WCPanelIQ
PanelDenied

Alice Rivera Pasillas — ADJ9915005

ALICE RIVERA PASILLAS, Applicant vs. DURHAM D M; OLD REPUBLIC INSURANCE COMPANY, administered by SEDGWICK CMS, Defendants

ADJ number
ADJ9915005
Decision date
Mar 12, 2023
District office
Santa Ana District Office
WCJ
Jennifer Kaloper-Bersin
Claim administrator
Sedgwick CMS (administering for Old Republic Insurance Company)
Commissioners
—

Injury / body parts: cervical spine, lumbar spine, left shoulder, left upper extremity

Summary

Applicant Alice Rivera Pasillas, a bus driver who sustained an industrial injury on December 17, 2014, had an accepted claim resolved by Stipulations with an Award of open future medical care. After her new attorney selected a new MPN physician, a dispute arose over whether defendants timely provided a treatment authorization letter, with applicant claiming a denial of care entitling her to treat outside the MPN. The WCJ found applicant failed to rebut the presumption of proper service of the February 8, 2022 authorization letter, relying on a fax confirmation, proof of service, and the testimony of applicant's attorney's staff member (Mr. Galicia), who acknowledged receipt of the letter but could not recall whether a proof of service was attached. The WCAB granted reconsideration to study the issues but ultimately affirmed the August 3, 2022 Findings of Fact, adopting and incorporating the WCJ's Report. The petition for reconsideration was effectively denied.

Issues

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Holding

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Analysis

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Applicant takeaway

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Defense takeaway

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Provider takeaway

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