Read Lien Claimant Representation Guidebook text version

2011

LIEN CLAIMANT REPRESENTATION GUIDEBOOK

TABLE OF CONTENTS CHAPTER ONE

FINDING INFORMATION............................................................ PAGE 9 - 14 http://www.dir.ca.gov/dwc/dwc_newsline.html http://www.dir.ca.gov/dwc/MedicalProvider.htm http://www.dir.ca.gov/ http://www.dir.ca.gov/wcab/wcab.htm http://www.dir.ca.gov/wcab/wcab_panel.htm http://www.dir.ca.gov/dwc/OMFS9904.htm http://www.dir.ca.gov/dwc/forms.html http://www.dir.ca.gov/dwc/eams/eams.htm http://www.dir.ca.gov/dwc/Liens/Liens.html

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http://www.dir.ca.gov/dwc/EAMS/EAMS_PublicSearch.htm

CHAPTER TWO

FILING AN APPLICATION.................................. .......................

Filing an Application by a Medical Provider: Cal Lab Code § 5501 Independence Indem. Co. v. Industrial Acci. Com. Labor Code section 5501.5 Cal. Lab. Code § 5405 §10770.5. Verification to Filing of Lien Claim or Application by Lien Claimant. How to File Instructions Forms Proof of Service

PAGE 15 - 32

CHAPTER THREE

FILING A LIEN ....................................................................

Cal Lab Code § 4903.5 8 CCR § 10886. Service on Lien Claimants

PAGE 33 - 52

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Kaiser Foundation Hospitals v. Workers' Comp. Appeals Bd., 155 Cal. App. 3d 917, 202 Cal. Rptr. 520 Loc Tran, Applicant v. Viet Nguyen Trucking Company, American All Risk Loss Administrators, Defendants W.C.A.B. No. AHM 0080703 LACHES, DOCTRINE OF Sample Trial Brief How to File Forms Declaration Proof of Service §10770.5. Verification to Filing of Lien Claim or Application by Lien Claimant.

CHAPTER FOUR

FILING A DECLARATION OF READINESS (DOR) ..............................

PAGE 53 - 64

§10770.6. Verification to Filing of Declaration of Readiness By or on Behalf of Lien Claimant How to File Forms Declaration Proof of Service

CHAPTER FIVE

APPEARING AT THE APPEALS BOARD .........................................

PAGE 65 - 82

http://www.dir.ca.gov/wcab/WCAB_Policy_ProcedureManual/WCABPolicy_ProcedureIndex.html §10240. Appearances Required. 8 CCR 10240 Instructions Flowchart DWC glossary of workers' compensation terms

CHAPTER SIX

UTILIZATION REVIEW.............................................................

Introduction State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230 [73 Cal.Comp.Cases 981] (Sandhagen) Definitions of Utilization Review

PAGE 83 - 152

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8 CCR § 9792.6(b) 8 CCR § 9792.7(b)(3) 8CCR § 9792.6(q)

LIEN CLAIMANT REPRESENTATION GUIDEBOOK

Utilization Review in Admitted Case Utilization Review in Denied Cases Cal Lab Code § 5402 Cal Lab Code § 5402 (c) Heike M. Ruvalcaba, Applicant v. Scott Roberg, DPM, State Compensation Insurance Fund, Defendants W.C.A.B. No. OXN 0129714--Workers' Compensation Appeals Board (Panel Decision) Opinion Filed March 9, 2007

En Banc Decision of Simmons v. California, 70 Cal. Comp. Cases 866 (W.C.A.B. 2005): Labor Code Section 4610(a) Special Rules Apply for Requesting Spinal Surgery En Banc Decision on Request for Spinal Surgery: Cervantes v. Workers' Comp. Appeals Bd., (En Banc) (2009)74 Cal. Comp. Cas. (MB) 1336 Flowchart Cases in Full

CHAPTER SEVEN

SELF-PROCURED MEDICAL TREATMENT........................................

Introduction Regents of the University of California v. Workers' Compensation Appeals Bd., (2005) 70 Cal. Comp. Cas. (MB) 1733 Labor Code § 3751 (b) Kenneth Grom vs. Shasta Wood Products (2004) supra (WCAB significant panel decision)]. Utilization Review in Denied Case Cal Lab Code § 5402 Cal Lab Code § 5402 (c) Heike M. Ruvalcaba, Applicant v. Scott Roberg, DPM, State Compensation Insurance Fund, Defendants W.C.A.B. No. OXN 0129714--Workers' Compensation Appeals Board (Panel Decision) Opinion Filed March 9, 2007: En Banc Decision of Simmons v. California, 70 Cal. Comp. Cases 866 (W.C.A.B. 2005): Kellogg Co. v. Workers' Compensation Appeals Bd. (Battle), (1996) 61 Cal. Comp. Cas. (MB) 519, 521 Thomas Finding Cal Lab Code § 3600 Cal Lab Code § 5412

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Cal Lab Code § 5411

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Fitzpatrick v. Fidelity & Casualty Co. (1936) 7 Cal 2d 230, 60 P2d 276 Granado v. Workmen's Comp. App. Bd. (1968) 69 Cal. 2d 399, 404 [71 Cal. Rptr. 678, 445 P.2d 294] SUCCESS OF SELF-PROCURED TREATMENT FOREMOST DAIRIES, INC. V. I.A.C. (MCDANNALD) (1965) 237 Cal. App. 2d 560, 577, 47 Cal. Rptr. 173, 30 Cal. Comp. Cases 320 THOMAS V. SPORTS CHALET, INC. (1977) 42 Cal.Comp.Cases 625, decided en banc (Thomas) Post Termination Leprino Foods v. Workers' Compensation Appeals Bd., (2007) 72 Cal. Comp. Cas. (MB) 605; 612 Chaparral Construction & Development v. Workers' Compensation Appeals Bd.,(2006) 71 Cal. Comp. Cas. (MB) 879 writ denied Jesus Hernandez, Applicant v. Warner Bros. Studios, PSI, Defendant, 2009 Cal. Wrk. Comp. P.D. LEXIS 353, Opinion Filed July 9, 2009 Labor Code § 4600 Bruce Knight, United Parcel Service; and Liberty Mutual Insurance Company October 10, 2006 71 Cal. Comp. Cases 1423 State Comp. Ins. Fund v. Workers' Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230 [73 Cal.Comp.Cases 981] (Sandhagen) SELF-PROCURED MEDICAL TREATMENT AND BEING PAID USUAL AND CUSTOMARY FEES CNA Ins. Cos. v. Workers' Compensation Appeals Bd. (Valdez), (1997) 62 Cal. Comp. Cas. (MB) 1145 Kunz v. Patterson Floor Coverings Inc.,(2002) 67 Cal. Comp. Cas. (MB) 1588 Tapia v. Workers' Comp. Appeals Bd., (2008) 73 Cal. Comp. Cas. (MB) 1338 Compensable Consequence Injuries Southern Cal. Rapid Transit Dist. v. Workers' Comp. Appeals Bd. (Weitzman) (1979) 25 Cal.3d 158 Ballard v. Workmen's Comp. Appeals Bd. (1971) 3 Cal.3d 852 [92 Cal. Rptr. 1, 478 P.2d 937, 36 Cal. Comp. Cases 34] Heaton v. Kerlan (1946) 27 Cal.2d 716 [166 P.2d 857, 11 Cal. Comp. Cases 78] Fitzpatrick v. Fidelity & Casualty Co. (1936) 7 Cal.2d 230 [60 P.2d 276] Beaty v. Workers' Comp. Appeals Bd. (1978) 80 Cal.App.3d 37 [144 Cal. Rptr. 78, 43 Cal. Comp. Cases 444] Dixon v. Ford Motor Co. (1975) 53 Cal.App.3d 499 [125 Cal. Rptr. 872, 40 Cal. Comp. Cases 1058] Laines v. Workers' Comp. Appeals Bd. (1975) 48 Cal.App.3d 872 State Comp. Ins. Fund v. Industrial Acc. Com. (Wallin) (1959) 176 Cal.App.2d 10 Granado v. Workmen's Comp. App. Bd. (1968) 69 Cal. 2d 399, 404 [71 Cal. Rptr. 678, 445 P.2d 294 Cases in Full

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CHAPTER EIGHT

MEDICAL PROVIDER NETWORKS (MPNS)......................................

PAGE 185 - 234

Bruce Knight, United Parcel Service; and Liberty Mutual Insurance Company October 10, 2006 71 Cal. Comp. Cases 1423 Jennifer Balkowitsch, Applicant v. Home Depot, PSI, adjusted by Sedgwick Claims Management Services, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 567, Opinion Filed August 11, 2008 Joaquin Valencia, Applicant v. Taylor Fresh Foods, Zurich North America, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 596, Opinion Filed August 6, 2008 Walter Roque, Applicant v. Louise's Trattoria, Liberty Mutual Insurance Company, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 349, Opinion Filed April 21, 2008 8 CCR 9767.5 Transferring Medical Treatment Into An MPN After The Injured Worker Had Been Treating Outside The MPN Labor Code § 4616.2(d)(3)(B) 8 Cal. Code Reg. § 9767.9(f) En Banc decision of "BABBITT" Sample Trial Brief Cases in Full

CHAPTER NINE

USUAL AND CUSTOMARY FEES................................................... PAGE 235 - 258

CNA Ins. Cos. v. Workers' Compensation Appeals Bd. (Valdez), 62 Cal. Comp. Cas. (MB) 1145 (Cal. App. 1st Dist. 1997) Kunz v. Patterson Floor Coverings, Inc. (2002) 67 Cal. Comp. Cases 1588 Gould v. Workers' Comp. Appeals Bd. (1992) 4 Cal. App. 4th 1059, 1068-1069 [6 Cal. Rptr. 2d 228] Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd. (1983) 34 Cal.3d 159, 168 [193 Cal.Rptr. 157, 666 P.2d 14 8 CCR 9789.22(j) Robert Klittich, Applicant v. Green Thumb International, State Compensation Insurance Fund, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 866, Opinion Filed August 11, 2008 Labor Code Section 5307.1 8 CCR "§ 9792.5. Payment for Medical Treatment Cal Lab Code § 3202.5 Preponderance of evidence standard Gould v. Workers' Compensation Appeals Bd. (Barry), 60 Cal. Comp. Cas. (MB) 1109 (Cal. App. 2d Dist. 1995)

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Tapia v. Workers' Comp. Appeals Bd., 73 Cal. Comp. Cas. (MB) 1338 (W.C.A.B. 2008) SELF-PROCURED MEDICAL TREATMENT AND BEING PAID USUAL AND CUSTOMARY FEES 8 CCR 9789.22 (j) Cases in full

CHAPTER TEN

PSYCHIATRIC INJURY..............................................................

Introduction / History Labor Code § 3208.3(e) Treating the consequence of the orthopedic injury or pain management ACOEM / AMA Guidelines (particularly page 398, B, Referral) ACOEM guidelines (page 108, paragraph 3) ACOEM Guidelines (at page 114) Granado v. Workmen's Comp. App. Bd. (1968) 69 Cal. 2d 399, 404 [71 Cal. Rptr. 678, 445 P.2d 294] 8 Cal. Code Reg. § 9785 Labor Code § 4061.5 County of Contra Costa v. Workers' Compensation Appeals Bd., 2005 Cal. Wrk. Comp. LEXIS 294; 70 Cal. Comp. Cases 1496 (Cal. App. 1st Dist. 2005) Flowchart Trial Brief on 6 Month Employment Issue Wal-Mart Stores v. Workers' Comp. Appeals Board (Garcia) (2003) 112 Cal.App.4th 1435 [68 Cal.Comp.Cases 1575] Matea v. Workers' Comp. Appeals. Bd. (2006) 144 Cal.App.4th 1435 [71 Cal.Comp.Cases 1522, 1522] Labor Code § 4604.5(c) Ernestina Molina, Applicant v. Den-Mat, Zenith Insurance Company, Defendants, 2004 Cal. Wrk. Comp. P.D. LEXIS 80, Opinion Filed October 4, 2004 Granado v. Workmen's Comp. App. Bd. (1968) 69 Cal. 2d 399, 404 [71 Cal. Rptr. 678, 445 P.2d 294]

PAGE 259 - 272

CHAPTER ELEVEN

RESPONDING TO NOTICE TO DISMISS / DISALLOW.............................. PAGE 273 - 284

Sample Responses

CHAPTER TWELVE

PETITION FOR RECONSIDERATION................................................. PAGE 285 - 290

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Rules and regulations regarding Petitions for Reconsideration

CHAPTER THIRTEEN

PPO CONTRACTS IN INDUSTRIAL MEDICINE.................................... PAGE 291 - 304

Woodruff v. Greenfield Trucking, W.C.A.B. No. BAK 0141023 (Sept. 4, 2007), 2007 Cal. Wrk. Comp. P.D. LEXIS 93 -- (Appeals Board panel decision). 9WCAB Rptr 10,337 (Nov 9, 2007) Tony Hoy, Applicant v. Northrop Grumman Corporation, Insurance Company of the State of Pennsylvania, AIG Claims, Defendants, 2006 Cal. Wrk. Comp. P.D. LEXIS 1, Opinion Filed February 7, 2006 Silent PPO Richard Balzano, Applicant v. City of Los Angeles, PSI, Defendant, 2005 Cal. Wrk. Comp. P.D. LEXIS 16, Opinion Filed April 13, 2005 Labor Code § 4609 Senate Bill 559 Susan Olsufka v. City of Sacramento 2005 cql. Wrk Comp. P.D. Lexis 27 Filed August 11, 2005 Flowcharts

CHAPTER FOURTEEN

CIGA AND ASSIGNED CLAIMS.................................................... PAGE 305 - 324

Waite v. California Insurance Guarantee Assn., 71 Cal. Comp. Cas. 591 (Cal. App. 2d Dist. 2006) R. J. Reynolds Co. v. California Ins. Guarantee Assn., supra, 235 Cal.App.3d at p. 600 Insurance Code section 1063.1, subdivision (c)(9) California Ins. Guarantee Assn. v. Workers' Comp. Appeals Bd., 153 Cal. App. 4th 524, 62 Cal. Rptr. 3d 855, 2007 Cal. App. LEXIS 1196, 72 Cal. Comp. Cas. 910 (Cal. App. 2d Dist. 2007) California Ins. Guarantee Assn. v. Workers' Comp. Appeals Bd., 153 Cal. App. 4th 524, 62 Cal. Rptr. 3d 855, 2007 Cal. App. LEXIS 1196, 72 Cal. Comp. Cas. (MB) 910 (Cal. App. 2d Dist. 2007) Mirna Licea v. Minson Corporation; California Insurance Guarantee Association for Phico Insurance Company, in liquidation ADJ 1857578 (AHM 0089872) decided June 23, 2009 Baxter Healthcare Corp v. California Insurance Guarantee Assn. (2000) 85 Cal. App. 4th 306, 314 Richey v. Ziegler (1938) 89 Cal App. 35 Insurance Code 1063.1 Burrow v. Pike (1987) 190 Cal. App. 3d 384 California Ins. Guarantee Assn. v. Workers' Comp. Appeals Bd., 136 Cal. App. 4th 1528, 39 Cal. Rptr. 3d 721, 2006 Cal. App. LEXIS 265, 71 Cal. Comp. Cas. (MB) 139, 2006 Cal. Daily Op. Service 1668, 2006 D.A.R. 2296 (Cal. App. 2d Dist.) St. Joseph's Hospital v. Workers' Compensation Appeals Bd., 70 Cal. Comp. Cas. 1612 (Cal. App. 1st Dist. 2005)

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California Insurance Guarantee Assn. v. Workers' Compensation Appeals Bd. , 71 Cal. Comp. Cas. 808 (Cal. App. 1st Dist.2006) Karaiskos v. Metagenics, Inc. (2002) 69 Cal.Comp.Cases 900 Black Diamond Asphalt, Inc. v. Superior Court, 114 Cal. App. 4th 109, 7 Cal. Rptr. 3d 466, 2003 Cal. App. LEXIS 1827, 2003 Cal. Daily Op. Service 10641, 2003 D.A.R. 13420 (Cal. App. 3d Dist. 2003) National Union Fire Ins. Co. of Pittsburgh, PA v. Cambridge Integrated Services Group, Inc., 171 Cal. App. 4th 35, 89 Cal. Rptr. 3d 473, 2009 Cal. App. LEXIS 170, 74 Cal. Comp. Cas. (MB) 184 (Cal. App. 1st Dist. 2009)

Sample Trial Brief on CIGA and Assigned Claims

CHAPTER FIFTEEN

FICTITIOUS BUSINESS NAME...................................................... PAGE 325 - 358

Business and Professions Code section 2285 Business and Professions Code section 2415 Cal Const, Art. XIV § 4 § 4. Workers' compensation Eduardo Alberdin (lead consolidated case), Robert Wileman, San Juana Ortega, et. al., Applicants v. State Compensation Insurance Fund, California Insurance Guarantee Association, Travelers Casualty Company of America, et. al., Defendants, 2009 Cal. Wrk. Comp. P.D. LEXIS 477, Opinion Filed September 21, 2009 Cases in Full

CHAPTER SIXTEEN

AUDIT COMPLAINT FORM ......................................................... PAGE 359 - 360

Instructions and Form

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