What the panel ordered
Petition for Reconsideration granted in part; Findings and Order of May 9, 2024, affirmed except amended to find lien claimant entitled to reimbursement for medical-legal evaluation; amount deferred; matter returned to WCJ for further proceedings.
Lien claimant Medland Medical seeks reconsideration of the Findings and Order issued by the WCJ on May 9, 2024, which denied lien claimant's lien in its entirety.
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 Board found that a contested claim existed at the time the medical-legal evaluation was performed, and the report by Dr. Haghighinia was relevant and admissible, entitling lien claimant to reimbursement for the medical-legal evaluation.
From the decision · page 3We note that applicant filed an application for adjudication on August 4, 2022. Defendant denied applicant's claim on August 22, 2022 (L.C. Exhibit 16) and denied liability for medical treatment on September 1, 2022 (L.C. Exhibit 15). We find that these facts adequately establish a "contested claim" for the purposes of Section 4620.
Lien claimant did not meet burden to prove compensable industrial injury (AOE/COE) and did not challenge this finding in the petition, so reimbursement for medical treatment services was denied.
From the decision · page 3We will not disturb the WCJ's finding that lien claimant is not entitled to reimbursement for medical treatment services because lien claimant did not prove that applicant sustained compensable industrial injury. As noted above, lien claimant did not challenge or address the finding as to AOE/COE in the Petition. (Lab. Code, § 5904 [Petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant denied applicant's claim on August 22, 2022, and denied liability for medical treatment on September 1, 2022, establishing a contested claim.
Favours Applicant prevailed
This established the existence of a contested claim at the time of the medical-legal evaluation, entitling lien claimant to reimbursement.
From the decision · page 3We note that applicant filed an application for adjudication on August 4, 2022. Defendant denied applicant's claim on August 22, 2022 (L.C. Exhibit 16) and denied liability for medical treatment on September 1, 2022 (L.C. Exhibit 15). We find that these facts adequately establish a "contested claim" for the purposes of Section 4620.
Lien claimant did not challenge the WCJ's finding that applicant did not sustain compensable industrial injury in the petition for reconsideration.
Favours Defendant prevailed
This resulted in affirming the denial of reimbursement for medical treatment services.
From the decision · page 3We will not disturb the WCJ's finding that lien claimant is not entitled to reimbursement for medical treatment services because lien claimant did not prove that applicant sustained compensable industrial injury. As noted above, lien claimant did not challenge or address the finding as to AOE/COE in the Petition. (Lab. Code, § 5904 [Petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].)
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.
Provided a comprehensive medical-legal evaluation report on September 26, 2022, which was found relevant and admissible for reimbursement purposes.
The report was relevant and admissible and could provide a basis for decision despite an incorrect injury date.
From the decision · page 3The WCJ also denies recovery for the medical legal report because "[] the report asserts the incorrect date of injury (of 6/12/2022) instead of the amended date of injury (of 5/12/2022), and was never sought to be corrected or amended, the reporting itself does not meet the requirement of being capable of proving or disproving a disputed medical fact, the determination of which is essential to an adjudication of the employee's claim for benefits and is "useless as evidence" [...]" (Opinion on Decision at p. 6.) We are not persuaded that an incorrect injury date by itself renders the med-legal report "useless" and find that the medical-legal reporting is otherwise relevant, admissible and could provide a basis for a decision. (Costa v. Hardy Diagnostic, (2007) 72 Cal. Comp. Cases 1492, 1498-1499 (Appeals Board en banc); see also Colamonico, supra at 1062.) Further, it does not appear to be disputed that Dr. Haghighinia was applicant's primary treating physician (PTP) at the time the September 26, 2022 medical-legal report was prepared and submitted. (L.C. Exhibit 8.) We also note that applicant's attorney's August 30, 2022 letter requesting the medical-legal reporting is attached to the report. (Id at 14.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4060(b)
Labor Code section 4060(b) allows a medical-legal evaluation by the treating physician.
The Board applied this to find lien claimant entitled to reimbursement for the medical-legal evaluation.
From the decision · page 2With regard to reimbursement of medical-legal services, Labor Code section 4060(b)1 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. (See also, Warren Brower v David Jones Construction (2014) 79 Cal.Comp.Cases 550 (Appeals Board en banc).)
Labor Code section 4620(a)
Labor Code section 4620(a) defines medical-legal expense as costs for proving or disproving a contested claim.
The Board applied this to determine the nature of medical-legal expenses and contested claims.
From the decision · page 2With regard to reimbursement of medical-legal services, Labor Code section 4060(b)1 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. (See also, Warren Brower v David Jones Construction (2014) 79 Cal.Comp.Cases 550 (Appeals Board en banc).)
Labor Code section 4064(a)
Labor Code section 4064(a) provides employer liability for costs of comprehensive medical evaluations authorized by section 4060.
The Board applied this to hold employer liable for medical-legal evaluation costs.
From the decision · page 2With regard to reimbursement of medical-legal services, Labor Code section 4060(b)1 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. (See also, Warren Brower v David Jones Construction (2014) 79 Cal.Comp.Cases 550 (Appeals Board en banc).)
Labor Code section 5904
Labor Code section 5904 provides that issues not raised in a petition for reconsideration are waived.
The Board applied this to affirm denial of reimbursement for medical treatment services due to waiver of challenge.
From the decision · page 3We will not disturb the WCJ's finding that lien claimant is not entitled to reimbursement for medical treatment services because lien claimant did not prove that applicant sustained compensable industrial injury. As noted above, lien claimant did not challenge or address the finding as to AOE/COE in the Petition. (Lab. Code, § 5904 [Petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].)
What proof carried it
The evidence the panel weighed, by kind.
Applicant's claim was denied by defendant on August 22, 2022, and medical treatment liability denied on September 1, 2022, establishing a contested claim.
From the decision · page 3We note that applicant filed an application for adjudication on August 4, 2022. Defendant denied applicant's claim on August 22, 2022 (L.C. Exhibit 16) and denied liability for medical treatment on September 1, 2022 (L.C. Exhibit 15). We find that these facts adequately establish a "contested claim" for the purposes of Section 4620.
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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.
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