ADJ10914834 — California WCAB decision

What the panel ordered

Findings and Order affirmed except amended to disallow sanctions and attorney's fees against defendant SCIF for the conduct at issue; defendant did not engage in bad faith actions or tactics.

Petition for Reconsideration granted to study factual and legal issues; WCJ Findings and Order issued December 21, 2020 reviewed.

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.

Medical treatment / UR / IMRMixedstress · psyche · digestive · head · back

The Board found that the cost petitioner met its burden to prove the medical-legal services were reasonably and necessarily incurred for a contested claim, and that defendant breached its duty to timely contest the fees, but did not engage in bad faith actions warranting sanctions.

From the decision · page 7With respect to the issue of whether defendant was liable for the cost of the copy services, interest, and penalties, we agree with the WCJ that cost petitioner met its burden of proof under sections 4620, 4621, and 4622. We observe that defendant's argument that applicant should not have engaged in discovery because applicant claimed injury to psyche and had been employed by it for less than six months to be disingenuous at best. The Application claimed injury to psyche and to applicant's digestive system, a physical injury. Notably, the C&R included release of claimed injury to the body parts of "stress," psyche, digestive, head and back. The six month prohibition in section 3208.3(d) only applies to injuries to psyche and not to claimed physical injuries. Thus, this argument is unwarranted and is not supported by the statutes, decisional law, or the evidence before us.

The facts that decided it

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

Applicant's claim included physical injuries not subject to the six-month employment limitation, supporting the validity of medical-legal expenses.

Favours Applicant prevailed

This fact undermined defendant's argument that discovery should be limited due to the threshold employment issue.

From the decision · page 7With respect to the issue of whether defendant was liable for the cost of the copy services, interest, and penalties, we agree with the WCJ that cost petitioner met its burden of proof under sections 4620, 4621, and 4622. We observe that defendant's argument that applicant should not have engaged in discovery because applicant claimed injury to psyche and had been employed by it for less than six months to be disingenuous at best. The Application claimed injury to psyche and to applicant's digestive system, a physical injury. Notably, the C&R included release of claimed injury to the body parts of "stress," psyche, digestive, head and back. The six month prohibition in section 3208.3(d) only applies to injuries to psyche and not to claimed physical injuries. Thus, this argument is unwarranted and is not supported by the statutes, decisional law, or the evidence before us.

Defendant admitted receipt of the invoice and issued an Explanation of Review denying payment but failed to prove timely contest of the invoice for Kaiser records.

Favours Applicant prevailed

This failure established defendant's breach of duty to timely contest the medical-legal fees.

From the decision · page 6Defendant contends that the evidence relied upon by the Court does not prove that defendant failed to timely contest the reasonableness and necessity of the bill of Matrix Document Imaging. Specifically, defendant argues that the Court relied on an invalid proof of service to make the determination that they did not "process" the invoice from Matrix Document Imaging. Defendant correctly notes that the proof of service for the invoice attached for the records of Kaiser Foundation Hospital dated 08/30/2017 (Cost Petitioner's Exhibit "5") describes the invoice served as "Invoices" which does not adequately describe the document being served. Defendant also correctly notes that the invoice dated 08/30/2017 lists the name of the defendant as ESIS even though the address listed below ESIS on the invoice is the correct address for State Compensation Insurance Fund. However these arguments are irrelevant because defendant has admitted to receiving the 08/30/2017 invoice contained in Cost Petitioner's Exhibit "5" and admitted to issuing an EOR denying payment for this invoice on 01/30/2018 (Defendant's Exhibit "C"). In addition, the proof of service is addressed to State Compensation Insurance Fund at PO Box 65005 Fresno, CA 93650. This is the same address listed for State Compensation Insurance Fund on the official address record. Defendant then argues that:

What proof carried it

The evidence the panel weighed, by kind.

Medical recordsfavours Applicant prevailed

Applicant's claim included both psyche and physical injuries, and the six-month employment limitation only applies to psyche injuries, not physical injuries.

From the decision · page 7With respect to the issue of whether defendant was liable for the cost of the copy services, interest, and penalties, we agree with the WCJ that cost petitioner met its burden of proof under sections 4620, 4621, and 4622. We observe that defendant's argument that applicant should not have engaged in discovery because applicant claimed injury to psyche and had been employed by it for less than six months to be disingenuous at best. The Application claimed injury to psyche and to applicant's digestive system, a physical injury. Notably, the C&R included release of claimed injury to the body parts of "stress," psyche, digestive, head and back. The six month prohibition in section 3208.3(d) only applies to injuries to psyche and not to claimed physical injuries. Thus, this argument is unwarranted and is not supported by the statutes, decisional law, or the evidence before us.

Documentary evidencefavours Applicant prevailed

Defendant admitted receiving the invoice and issuing an Explanation of Review denying payment, but failed to prove timely contest of the invoice for Kaiser records.

From the decision · page 6Defendant contends that the evidence relied upon by the Court does not prove that defendant failed to timely contest the reasonableness and necessity of the bill of Matrix Document Imaging. Specifically, defendant argues that the Court relied on an invalid proof of service to make the determination that they did not "process" the invoice from Matrix Document Imaging. Defendant correctly notes that the proof of service for the invoice attached for the records of Kaiser Foundation Hospital dated 08/30/2017 (Cost Petitioner's Exhibit "5") describes the invoice served as "Invoices" which does not adequately describe the document being served. Defendant also correctly notes that the invoice dated 08/30/2017 lists the name of the defendant as ESIS even though the address listed below ESIS on the invoice is the correct address for State Compensation Insurance Fund. However these arguments are irrelevant because defendant has admitted to receiving the 08/30/2017 invoice contained in Cost Petitioner's Exhibit "5" and admitted to issuing an EOR denying payment for this invoice on 01/30/2018 (Defendant's Exhibit "C"). In addition, the proof of service is addressed to State Compensation Insurance Fund at PO Box 65005 Fresno, CA 93650. This is the same address listed for State Compensation Insurance Fund on the official address record. Defendant then argues that:

ADJ10914834 · August 29, 2025

What the panel ordered

What was disputed, and how it came out

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The facts that decided it

The rules the panel named

What proof carried it

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