ADJ14743350 — California WCAB decision

What the panel ordered

Petition for Reconsideration granted, Findings and Order of January 16, 2024 rescinded, matter returned to WCJ for further proceedings

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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 prevailedcervical spine · shoulders · back

The Appeals Board held that a medical-legal report from the treating physician is a reasonable and necessary medical-legal expense for which the defendant is liable, overruling the WCJ's finding that only a PQME or AME report is proper for causation on a denied claim.

The facts that decided it

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

Dr. Omar Haghighinia's medical-legal report was a valid comprehensive initial treatment evaluation and a medical-legal report for proving or disproving a contested claim.

Favours Applicant prevailed

This fact supported the finding that the report was reasonable and necessary, making the defendant liable for payment.

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

Concluded applicant's injury was industrial and submitted a medical-legal report for proving or disproving a contested claim.

The report was found to be a valid comprehensive initial treatment evaluation and a medical-legal report for which payment is reasonable and necessary.

From the decision · page 2FACTS Applicant sustained industrial injury to her cervical spine, shoulders, and back while working for defendant as a deli clerk on February 2, 2021. Defendant denied the claim on May 5, 2021. (Ex. 101.) On January 13, 2022, applicant's primary treating physician (PTP) Dr. Omar Haghighinia examined applicant and submitted an evaluation. (Ex. 3.) In his report, Dr. Haghighinia stated that it was a medical-legal report and that it was performed for the purpose of proving or disproving a contested claim. (Ex. 3, p. 2.) He concluded that applicant's injury was industrial. (Ex. 3, p. 11.) Panel QME Dr. Michael Chuang submitted PQME reports on March 25, 2022, and January 3, 2023. (Exs. A and 102.) The case settled with a Compromise and Release agreement signed on January 26, 2023, and an order approving issuing on the same date. The case came to trial on October 2, 2023, on the issue of the lien to be paid to Medland Medical Tustin for Dr. Haghighinia's report.

QMERelied upon

Submitted PQME reports relevant and admissible for the case.

The PQME reports were relevant and admissible but did not exclude the treating physician's report as a compensable medical-legal expense.

From the decision · page 2FACTS Applicant sustained industrial injury to her cervical spine, shoulders, and back while working for defendant as a deli clerk on February 2, 2021. Defendant denied the claim on May 5, 2021. (Ex. 101.) On January 13, 2022, applicant's primary treating physician (PTP) Dr. Omar Haghighinia examined applicant and submitted an evaluation. (Ex. 3.) In his report, Dr. Haghighinia stated that it was a medical-legal report and that it was performed for the purpose of proving or disproving a contested claim. (Ex. 3, p. 2.) He concluded that applicant's injury was industrial. (Ex. 3, p. 11.) Panel QME Dr. Michael Chuang submitted PQME reports on March 25, 2022, and January 3, 2023. (Exs. A and 102.) The case settled with a Compromise and Release agreement signed on January 26, 2023, and an order approving issuing on the same date. The case came to trial on October 2, 2023, on the issue of the lien to be paid to Medland Medical Tustin for Dr. Haghighinia's report.

The rules the panel named

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

Labor Code section 4620(a)

Labor Code section 4620(a) - Definition of medical-legal expense for proving or disproving a contested claim.

Medical-legal expenses are allowable if capable of proving or disproving a contested claim and reasonably necessary at the time incurred.

From the decision · page 3Section 4060(b) allows a medical-legal evaluation by the treating physician. Section 4620(a) defines medical-legal expense as "any costs and expenses...for the purpose of proving or disproving a contested claim." Section 4064(a) provides that the employer is liable for the cost of a comprehensive medical evaluation that is authorized by section 4060. The regulations provide that the "primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation..." (Cal. Code Regs., tit. 8, § 9785(d).)

Labor Code section 4064

Labor Code section 4064(a) - Employer liability for reasonable and necessary comprehensive medical-legal evaluations.

The employer is liable for the cost of reasonable and necessary medical-legal reports performed by the treating physician.

From the decision · page 2The employer shall be liable for the cost of each reasonable and necessary comprehensive medical-legal evaluation obtained by the employee pursuant to Sections 4060, 4061, and 4062. Each comprehensive medical-legal evaluation shall address all contested medical issues arising from all injuries reported on one or more claim forms, except medical treatment recommendations, which are subject to utilization review as provided by Section 4610, and objections to utilization review determinations, which are subject to independent medical review as provided by Section 4610.5.

Labor Code section 4060(b)

Labor Code section 4060(b) - Medical-legal evaluation by the treating physician allowed.

A medical-legal evaluation performed by the treating physician is a medical-legal evaluation obtained pursuant to section 4060 and is compensable.

From the decision · page 3Section 4060(b) allows a medical-legal evaluation by the treating physician. Section 4620(a) defines medical-legal expense as "any costs and expenses...for the purpose of proving or disproving a contested claim." Section 4064(a) provides that the employer is liable for the cost of a comprehensive medical evaluation that is authorized by section 4060. The regulations provide that the "primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation..." (Cal. Code Regs., tit. 8, § 9785(d).)

ADJ14743350 · April 8, 2024

What the panel ordered

What was disputed, and how it came out

The facts that decided it

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What the panel did with the medical opinions

The rules the panel named

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