ADJ10425538 — California WCAB decision

What the panel ordered

The Petition for Reconsideration filed by defendant was denied.

Defendant Ross Stores/Arch Insurance Company/Sedgwick CMS filed a Petition for Reconsideration of the October 16, 2024 Findings and Award, which was denied by the WCAB panel decision dated January 21, 2025.

Read the official decision →

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.

Penalties under Labor Code §5814Applicant prevailedleft knee

The WCJ found that defendant unreasonably refused or delayed medical treatment to applicant's left knee, constituting bad faith under Labor Code section 5813, and awarded penalties and attorney's fees accordingly. The WCAB panel denied defendant's petition for reconsideration, affirming the award.

The facts that decided it

What the panel treated as outcome-determinative, and which side it favoured.

Defendant unreasonably refused or delayed medical treatment to applicant's left knee.

Favours Applicant prevailed

This finding supported the award of penalties and attorney's fees under Labor Code sections 5813 and 5814.

What the panel did with the medical opinions

The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.

QMERelied upon

Found the left knee to be a compensable injury as a consequence of the right knee injury, citing antalgic gait as causative.

The WCJ relied on Dr. King's consistent opinion supporting compensability of the left knee injury.

From the decision · page 7Dr. King authored his first report on June 13, 2019 (Jt. Ex. 1) finding the left knee to be a compensable injury to her right knee stating the applicant "has suffered from antalgic gait for nearly three years, which in my medical opinion, is sufficient to have resulted in a spraining/straining type injury to the left knee as a compensable consequence" (Jt. Ex. 1). In response to this report defendants set up a Labor Code § 4050 exam with Dr. Pallia. Dr. Pallia is not a treating physician, a consulting physician or AME/PQME. He authored his first report of November 7, 2019 (Jt. Ex. 6) and a subsequent report on March 15, 2020 (Jt. Ex. 7). The defendants also requested a report from Michael Kimball, a prior treating physician who last saw the applicant in May 2016 and then later deposed Dr. Kimball July 6, 2021.

otherRejected

Provided non-admissible medical evidence raising the issue of antalgic gait, which formed the basis for denial and subsequent discovery delays.

The WCJ found Dr. Pallia's reports non-admissible and the basis for bad faith delay by defendant.

From the decision · page 8treating physician, Dr. Kimball (Def. Ex. G and H) as well as taking the deposition of Dr. Kimball on July 6, 2021 (Def. Ex. F). The defense also solicited reports from Dr. Christopher Pallia who was neither a PQME nor a treating physician, and therefore not admissible as evidence (Def. Ex. I and Ct. Ex. XX). It was Dr. Pallia who raised the issue of "antalgic gait" which then formed the basis of the denial which issued November 18, 2019 (App. Ex. 4) and from which all the subsequent discovery flowed.

PTPRelied upon

Treating physician who found the left knee compensable and requested authorization for treatment.

The WCJ relied on Dr. Harris's findings supporting compensability of the left knee injury.

From the decision · page 6This case was originally settled by way of Stipulations with Request for Award on July 5, 2018 for the right knee (Jt. Ex. 12). A timely Petition to Re-open was filed November 1, 2018 alleging left knee injury as a compensable consequence of the right knee injury for which an Award was issued on July 5, 2018 (Jt. Ex. 11- Findings & Award right knee). Dr. Thomas Harris, the treating physician for the applicant found the left knee to be compensable and requested authorization for treatment on November 26, 2018, along with a Request for Authorization for treatment for the left knee. (Applicant's Ex. 1 also marked as Ex. 1 in the 12/19/2019 hearing).

The rules the panel named

Authorities as the decision cited them, with how this panel applied each one.

Labor Code section 5813

Labor Code section 5813 applies to bad faith actions or tactics that are frivolous or solely intended to cause unnecessary delay.

The WCJ found that defendant's unreasonable refusal or delay of medical treatment constituted bad faith under section 5813, supporting the award of attorney's fees.

From the decision · page 9states that "Sedgwick CMS did unreasonably refuse or delay medical treatment to the applicant's left knee". Labor Code § 5813 applies to bad faith actions or tactics that are frivolous or solely intended to cause unnecessary delay. Therefore it was not necessary to make a specific finding of "Bad Faith", rather the finding of that Sedgwick CMS unreasonably refused or delayed medical treatment to the applicant's left knee is equivalent to a finding of bad faith otherwise the delay or denial would not be "unreasonable".

Labor Code section 5814

Labor Code section 5814 authorizes penalties for unreasonable refusal or delay of medical treatment.

The WCJ awarded penalties under section 5814 for defendant's unreasonable refusal or delay of medical treatment to the applicant's left knee.

Labor Code section 5814.5

Labor Code section 5814.5 allows for attorney's fees for enforcement of an Award.

The WCJ found that attorney's fees were proper under section 5814.5 because the left knee injury was part of the original Award for the right knee, and also under section 5813 for bad faith conduct.

From the decision · page 4Lastly, the July 5, 2018 Award based on applicant's right knee injury includes medical treatment "to cure or relieve from the effects of said injury(ies)." (See Stipulations with Request for Award dated July 5, 2018.) Since applicant's left knee injury was claimed, and later found, to be a compensable consequence of applicant's right knee injury, the July 5, 2018 Award includes medical treatment to applicant's left knee injury. As such, we find the award of fees pursuant to section 5814.5 proper. Even if not proper, the award of fees is proper under section 5813 because of defendant's bad-faith actions or tactics that were frivolous or intended to cause unnecessary delay.

ADJ10425538 · January 21, 2025

What the panel ordered

What was disputed, and how it came out

The facts that decided it

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What the panel did with the medical opinions

The rules the panel named

What proof carried it

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