Back in April, the California Workers' Compensation Appeals Board (CWCAB) ruled that eligibility for workers' compensation benefits could not be established by a report from a physician working outside of an injured worker's medical provider network (MPN).

Not surprisingly, the ruling engendered consternation among both work comp lawyers and physicians who viewed it as both poorly conceived and overly broad.

However, it now appears that change could be coming, as the CWCAB recently announced that it was reconsidering the ruling.

The case

The case in question involved Southern California resident Elayne V., a food demonstration employee for Warehouse Demo Services who was injured while working at a Costco.

Elayne V. began receiving medical care for her injuries through her employer's MPN. However, after three weeks of treatment, she did not feel as if her health was improving, and sought medical care from a physician outside of the MPN - and without the consent of her employer.

She was ultimately able to secure four months of temporary disability based a report she received from this non-MPN or "outside" physician.

While an administrative law judge (ALJ) accepted the report and approved the award of work comp benefits, her employer disagreed and pursued the matter to the CWCAB.

CWCAB

Here, the CWCAB unanimously reversed the ruling of the ALJ, holding that an injured employee cannot seek treatment/opinions outside of their employer's MPN without securing prior approval.

Specifically, it indicated that California regulations mandate that injured employees whose employers have MPNs are required to receive their treatment from MPN physicians, and if they are unhappy with their medical care, the regulations indicate they are entitled to a second opinion/treatment from another MPN physician.

The CWCAB ruled that since Elayne V. only saw one MPN physician for a span of three weeks and sought outside treatment without securing any type of consent from her employer, the non-network physician's report was inadmissible.

It is worth noting that the only explanation offered by the CWCAB for its decision to review Elayne V.'s case is that it believed "reconsideration must be granted" after examining a motion from Elayne V.'s attorneys.

Stay tuned for further updates from our San Diego workers' compensation firm ...

This post was for informational purposes only and is not to be construed as legal advice. Names have been withheld to protect the identity of the parties.

Related Resources:

California WC Appeals Board takes back physician ruling (Insurance Journal)