ADJ16468047 — California WCAB decision

What the panel ordered

Petition for Reconsideration granted in part; Findings and Order affirmed except issue of reimbursement for medical-legal evaluation deferred and matter returned to WCJ for further proceedings.

Lien claimant Spectrum Medical Group, Inc. seeks reconsideration of the Findings and Order issued by the WCJ on January 8, 2024, which denied lien claimant's lien in its entirety for failure to prove injury AOE/COE and compliance with AD Rule 9793(h).

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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 / IMRRemanded

The WCJ's application of AD Rule 9793(h) was found to be inconsistent with Labor Code sections 4060(b), 4064(a), and 4620(a), and the issue of reimbursement for the medical-legal evaluation was deferred for further proceedings.

From the decision · page 3Based on our review of the record, it appears that the WCJ's application of AD Rule 9793(h) failed to consider sections 4060(b), 4064(a), and 4620(a). In addition, we do not believe that the finding of no liability for the medical legal evaluation is fully supported by the present record, and it may be that application of A.D. Rule 9783 to otherwise preclude recovery for medical-legal reporting by a PTP is not correct.

The facts that decided it

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

Lien claimant did not prove injury arose out of and in the course of employment (AOE/COE)

Favours Defendant prevailed

This failure meant lien claimant could not meet the threshold for reimbursement of medical treatment services, leading to denial of the lien.

From the decision · page 5treatment. In the instant matter, the applicant was not present at the lien trial and lien claimant did not subpoena applicant to testify. Injury was denied in this matter. Based upon the late reporting of the asserted injury to the employer, as evidenced by the language in the Compromise and Release, EAMS Doc ID 43906322, and defendant's denial of injury, Defendant's Exhibit A, the court finds there to be no substantial evidence supporting an injury at work. Considering the facts of this case, the court finds, in order to award medical treatment, lien claimant needed to establish its prima facie case and the applicant's testimony was necessary. Accordingly, we grant lien claimant's Petition for Reconsideration, amend the F&O to defer the issue of whether lien claimant is entitled to reimbursement for the medical-legal evaluation, and return this matter to the WCJ for further proceedings and a new decision on the issue consistent with this opinion. We otherwise affirm the F&O. For the foregoing reasons, IT IS ORDERED that Lien Claimant's Petition for Reconsideration of the Findings and Order of January 9, 2024 is GRANTED. IT IS FURTHER ORDERED as the Decision After Reconsideration of the Workers' Compensation Appeals Board that the Findings and Order of January 9, 2024 is AFFIRMED except it is AMENDED as follows:

Applicant was not present at lien trial and was not subpoenaed to testify

Favours Defendant prevailed

Applicant's testimony was necessary to establish a prima facie case for medical treatment reimbursement; absence led to failure of proof and denial of lien.

From the decision · page 5treatment. In the instant matter, the applicant was not present at the lien trial and lien claimant did not subpoena applicant to testify. Injury was denied in this matter. Based upon the late reporting of the asserted injury to the employer, as evidenced by the language in the Compromise and Release, EAMS Doc ID 43906322, and defendant's denial of injury, Defendant's Exhibit A, the court finds there to be no substantial evidence supporting an injury at work. Considering the facts of this case, the court finds, in order to award medical treatment, lien claimant needed to establish its prima facie case and the applicant's testimony was necessary. Accordingly, we grant lien claimant's Petition for Reconsideration, amend the F&O to defer the issue of whether lien claimant is entitled to reimbursement for the medical-legal evaluation, and return this matter to the WCJ for further proceedings and a new decision on the issue consistent with this opinion. We otherwise affirm the F&O. For the foregoing reasons, IT IS ORDERED that Lien Claimant's Petition for Reconsideration of the Findings and Order of January 9, 2024 is GRANTED. IT IS FURTHER ORDERED as the Decision After Reconsideration of the Workers' Compensation Appeals Board that the Findings and Order of January 9, 2024 is AFFIRMED except it is AMENDED as follows:

ADJ16468047 · April 2, 2024

What the panel ordered

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The facts that decided it

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