Disclaimer: The statements and opinions contained in this publication are those of the contributors only and are not necessarily those of The State Bar of California, the Workers' Compensation Section, or any government body. This information is intended to be a reference tool only and is not meant to be relied upon as legal advice.
Did you know that North Dakota became the first state to adopt a workers’ compensation drug formulary in 2006? In California, the Medical Treatment Utilization Schedule (MTUS), the set of regulations used to assess the appropriateness of industrial medical treatment, was recently updated and now consists of practice guidelines and a drug formulary. With limited exception, the formulary covers drugs that are prescribed or dispensed on or after January 1, 2018 to treat work-related injuries or illnesses, regardless of their date. The MTUS drug formulary contains a list of drugs (see 8 CCR § 9792.27.15) that are categorized as being either “Exempt,” i.e. not requiring prospective review and authorization, or “Non-Exempt,” i.e., requiring prospective review and authorization, with disputes subject to UR and IMR. These types of current topics will be discussed at the Workers’ Compensation Section’s upcoming “2018 Spring Education Conference” on April 21st … where we’ll look forward to seeing you!
Earn 6 Hours of participatory MCLE and Legal Specialization Credit
Saturday, April 21, 2018
The Cliffs Resort
2757 Shell Beach Rd
Pismo Beach, CA 93449
Register Online Here!
Schedule | Essential Info | Printable Brochure | Mail/fax Registration Form
Click Here for more information!
On March 6, 2018, in County of San Diego v. Workers’ Compensation Appeals Board (Pike), the Court of Appeals filed a published opinion, holding that, under Labor Code section 4656(c)(2), an injured worker is not entitled to either temporary disability benefits or full salary benefits under Labor Code section 4850—more than five years from the date of injury. This decision reversed the decisions of the WCJ and WCAB, which held that, under Labor Code section 4656 (c)(2), an injured employee was entitled to temporary disability benefits and full salary benefits under Labor Code section 4850 for up to 104 weeks within a five-year period and unlimited benefits thereafter. For obvious reasons, an adverse decision could have had enormous consequences within the workers’ compensation system.
In Pike, the injured worker was employed as a deputy sheriff for the County of San Diego. He sustained an injury on July 31, 2010 to his right shoulder. His claim resolved in May 2011 by stipulations with request for award based on a disability rating of 12%. On May 26, 2015, he filed a timely petition to reopen. He sought salary continuation under Labor Code section 4850 from September 15, 2015 through March 28, 2016, and he also sought temporary disability benefits from March 29, 2016 through August 18, 2016. The County paid him Labor Code section 4850 benefits through July 31, 2015, representing payments until five years from the date of his injury. The WCJ awarded Pike the additional benefits beyond July 31, 2015. The County filed a petition for reconsideration. The WCAB upheld the opinion of the WCJ.
The Court of Appeals reversed the decision of the WCJ and WCAB, holding that an injured worker is not entitled to temporary disability benefits or Labor Code section 4850 benefits beyond five years from the date of injury. Several reasons supported this decision.
First, in reviewing the legislative history, the court observed that an Assembly Floor Analysis had noted the intention of the bill would be to extend the window in which an injured worker could receive temporary disability benefits from two years to five years.
Second, the court observed that, although there was no authority analyzing the limitations under Labor Code section 4656(c)(2), there was analogous authority to the original Labor Code setion 4656. In Radesky v. City of Los Angeles (1974) 37 Cal.App.3d 537, 542, the court considered whether the five-year limitation in former section 4656 applied to a municipal workers’ claims for benefits under a provision of the municipal code that incorporated portions of State law. The court held that the applicant was not entitled to temporary disability beyond five years from the date of injury. By analogy, the court in Pike held that, based on similar language in the statute, a similar finding was warranted.
Pike and its amicus CAAA advocated the position that, under Labor Code sections 5410, 5803, and 5804, the WCAB had jurisdiction to award benefits beyond five years from the date of injury. The court in Pike was unpersuaded by this position. Citing Nickelsberg v. Workers’ Comp. Appeals Bd. (1991) 54 Cal.3d 288, it emphasized that the California Supreme Court made clear that the jurisdictional limitations in sections 5410, 5803, and 5804 are separate and distinct from the substantive law limiting an award of temporary disability benefits in section 4656. Thus, even though the WCAB had jurisdiction to determine benefits more than five years from the date of injury, it lacked the power under the expressed limitation in the statute. Simply stated, the court concluded that, in order to award benefits, the WCAB “must have jurisdiction to act, and the law must entitle the worker benefits.” (Emphasis in original.)
Finally, the court noted that there was no reason to evaluate Labor Code section 4850 benefits any differently than temporary disability. In footnote 10, it recognized that, in County of Alameda v. Workers’ Comp. Appeals Bd. (Knittel) (2013) Cal.App.4th 278—a successful Hanna Brophy decision, the Court of Appeals held that Labor Code section 4850 benefits are disability benefits within Labor Code section 4656(c)(2) for purposes of the 104-week cap on TTD benefits. The court reasoned that it could see no reason, and none was provided by Pike, as to why the five-year limitation would not apply with equal force.
© Copyright 2018 Christian P. Kerry. All rights reserved. Reprinted with permission.