Mendoza v. Huntington Hospital, PSI; and Sedgwick Claims Management Services, Inc. ADJ6820138/ADJ6820197 En Banc Opinion and Decision After Removal and Order Admitting Documentary Evidence
June 7, 2010
Holding:
The Workers' Compensation Appeals Board, en banc, issued an Opinion and Decision on June 3, 2010 invalidating Administrative Director Rule 30(d)(3), 8 Ca. Code of Regs. 30. This rule provided in relevant part as follows:
Whenever an injury or illness claim of an employee has been denied entirely by the claims administrator, or if none by the employer, only the employee may request a panel of qualified medical evaluators, as provided in Labor Code sections 4060(d) and 4062.1 if unrepresented, or as provided in Labor Code sections 4060(c) and 4062.2 if represented.
This rule stood for the proposition that a defendant which had already denied a claim would be prevented from subsequently obtaining a qualified medical evaluator panel list from the Medical Director on the issue of compensability. Expressed differently, this rule required that a defendant had to use the LC 4060/4062.2 objection process while a claim was delayed, prior to any actual denial.
After defining its authority to so rule, the WCAB held that the AD rule conflicts with LC sections 4060(c) and 4062.2. The Board specifically holds that neither of these sections provides that "only the employee may request" a QME panel list after an employer has denied the compensability of a claimed injury. Rather, the Board holds that either party may make a QME panel request at any time after the filing of a claim form. In addition, the Board holds that nothing in LC 5402(b) related to the 90 day presumption of compensability requires the employer/defendant to request a QME panel list before it denies liability for an injury.
The WCAB also held that the time limits of LC 4062(a) for objecting to a treating physician's medical determination do not apply when the injury has been entirely denied by the defendant; and LC 4062.2 does not establish timelines for initiating or completing the process for obtaining a medical-legal report on compensability.
In reaching this ruling, the WCAB dismissed the arguments put forth by the DWC in its invited briefing while advising defendants that they cannot "simply sit on [their] hands without consequences." Defendants must still act in good faith in denying claims, timely pursue medical-legal opinions, and timely act to complete discovery.
Impact:
En banc decisions of the Appeals Board are binding precedent on all Appeals Board panels and workers' compensation judges. By invalidating this rule, defendants have greater flexibility in timely denying claims within the 90 day time constraints of LC 5402(b), as well as increased capability of obtaining panel Qualified Medical Examiner lists on issues associated with compensability. No longer will defendants have to delay denial of claims in order to engage in the panel Qualified Medical Examiner selection process, and risk exceeding the 90 day deadline for denying claims. No longer will defendants have to engage in the "lengthy" process of obtaining WCAB orders directing the Medical Director to issue panel QME lists.
For additional information, please contact Laughlin, Falbo, Levy & Moresi, LLP.
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