What the panel ordered
The WCAB denied the Petition for Reconsideration, affirming the WCJ's Findings that the employer did not neglect or refuse to provide timely medical treatment within the MPN.
Applicant sought reconsideration of the Findings of Fact issued by the WCJ on March 16, 2021, which found no neglect or refusal by defendant to provide timely treatment within the MPN.
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 did not meet her burden to prove neglect or refusal by defendant to provide timely treatment within the MPN; defendant timely acknowledged claim and scheduled treatment appointment within a reasonable time frame.
From the decision · page 1Applicant seek reconsideration of the Findings of Fact (Findings) issued by the workers' compensation administrative law judge (WCJ) on March 16, 2021. By the Findings, the WCJ found that applicant did not sustain her burden of proving a denial of care within the employer's medical provider network (MPN) that would entitle her to treat outside the MPN at the employer's expense. The WCJ further found that the employer may satisfy its responsibility for providing treatment through its MPN.
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Defendant sent claimant a letter acknowledging her claim and providing MPN information within 8 days of claim form submission.
Favours Defendant prevailed
This timely communication shows defendant did not neglect or refuse to provide treatment within the MPN, defeating applicant's claim to treat outside the MPN.
From the decision · page 5Applicant sent her DWC-1 claim form to the employer by mail on August 19, 2020. The insurer sent applicant a letter acknowledging her claim and providing her with information regarding how to obtain treatment in the MPN on August 27, 2020. A second letter was sent to applicant on August 31, 2020 advising applicant of an appointment for her to receive treatment at Concentra.
Defendant scheduled an appointment for treatment at Concentra within a reasonable time frame after claim form submission.
Favours Defendant prevailed
Scheduling treatment promptly supports the finding that defendant met its duty to provide timely medical treatment within the MPN.
From the decision · page 2A delay letter was issued by defendant on August 31, 2020. (Defendant's Exhibit D, Delay letter from Insurance Company of the West, August 31, 2020.) On the same date, defendant sent applicant a letter notifying her of an appointment for treatment at Concentra scheduled for September 14, 2020. (Defendant's Exhibit C, An appointment letter to the applicant, August 31, 2020.) A separate letter was sent to Concentra advising that it had been designated as the treating physician. (Defendant's Exhibit E, Letter to Concentra from Insurance Company of the West, August 31, 2020.)
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
Labor Code section 4600(a)
Labor Code section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury.
Employer must provide treatment unless neglect or refusal is shown, then employee may self-procure treatment at employer's expense.
From the decision · page 3Labor Code section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).)1 If an employer has established an MPN, an injured worker is generally limited to treating with a physician from within the employer's MPN. (Lab. Code, § 4600(c), 4616 et seq.) However, if the employer neglects or refuses to provide reasonably necessary medical treatment, whether through an MPN or otherwise, then an injured worker may self-procure medical treatment at the employer's expense. (Lab. Code, § 4600(a); see also McCoy v. Industrial Acc. Com. (1966) 64 Cal.2d 82, 87 [31 Cal.Comp.Cases 93] ["the employer is required to provide treatment which is reasonably necessary to cure or relieve the employee's distress, and if he neglects or refuses to do so, he must reimburse the employee for his expenses in obtaining such treatment"].)
Labor Code sections 4600(c), 4616 et seq.
If an employer has established an MPN, an injured worker is generally limited to treating with a physician from within the employer's MPN.
Limits injured worker to MPN treatment unless employer neglects or refuses to provide treatment.
From the decision · page 3Labor Code section 4600 requires the employer to provide reasonable medical treatment to cure or relieve from the effects of an industrial injury. (Lab. Code, § 4600(a).)1 If an employer has established an MPN, an injured worker is generally limited to treating with a physician from within the employer's MPN. (Lab. Code, § 4600(c), 4616 et seq.) However, if the employer neglects or refuses to provide reasonably necessary medical treatment, whether through an MPN or otherwise, then an injured worker may self-procure medical treatment at the employer's expense. (Lab. Code, § 4600(a); see also McCoy v. Industrial Acc. Com. (1966) 64 Cal.2d 82, 87 [31 Cal.Comp.Cases 93] ["the employer is required to provide treatment which is reasonably necessary to cure or relieve the employee's distress, and if he neglects or refuses to do so, he must reimburse the employee for his expenses in obtaining such treatment"].)
Labor Code section 5705
The burden of proof rests upon the party with the affirmative of the issue.
Applicant must prove neglect or refusal to provide treatment to treat outside MPN.
Labor Code section 5402(c)
Section 5402(c) requires employer to authorize treatment within one working day after claim form is filed.
Employer timely authorized treatment within reasonable time frame here.
Administrative Director Rule 9767.5(c)
AD Rule 9767.5(c) permits treatment outside MPN if employee cannot obtain reasonable and necessary treatment within applicable access standards and time frames.
Applicant did not show conditions for treatment outside MPN were met.
From the decision · page 64 Moreover, AD Rule 9767.5(f) does not provide the remedy of treating outside the MPN for failure to comply with it. AD Rule 9767.5(c) provides for treatment outside the MPN where the employee "is not able to obtain from an MPN physician reasonable and necessary medical treatment within the applicable access standards in subdivisions (a) or (b) and the required time frames in subdivisions (f) and (g)..." Applicant has not shown that all of the conditions in subdivision (c) are present in this matter such that she may be permitted to treat outside the MPN per AD Rule 9767.5(c).
What proof carried it
The evidence the panel weighed, by kind.
Defendant sent claimant a letter acknowledging her claim and providing MPN information within 8 days of claim form submission; scheduled treatment appointment within a reasonable time frame.
From the decision · page 5Applicant sent her DWC-1 claim form to the employer by mail on August 19, 2020. The insurer sent applicant a letter acknowledging her claim and providing her with information regarding how to obtain treatment in the MPN on August 27, 2020. A second letter was sent to applicant on August 31, 2020 advising applicant of an appointment for her to receive treatment at Concentra.
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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.
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