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Lisa Hill Sanders — ADJ11998519

LISA HILL SANDERS, Applicant vs. KAISER PERMANENTE, permissibly self-insured; Administered by SEDGWICK CLAIMS MANAGEMENT SERVICES, Defendants

ADJ number
ADJ11998519
Decision date
Apr 20, 2021
District office
Los Angeles
WCJ
—
Claim administrator
Sedgwick Claims Management Services (administering for Kaiser Permanente, permissibly self-insured)
Commissioners
MARGUERITE SWEENEY, COMMISSIONER, CRAIG SNELLINGS, COMMISSIONER, DEIDRA E. LOWE, COMMISSIONER

Injury / body parts: psyche

LC §5813LC §5811LC §5502LC §5902LC §5904LC §5903LC §5952LC §4622LC §4603.3LC §4603.6CCR §10451.1CCR §10786CCR §10561CCR §10421

Summary

Dr. Elena Konstat, a PQME (cost petitioner), billed defendant $5,825 for a February 16, 2018 psyche evaluation, including 74 units under ML104. Defendant's March 25, 2018 EOR erroneously processed only 7 units (instead of 74), reducing payment to $848.11. Full correct payment was not made until an April 16, 2019 settlement, after cost petitioner hired an attorney. The dispute centered on whether cost petitioner could recover attorney's fees under Labor Code section 5813 and former WCAB Rule 10451.1(g)(1), which require an underlying finding of bad faith. The Board found the WCJ's no-bad-faith finding may not be supported by substantial evidence because defendant's April 24, 2018 EOR correctly identified 74 units, suggesting defendant knew of the error well before March 2019. The Board affirmed its prior decision but amended it to defer the bad faith and attorney's fee issues, remanding to the WCJ for further proceedings.

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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