ADJ11186589 — California WCAB decision

What the panel ordered

Affirmed Findings and Order except issue of medical-legal expenses payment deferred

Decision After Reconsideration affirming the Findings and Order of May 10, 2021, with amendment to defer issue of medical-legal expenses payment

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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 prevailedneck · arm · wrist · back

The WCJ and the Board found no injury arising out of and in the course of employment based on the evidence and prior Findings and Order.

From the decision · page 1Lien claimant Ameri Chiropractic (lien claimant) seeks reconsideration of a workers' compensation administrative law judge's (WCJ) Findings and Order (F&O) of May 10, 2021, wherein it was found that applicant did not sustain injury arising out of and in the course of employment (AOE/COE) to the neck, arm, wrist, and back pursuant to the prior Findings & Order of April 12, 2019; that lien claimant is not entitled to any payments pursuant to Labor Code1 section 5402(c) as it failed to establish when the claim form was supplied to the employer by applicant or when the employer had knowledge of the injury alleged herein from any other source; that the services provided by lien claimant were self-procured medical expenses and defendant is not liable for reimbursement of those expenses; that lien claimant failed to establish any basis for reimbursement of the lien claim; and there is no basis to award costs to defendant or impose sanctions on lien claimant.

The facts that decided it

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

Applicant did not sustain injury arising out of and in the course of employment to neck, arm, wrist, and back.

Favours Defendant prevailed

This fact led to denial of liability for self-procured medical treatment and dismissal of the claim.

From the decision · page 1Lien claimant Ameri Chiropractic (lien claimant) seeks reconsideration of a workers' compensation administrative law judge's (WCJ) Findings and Order (F&O) of May 10, 2021, wherein it was found that applicant did not sustain injury arising out of and in the course of employment (AOE/COE) to the neck, arm, wrist, and back pursuant to the prior Findings & Order of April 12, 2019; that lien claimant is not entitled to any payments pursuant to Labor Code1 section 5402(c) as it failed to establish when the claim form was supplied to the employer by applicant or when the employer had knowledge of the injury alleged herein from any other source; that the services provided by lien claimant were self-procured medical expenses and defendant is not liable for reimbursement of those expenses; that lien claimant failed to establish any basis for reimbursement of the lien claim; and there is no basis to award costs to defendant or impose sanctions on lien claimant.

Applicant's first treatment visit was on February 1, 2018, after defendant's denial letter dated January 30, 2018.

Favours Defendant prevailed

This timing showed no liability for treatment before denial, supporting denial of reimbursement for self-procured medical treatment.

From the decision · page 4claimant's billing reflects that applicant's first visit was on February 1, 2018, two days after the denial. While lien claimant submitted a medical treatment report dated January 18, 2018, there is nothing to indicate that it was served or that there was a charge for it. Thus, we affirm the WCJ's finding that lien claimant failed to prove that it was entitled to payment for treatment rendered before the denial on January 30, 2018.

Defendant issued a denial letter on January 30, 2018, indicating a contested claim likely existed when medical-legal expenses were incurred.

Favours Applicant prevailed

This fact supported deferral of the issue of payment for medical-legal expenses for further adjudication.

From the decision · page 5The WCJ failed to address the applicability of sections 4620 and 4621 and several factors show that a contested claim existed when the medical-legal expenses were incurred. We note however that, defendant issued a denial letter on January 30, 2018, and thus, here it is likely there was a contested claim under section 4620(a). We will amend the F&O to defer the issue of whether lien claimant is entitled to payment for medical-legal expenses, so that the issues raised under sections 4620, 4621, and 4622 may be adjudicated in the first instance.

The rules the panel named

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

Kunz v. Patterson Floor Coverings (2002) 67 Cal.Comp.Cases 1588 (en banc)

A lien claimant must establish injury by preponderance of evidence to recover for self-procured medical treatment.

Applied to deny reimbursement for self-procured medical treatment without established injury.

From the decision · page 3A lien for self-procured medical treatment is allowable when the treatment rendered is reasonably required to cure or relieve an injured worker from the effects of an industrial injury. (Lab. Code, § 4600(a), 4903(b).) A defendant will not be liable for self-procured medical treatment where there is no industrial injury. (Kunz v. Patterson Floor Coverings (2002) 67 Cal.Comp.Cases 1588, 1593 (en banc).) Therefore, where a lien claimant, rather than the injured worker, litigates the issue of entitlement to payment for industrially-related medical treatment, the lien claimant stands in the shoes of the injured worker and the lien claimant must establish injury by preponderance of evidence. (Kaiser Foundation Hospitals v. Workers' Comp. Appeals Bd. (Martin) (1985) 39 Cal.3d 57, 67 [50 Cal.Comp.Cases 411]; Kunz, supra, 67 Cal.Comp.Cases at p. 1592.)

Colamonico v. Secure Transportation (2019) 84 Cal. Comp. Cases 1059 (Appeals Board en banc)

Sections 4620 and 4621 require proof of a contested claim for reimbursement of medical-legal expenses.

Applied to defer issue of payment for medical-legal expenses pending adjudication of contested claim elements.

From the decision · page 5In the present matter, the WCJ found that lien claimant failed to establish any basis for reimbursement for the lien claim filed in this matter. We disagree. Here, the issue of whether lien claimant was entitled to payment for medical-legal costs was not an issue raised at trial. In the Petition for Reconsideration, lien claimant raises the issue because the WCJ found that it was not entitled to any payment.

ADJ11186589 · June 18, 2026

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

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