Authorities as the decision cited them, with how this panel applied each one.
Insurance Code section 1063.1
CIGA's liability defined as covered claims under Insurance Code section 1063.1.
CIGA must cover obligations of insolvent insurer to provide benefits under workers' compensation law.
From the decision · page 2CIGA's liability is specifically defined in Insurance Code section 1063.1 as "covered
claims." (Ins. Code, § 1063.1.) In the case of a policy of workers' compensation insurance, CIGA
must cover the obligations of an insolvent insurer "to provide benefits under the workers'
compensation law." (Ins. Code § 1063.1(c)(1)(F).) "[C]overed claims" under section 1063.1 "are
not coextensive with an insolvent insurer's obligations under its policies." (Industrial Indemnity
Co. v. Workers' Comp. Appeals Bd. (Garcia) (1997) 60 Cal.App.4th 548, 557 [62 Cal.Comp.Cases
1661].) Insurance Code section 1063.1(c)(5)(A) states: "`Covered claims' does not include an
Labor Code section 4600
Employers must provide medical treatment to cure or relieve effects of industrial injury under Labor Code section 4600.
Timely provision of reasonable medical treatment is essential; employer liable for reasonable expenses if neglects or refuses.
From the decision · page 3An employer must provide an injured worker with medical treatment to cure or relieve the
injured worker from the effects of an industrial injury. (Lab. Code, § 4600.) Timely provision of
reasonable medical treatment is an essential element of workers' compensation. (Cal. Const.,
Article XIV, § 4; McCoy v. Industrial Acc. Com. (1966) 64 Cal.2d 82, 87
[31 Cal.Comp.Case0s 93]; Zeeb v. Workmen's Comp. Appeals Bd. (1967) 67 Cal.2d 496, 501
[32 Cal.Comp.Cases 441]; Braewood Convalescent Hosp. v. Workers' Comp. Appeals
Bd. (Bolton) (1983) 34 Cal.3d 159, 165 [48 Cal.Comp.Cases 566]; see also, Lab. Code, § 4600.) If
the employer neglects or refuses to provide reasonable medical care, "the employer is liable for
reasonable expense incurred by or on behalf of the employee in providing treatment." (Lab. Code,
§ 4600(a).)
Labor Code section 4610
Employers must establish utilization review process under Labor Code section 4610.
Legislature requires medical expert decision to deny, delay, or modify treatment.
From the decision · page 3Reasonable medical treatment must be provided based on the Medical Treatment
Utilization Schedule (MTUS) and paid for in accordance with the Official Medical Fee Schedule
(OMFS). (Lab. Code, § 4600(b), 4603.2(b)(2), 5307.1 and 5307.27.) Employers must establish a
UR process to resolve disputes over whether medical treatment should be authorized. (Lab. Code,
§ 4610.) The Legislature required employers to establish a UR process to ensure that a medical
expert makes the decision to deny, delay, or modify treatment. (State Comp. Ins. Fund v. Workers'
Labor Code section 4610.5
Independent Medical Review process established by SB 863 under Labor Code section 4610.5.
Addresses treatment disputes not resolved by utilization review.
From the decision · page 4Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230, 241 [73 Cal.Comp.Cases 981.) In
Sandhagen, the California Supreme Court concluded that "the Legislature's purpose in enacting
the utilization review process in section 4610" was "to require employers to conduct utilization
review when considering employees' requests for medical treatment." (Id. at 244-245.) A major
legislative reform package, Senate Bill No. 863 (2011-2012 Reg. Sess. chaptered as Statutes 2012,
chapter 363 (SB 863)) created an Independent Medical Review (IMR) process to address treatment
disputes not resolved by UR. (Lab. Code, § 4610.5.)
Labor Code section 4603.6
Independent Bill Review process established by SB 863 under Labor Code section 4603.6.
Sets requirements for second review of medical provider bills and assignment to independent reviewer.
From the decision · page 4Similarly, to dispute a medical provider's bill for medical treatment services, an employer
must pay or object to provider bills within a certain time frame and provide an explanation of
review for any bills not paid. (Lab. Code, § 4603.2.) SB 863 added language to section 4603.2
setting "forth requirements for the second review that a medical provider may request (and must
request) prior to seeking independent review of a bill." (California Ins. Guarantee Assn. v.
Workers' Comp. Appeals Bd. (2014) 232 Cal.App.4th 543, 555 [79 Cal.Comp.Cases 1481].) SB
863 also added section 4603.6 which establishes an Independent Bill Review (IBR) process,
including setting forth when an IBR may be requested, what will occur if an IBR is not requested
within the prescribed time, how such a request is to be made, and how the IBR will be assigned to,
and addressed by, an independent reviewer.