions (c) and (d), and what constitutes "hire" in California for purposes of California workers' compensation proceedings more generally. Specifically, Gandy provided the following reasoning for rejecting the Appeals Board's interpretation of those subdivisions:

  The WCJ found no jurisdiction because applicant was not hired or regularly employed in California, but reconsideration was granted to consider the impact of the Court of Appeal decision Gandy (2025) which interprets 'hire' under section 3600.5 and favors a liberal construction to find California jurisdiction when a California-based team is involved.

  Official decision · page 1 →
• ADJ19403295 · 2026-06-08 · San Francisco District OfficeStatute of limitationsremanded

  Determinative passage · p.10Accordingly, the record is not fully developed and the WCJ's decision was not based on substantial evidence. We grant KForce's Petition as one seeking reconsideration, rescind the March 2, 2026 Findings of Fact, and return this matter to the trial level for further proceedings consistent with this decision.

  The WCJ's March 2, 2026 Findings of Fact on date of injury and statute of limitations were rescinded due to insufficient substantial evidence and incomplete record development.

  Official decision · page 10 →
• ADJ19384154 · 2026-06-04 · Santa Ana District OfficeJurisdiction / venueremanded

  Determinative passage · p.3(See Defendants' Trial Brief, at p. 1 ["It does appear there is personal jurisdiction over the Cardinals based on applicant's testimony that he worked in California briefly for the Cardinals in 2012."].) The matter went to trial on three issues: (1) subject matter jurisdiction over the case; (2) personal jurisdiction over each defendant; and (3) whether any defendant is exempt according to section 3600.5. (Minutes of Hearing / Summary of Evidence ("MOH/SOE"), 9/9/2025, at p. 2.) Applicant was the sole witness to testify. (MOH/SOE, 11/10/2025, at pp. 2§ 11.) The WCJ issued his F&O on March 2, 2026, finding as relevant to this Petition (1) personal jurisdiction over the Dodgers, and (2) that section 3600.5, subdivisions (c) and (d) do not bar applicant's claim. The appended Opinion on Decision makes clear that the WCJ based his finding on the rationale that the Dodgers, a California-based employer, employed applicant during the last year of his professional career. (Opinion on Decision, at pp. 6§ 8.) The F&O deferred the question of personal jurisdiction over the other defendants. (F&O, at p. 3.)

  The WCJ found personal jurisdiction over the Dodgers and that section 3600.5 subdivisions (c) and (d) do not bar the claim; however, the Appeals Board found concerns about substantial evidence on hire and work in California by the Dodgers, requiring further review.

  Official decision · page 3 →
• ADJ13039423 · 2026-06-01 · Anaheim District OfficeAOE/COEdefendant prevailed

  Determinative passage · p.13vehicle's air-conditioning in December 2020 and January 2021. (See MOH/SOE (12-17-2025) supra at 5:11-14; 8:10-11; 8:25-9:3.) The timeline of events as relayed by the applicant is inconsistent. Based on the totality of the evidence before the Court, and without any evidence offered in support of applicant's suspicion, it is found that applicant did not sustain his burden of proving by a preponderance of the evidence that he sustained an injury arising out of and in the course of hi[s] employment with Northup Grumman. (Opinion on Decision, March 5, 2026, at pp. 1-10, EAMS Doc ID numbers omitted.) Accordingly, we deny the Petition for Reconsideration.

  Applicant failed to prove industrial causation by a preponderance of the evidence; the evidence was speculative and inconsistent.

  Official decision · page 13 →
• ADJ15615310 · 2026-06-01 · Santa Ana District OfficeApportionmentapplicant prevailed

  Determinative passage · p.15Dr. Mack's apportionment opinion fails to satisfy the requirements as set forth in Escobedo6. His analysis relies primarily on the timing of Applicant's employment and the existence of pre-existing conditions, without explaining "how and why" those conditions are causing permanent disability at the time of the evaluation. As explained in Escobedo, a medical opinion on apportionment must do more than state percentages. It must explain the causal relationship between the industrial injury and the permanent disability and separately explain how and why nonindustrial factors are responsible for a portion of that disability. Dr. Mack's reports do not provide this required analysis. The deficiency is also apparent with respect to the cubital tunnel syndrome. While Dr. Mack relates this condition to the elbow pathology, he does not explain why 50% of the resulting disability is attributable to nonindustrial factors or identify what those factors are. A mere medical relationship between conditions does not establish apportionment. Because Defendant bears the burden of proof on apportionment, and because the medical evidence offered does not constitute substantial evidence, the Court is not permitted to rely upon it. Accordingly, an unapportioned award is warranted.

  The Appeals Board found Dr. Mack's apportionment opinion was not substantial evidence as it lacked required detailed explanation and reasoning, thus denying apportionment and awarding an unapportioned permanent disability.

  Official decision · page 15 →
• ADJ14079246 · 2026-05-26 · San Francisco District OfficePermanent disability ratingremanded

  Determinative passage · p.6However, the WCJ did not follow Dr. Mandell's conclusions and determined that the WPI for the shoulder should be 5%, with a permanent disability rating of 11% and therefore applicant's permanent disability rating, including both the neck and right shoulder, was 26%. (Opinion on Decision (OOD), pp. 4-6; F&A, pp. 1-2.) The WCJ stated that Dr. Mandell's alternative rating might be viable under other circumstances. (OOD, pp. 4-6.) The WCJ explained that Dr. Mandell's use of grip strength was incorrect for an injury above the elbow and that the correct table for applicant's injury was 16-35 on page 510 of the AMA Guidelines. (OOD, pp. 4-6.)

  The WCJ's 5% WPI rating for the right shoulder was not supported by substantial medical evidence, and Dr. Mandell's 17% WPI rating based on grip strength loss was not adequately clarified or supported. The Appeals Board found a lack of substantial evidence to support either rating and remanded for further proceedings.

  Official decision · page 6 →
• ADJ13355568 · 2026-05-08 · Oakland District OfficeStatute of limitationsremanded

  Determinative passage · p.5Here, the WCJ failed to determine the date of injury in accordance with section 5412 and failed to determine when CIGA last paid benefits under section 5405(c) for its administrated claim. Accordingly, upon return, the WCJ must determine not only when CIGA had knowledge of its right to file an Application, but must also determine when applicant first suffered temporary or permanent disability from the cumulative injury in order to raise a cognizable claim for CIGA's reimbursement of benefits. In addition, the WCJ must determine when CIGA last paid benefits on companion case number ADJ2881803, to determine the applicability of section 5405(c) in the

  The WCJ failed to determine the date of injury under section 5412 and when CIGA last paid benefits under section 5405(c), thus the claim's timeliness could not be properly assessed.

  Official decision · page 5 →

Also recorded as

The same claims administrator is printed several ways across the decisions, and all of them were counted as one. These are the twelve commonest of 57.

• SEDGWICK CLAIMS MANAGEMENT SERVICES
• SEDGWICK CMS
• SEDGWICK
• SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.
• Sedgwick Claims Management Services
• Sedgwick
• Sedgwick Claims Management Services, Inc.
• Sedgwick CMS
• SEDGWICK CLAIMS MANAGEMENT
• Sedgwick Claims Management
• SEDGWICK RIVERSIDE
• SEDGWICK CMS, INC.

Is this your company and something here is wrong? Tell us and we will fix it. Every figure on this page is a count of released decisions this claims administrator is named in, and the decisions themselves are listed above with the passage each turned on.