ADJ16590361 — California WCAB decision

What the panel ordered

Petition for Reconsideration denied.

Petition for Reconsideration filed by defendant and denied by the WCAB panel.

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 prevailedhead · neck

The defendant neglected to provide medical treatment within the MPN, failing to arrange initial appointments despite authorizing physicians, thus the applicant is entitled to treat outside the MPN at defendant's expense.

From the decision · page 4The matter proceeded to an expedited hearing on July 10, 2023 on applicant's contention that he was entitled to treat outside defendant's Medical Provider Network ("MPN") as the MPN did not meet the access standards pursuant to Title 8, California Code of Regulations 9767.5. I issued my Finding and Order on August 2, 2023 where I found that applicant had not provided sufficient evidence to establish that defendant's MPN did not meet the access standards, however, I found that the defendants had neglected to provide medical treatment in this case. It was on that basis that I found the applicant was entitled to treat outside the MPN at defendant's expense. It is from this Finding and Order that defendant has filed a petition for reconsideration.

The facts that decided it

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

Defendant authorized physicians designated by applicant but did not arrange initial appointments within the MPN despite knowing difficulties in obtaining care.

Favours Applicant prevailed

This failure constituted neglect to provide medical treatment, entitling applicant to treat outside the MPN at defendant's expense.

From the decision · page 6Defendant took no affirmative steps to arrange for the initial medical treatment within their MPN. Although defendants did authorize each physician designated by applicant, they did not arrange for an initial appointment. Defense, by its own admission, knew that there were difficulties in getting a doctor within their MPN who was accepting patients. (Exhibit 1, page 5.) Despite this knowledge, defendant did not arrange for an initial appointment with a physician within the MPN or assist applicant in establishing care. As defendant neglected to provide medical treatment, I found that the applicant is entitled to treat outside the defendant's MPN at defendant's expense.

Applicant designated multiple treating physicians and requested authorization, but defendant delayed or failed to timely authorize or arrange treatment.

Favours Applicant prevailed

This delay and failure to arrange treatment supported the finding of neglect to provide medical treatment.

From the decision · page 5An application for adjudication of claim was filed on the applicant's behalf on August 22, 2022. (EAMS Document ID 42770059.) A DWC-1 claim form was signed by the applicant on December 21, 2021, and filed and served on defendants at the same time as the application. (EAMS Document ID 42770061.) Applicant designated a treating physician, Dr. Goldin, on September 30, 2022 by letter to both defense counsel and the third-party administrator. (Applicant's Exhibit 5.) Defendant belatedly authorized that treatment more than two months later. (Defendant's Exhibit C.) However, defendant apparently did not arrange for the initial appointment. Applicant designated two additional physicians as treating doctors between January and February, 2023. (Applicant's Exhibit 3 and 4.) Defense counsel, in a March 8, 2023 email to applicant's counsel, admitted that they have authorized several doctors that were not accepting patients but it was "not our delay." (Applicant's Exhibit 1, page 5.) Defendant's apparent position was that applicant was not able to receive medical care within their "it was not our delay." (Id.) Knowing that the applicant was having difficulty obtaining medical care within the MPN, defendant took the position that they were under no obligation to assist.

ADJ16590361 · October 16, 2023

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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