ADJ11626597 · December 29, 2023

Optimal Health Institute failed to meet its burden of proof to show a legal or factual basis for treatment outside the MPN, and no evidence of denial of treatment for claimed body parts was found.

From the decision · page 4The issue here is the lien claim filed by Optimal Health Institute against Defendant State Compensation Insurance Fund (SCIF) for medical services provided by Dr. Shen, specialty unknown, and Dr. Kan, a chiropractor. The Findings and Order denying recovery on this lien claim was served on October 12, 2023, and Optimal Health Institute has now filed a timely verified Petition for Reconsideration.

Optimal Health Institute and doctors knew they were treating without authorization outside the MPN and were given ample notice of non-membership and denial of liability by SCIF

Favours Defendant prevailed

This knowledge and notice negated any legal or factual basis for recovery on the lien claim.

From the decision · page 7Per the Petition for Reconsideration, the lien claim is based on a claim that the services that were provided were for treatment of body parts that were denied by SCIF. While it might be ambivalent in other areas, on this issue the evidence is clear that there was no denial of treatment of any body part before or during the time that Dr. Shen and Dr. Kan chose to provide treatment, which are the relevant periods here. The evidence is also clear that Dr. Shen and Dr. Kan knew they were treating without authorization, and that they were provided with ample notice that SCIF had an MPN, that they were not within the MPN (a fact they have never disputed) and that SCIF denied any liability to pay for their services. They chose to provide services anyway.

No evidence was submitted showing denial of treatment for any body parts claimed injured other than upper back and thoracic area accepted by SCIF

Favours Defendant prevailed

Without evidence of denial, the claim for treatment outside the MPN lacked foundation and failed.

From the decision · page 5The primary document that Optimal points to in support of its position is Defendant's Exhibit K, which is a January 29, 2018 letter to Kaiser authorizing it to provide treatment. Optimal claims that this document shows that body parts other that "upper back and thoracic" were denied. The full sentence referencing "upper back and thoracic" in that exhibit is: "State Compensation Insurance Fund, the claims administrator for Modative, Inc., has accepted liability for the industrial injury of Charleston the applicant on January 22, 2018 to his upper back and thoracic." The rest of the letter authorizes Kaiser as the identified Primary Treating Physician of reporting and other responsibilities. There is nothing in the letter stating or implying that the applicant had claimed that other body parts were injured and that those additional body parts were denied. All that can be understood from the reference to "upper back and thoracic" in the context of the only sentence in which body parts are mentioned in this letter is that these were the body parts that the applicant reported as injured at that time and that they were accepted.

Dr. Shen's reports did not indicate any denial of treatment to the applicant and showed knowledge of the MPN and lack of authorization to treat outside it.

Reports showed no claim of denial of treatment and awareness of MPN and non-membership status.

From the decision · page 6It should also be noted that Dr. Shen does not say in any of the histories given in his reports that the applicant was denied treatment (Exhibits 3-9, on p. 1-2 in Exhibit 3 and generally p. 1-2 or p. 2 on the subsequent reports). In the "Discussion" section of his reports (generally on p. 3 or 4 of the reports), he includes a sentence, "Patient wishes to exercise her [sic] right to select a treating doctor of his choice," with no further elaboration. The histories in Dr. Kan's reports (Exhibits 10- 13) are briefer than Dr. Shen's but also have no claim that SCIF denied treatment to the applicant. Based on their reports, they had no belief at the time they provided services that SCIF had denied the applicant treatment or that their providing treatment to the applicant was due to a denial of treatment.

Dr. Kan was an administrator of Optimal Health Medical Center and secondary treating doctor, aware of the MPN and non-membership status, and did not claim denial of treatment in reports.

Evidence showed Dr. Kan's administrative role and knowledge of MPN and non-membership; no denial claim in reports.

From the decision · page 4There is no evidence that Dr. Shen tried to get advance authorization for his initial evaluation, and SCIF advised him long before the second evaluation that there was an applicable MPN, he was not a member, and they therefore did not have liability for any bills for his services. That and subsequent notices were addressed to him and sent to the address on his reports, and there was no claim made that he did not receive them. The evidence showed that Dr. Kan was active in the administration of the medical group, particularly that he was the Secretary, Chief Financial Officer and a Director of Optimal Health Medical Center (Exhibit Q) as well as the doctor that Dr. Shen

Labor Code Section 5705

Burden of proof on lien claimant to show legal or factual basis for treatment outside MPN

Optimal Health Institute had the burden to prove entitlement to payment for treatment outside the MPN and failed to do so.

From the decision · page 6In the Petition for Reconsideration, Optimal is claiming that it should be compensated for the treatment provided by Dr. Shen and Dr. Kan because SCIF had denied treatment. It has the affirmative of that issue, as it is foundational to its claim for payment, and therefore has the burden of proof on that issue (Labor Code Section 5705). It has not met that burden of proof, and both of its arguments in the Petition for Reconsideration, which are based on that foundational fact, fail accordingly.

No evidence of denial of treatment for claimed body parts before or during treatment by Dr. Shen and Dr. Kan

From the decision · page 5As reflected in the Reporter's Minutes of Hearing, no issue was raised at time of trial on whether SCIF denied any body parts the applicant claimed were injured in the subject industrial injury or whether SCIF denied treatment to any body parts the applicant claimed were injured in the subject industrial injury. In its Petition for Reconsideration, Optimal raises the claimed denial of body parts as the primary justification for Dr. Shen and Dr. Kan to treat the applicant. There has never been a claim that they were actually in the MPN, so the focus is on whether they could treat the applicant outside of the MPN.