What the panel ordered
Findings and Order issued November 15, 2019, rescinded; new decision finds all UR decisions timely, denies penalties under Labor Code section 5814 and attorney's fees under section 5814.5; awards medical treatment to cure or relieve injury effects.
Reconsideration granted to study factual and legal issues; original Findings and Order (F&O) issued November 15, 2019, was rescinded and replaced by this decision after reconsideration.
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.
Applicant failed to prove unreasonable delay or denial of treatment; thus, penalties and attorney's fees were denied.
From the decision · page 1310. Applicant has not shown an unreasonable delay or denial of treatment such that penalties are owed under Labor Code section 5814.
The Appeals Board found all UR decisions timely issued and communicated, thus precluding jurisdiction to address medical necessity and denying penalties for delay.
From the decision · page 137. The UR decisions dated 7/17/18, 6/22/18, 5/25/18, 2/12/18, 1/4/18, 12/18/17, 11/28/17, 11/24/17, and 10/4/2017 were timely issued.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
All UR decisions at issue were timely issued and communicated
Favours Defendant prevailed
This precluded Appeals Board jurisdiction to address medical necessity and denied penalties for delay
From the decision · page 137. The UR decisions dated 7/17/18, 6/22/18, 5/25/18, 2/12/18, 1/4/18, 12/18/17, 11/28/17, 11/24/17, and 10/4/2017 were timely issued.
Applicant failed to identify specific evidence of unreasonable delay or denial of treatment
Favours Defendant prevailed
Applicant did not meet burden of proof for penalties under Labor Code section 5814
From the decision · page 12parse through a voluminous record to hunt out which treatment applicant is alleging was unreasonably delayed or denied in the absence of specific allegations and identification of specific evidence by applicant in support of those allegations.
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.
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4610
Labor Code section 4610 regarding timeliness of utilization review decisions
Applied to determine timeliness of UR decisions and Appeals Board jurisdiction
From the decision · page 6employer. (Lab. Code, § 4610 et seq.) These time limits are mandatory. In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) (Dubon II), the Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) If the UR decision is timely, the Appeals Board has no jurisdiction to address disputes regarding the UR because "[a]ll other disputes regarding a UR decision must be resolved by IMR." (Id. at p. 1299.)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc)
Held Appeals Board has jurisdiction to determine timeliness of UR decisions; if timely, medical necessity disputes go to IMR
From the decision · page 6employer. (Lab. Code, § 4610 et seq.) These time limits are mandatory. In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc) (Dubon II), the Appeals Board held that it has jurisdiction to determine whether a UR decision is timely. If a UR decision is untimely, the determination of medical necessity for the treatment requested may be made by the Appeals Board. (Id. at p. 1300.) If the UR decision is timely, the Appeals Board has no jurisdiction to address disputes regarding the UR because "[a]ll other disputes regarding a UR decision must be resolved by IMR." (Id. at p. 1299.)
Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519
Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519 (significant panel decision)
Held that timely made but untimely communicated UR decisions are untimely; applied to communication timeliness
From the decision · page 6Subsequent to Dubon II, in a significant panel decision, the Appeals Board held that a UR decision that is timely made, but is not timely communicated, is untimely. (Bodam v. San Bernardino County/Dept. of Social Services (2014) 79 Cal.Comp.Cases 1519.)5 In Bodam, the employer did not notify the requesting physician of its UR decision within 24 hours and did not send written notice of the UR decision to the physician, applicant or applicant's attorney within two business days after the UR decision was made. (Id. at p. 1523.)6 The UR decision was therefore deemed untimely and the Appeals Board had authority to determine the issue of medical necessity for the disputed treatment.
Labor Code sections 5814 and 5814.5
Labor Code sections 5814 and 5814.5 regarding penalties and attorney's fees for unreasonable delay or refusal of medical treatment
Applied to determine entitlement to penalties and attorney's fees
From the decision · page 11An employee shall not be entitled to an increase in compensation under Section 5814 for unreasonable delay in the provision of medical treatment for periods of time necessary to complete the utilization review process in compliance with Section 4610. A determination by the appeals board or a final determination of the administrative director pursuant to independent medical review that medical treatment is appropriate shall not be conclusive evidence that medical treatment was unreasonably delayed or denied for purposes of penalties under Section 5814. In no case shall this section preclude an employee from entitlement to an increase in compensation under Section 5814 when an employer has unreasonably delayed or denied medical treatment due to an unreasonable delay in completion of the utilization review process set forth in Section 4610.
What proof carried it
The evidence the panel weighed, by kind.
UR decisions were timely issued and communicated
From the decision · page 137. The UR decisions dated 7/17/18, 6/22/18, 5/25/18, 2/12/18, 1/4/18, 12/18/17, 11/28/17, 11/24/17, and 10/4/2017 were timely issued.
Applicant failed to identify specific evidence of unreasonable delay or denial of treatment
From the decision · page 12parse through a voluminous record to hunt out which treatment applicant is alleging was unreasonably delayed or denied in the absence of specific allegations and identification of specific evidence by applicant in support of those allegations.
The same issues, filtered across the whole corpus — or paste your own facts and let the search rank by factor match.
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.
- The injured worker is not named here, and the case caption is not printed. Physicians appear as the decision names them, because a medical opinion is an act in a public proceeding.
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