Zenith Insurance v. Workers' Compensation Appeals Board

Opinion

McINTYRE, J.

Zenith Insurance Company (Zenith), a workers’ compensation insurance carrier, seeks review of an order by the Workers’ Compensation Appeals Board (the Board) refusing to reconsider the decision of a workers’ compensation judge (the WCJ) awarding facility fees to two outpatient medical treatment centers. We conclude the Board erred in denying the petition for reconsideration because the lien claimants failed to establish their licensure or accreditation as an essential element of their lien claims. As such, the Board’s decision was not supported by substantial evidence and is annulled.

FACTUAL AND PROCEDURAL BACKGROUND

Gilberto Capi injured his lower back while working as a book binder for International Coil Bindery, then insured for workers’ compensation claims by Zenith. Capi received outpatient medical treatment for his injury from various providers, including Beach Cities Surgery Center (Beach Cities) and Pain Intervention Therapy of San Diego (PIT; together the lien claimants). Zenith settled Capi’s claims via a compromise and release; however, it disputed the reimbursement claims made by several of Capi’s health care providers, including the claims for facility fees sought by the lien claimants.

At a lien conference hearing, Zenith informed the WCJ that it had filed a civil action against the hen claimants and others that alleged, among other things, that the lien claimants illegally billed for facility fees when they were unlicensed and unaccredited in violation of the Business and Professions Code and the Health and Safety Code.

(Zenith Ins. Co. v. Brett L. Allen et al.

(Super. Ct. San Diego County, 2004, No. GIN036344).) Zenith presented a copy of its civil complaint to the WCJ, requested additional time to complete discovery and for the matter to be stayed pending resolution of its civil action. A pretrial conference statement listed the issues in dispute, including whether the lien claimants engaged in a fraudulent scheme involving billing

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improprieties. The WCJ refused to continue the matter and the case proceeded to trial. In his findings of fact and order, the WCJ allowed the liens of Beach Cities and PIT, in the respective amounts of $22,100 and $24,000.