ADJ16497715 · July 8, 2024

The record does not fully support a finding of no liability for the medical-legal evaluation; issue deferred for further development of the record.

From the decision · page 6Therefore, we defer the issue of whether lien claimant is entitled to reimbursement for the cost of the medical-legal evaluation.

Lien claimant did not prove that applicant sustained compensable industrial injury; no challenge to AOE/COE finding in the Petition.

From the decision · page 6We will not disturb the WCJ's finding that lien claimant is not entitled to reimbursement for medical treatment services because lien claimant did not prove that applicant sustained compensable industrial injury. We note that lien claimant did not challenge or address the finding as to AOE/COE in the Petition. (Lab. Code, § 5904 [Petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].)

Lien claimant did not prove that applicant sustained compensable industrial injury and did not challenge the AOE/COE finding in the Petition.

Favours Defendant prevailed

Failure to challenge the AOE/COE finding resulted in waiver and disallowance of the lien for self-procured medical treatment.

From the decision · page 6We will not disturb the WCJ's finding that lien claimant is not entitled to reimbursement for medical treatment services because lien claimant did not prove that applicant sustained compensable industrial injury. We note that lien claimant did not challenge or address the finding as to AOE/COE in the Petition. (Lab. Code, § 5904 [Petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].)

Applicant designated Dr. Nia as primary treating physician and acknowledged the claim was contested at the time of the medical-legal evaluation.

Favours Applicant prevailed

Supported the finding that the medical-legal evaluation was obtained in the context of a contested claim, relevant to the deferred issue of liability for the evaluation.

From the decision · page 4DISCUSSION In its Answer, defendant denied applicant's claim of injury on August 26, 2022, and in the C&R of November 17, 2022, defendant again denied all claims. It does not appear to be disputed that Dr. Nia was applicant's primary treating physician (PTP) at the time the August 26, 2022 medical-legal report was prepared and submitted because applicant signed the designation of Dr. Nia and Spectrum as her primary treating physician and acknowledged that her claim was contested and that an evaluation was appropriate.

Dr. Nia concluded applicant had sustained an industrial injury but no need for further medical treatment and no permanent disability; opined that prolonged standing only exacerbated a non-industrial laceration and did not result in new injuries or disabilities.

Dr. Nia's report was considered in determining compensability and medical necessity for self-procured treatment.

From the decision · page 3In my opinion the prolonged standing between 5/23/2022 to 6/17/2022 while working forabove named employer has only exacerbated her non-industrial laceration of the right foot and has not resulted in any new injuries or disabilities. Today's examination of the right foot is within normal limits with no abnormalities noted. I will need all medical records including the ones from emergency room and urgent care for review. I will also recommending future medical records by the neurologist to be forwarded for my review as well.

Labor Code sections 4060(b), 4064(a), 4620(a)

Labor Code section 4060(b) allows a medical-legal evaluation by the treating physician; section 4620(a) defines medical-legal expense as costs for proving or disproving a contested claim; section 4064(a) provides employer liability for the cost of a comprehensive medical evaluation authorized by section 4060.

Applied to determine whether the medical-legal evaluation by the PTP is a recoverable expense and whether the employer is liable for its cost.

From the decision · page 4Moreover, applicant presented herself for the evaluation on August 26, 2022, and the report of the evaluation states that it was obtained at the request of a party, and it was sent to applicant's attorney and to defendant. Labor Code section 4060(b) allows a medical-legal evaluation by the treating physician.1 Section 4620(a) defines medical-legal expense as "any costs and expenses...for the purpose of proving or disproving a contested claim." Section 4064(a) provides that the employer is liable for the cost of a comprehensive medical evaluation that is authorized by section 4060. AD Rule 9793(h) states: (h) "Medical-legal expense" means any costs or expenses incurred by or on behalf of any party or parties, the administrative director, or the appeals board for X-rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony, and as needed, interpreter's fees, for the purpose of proving or

AD Rule 9793(h)

AD Rule 9793(h) defines medical-legal expense and sets conditions for recovery, but does not override the Labor Code sections.

Considered in determining whether the medical-legal evaluation by the PTP is a recoverable expense.

From the decision · page 411 Unless otherwise stated, all further statutory references are to the Labor Code.

Applicant did not challenge or address the finding as to AOE/COE in the Petition for Reconsideration, thus waiving the issue.

From the decision · page 6We will not disturb the WCJ's finding that lien claimant is not entitled to reimbursement for medical treatment services because lien claimant did not prove that applicant sustained compensable industrial injury. We note that lien claimant did not challenge or address the finding as to AOE/COE in the Petition. (Lab. Code, § 5904 [Petitioner is deemed to have waived an issue that is not raised in the petition for reconsideration].)