Pearson Ford v. Workers' Comp. Appeals Bd.
D070915
| Cal. Ct. App. | Nov 1, 2017Background
- In 2006 Hernandez crushed a left-hand finger at work; he received workers' compensation and continued treatment for pain through 2010.
- Surveillance in early 2010 showed Hernandez using his left hand (driving, carrying groceries, lifting a washing machine) despite wearing a sling and claiming severe dysfunction.
- Hernandez was examined repeatedly by agreed medical examiner (Dr. Byron F. King), pain specialist Dr. Strauser, and orthopedist Dr. Balourdas; Dr. King ultimately found objective impairment and chronic regional pain syndrome after later, more cooperative exams.
- Hernandez pled guilty in 2012 to one count of workers’ compensation fraud (Insurance Code § 1871.4) based on a May 2010 visit and was ordered to pay $9,000 restitution.
- In 2016 a WCJ awarded Hernandez a 70% permanent disability, life pension, indemnity and future medical benefits; the WCAB denied reconsideration.
- Pearson Ford petitioned for writ of review challenging the award on statutory-bar and insufficiency-of-evidence grounds; the Court of Appeal affirmed the WCAB.
Issues
| Issue | Plaintiff's Argument (Pearson Ford) | Defendant's Argument (Hernandez / WCAB) | Held |
|---|---|---|---|
| Whether a conviction for workers’ comp fraud (Ins. Code § 1871.4) bars all benefits under § 1871.5 | Hernandez’s conviction for fraudulent statements to treating doctors bars any award tied to those claims | Section 1871.5 only bars compensation "owed or received as a result of" the fraud; independent compensable injuries remain recoverable | Court held § 1871.5 did not bar the award because medical evidence supporting impairment was independent of the fraud (Tensfeldt framework applies) |
| Whether substantial medical evidence supports permanent disability | Dr. King’s ratings depart from AMA Guides and are unreliable given prior inconsistent presentations | Dr. King provided objective tests, explained departures from AMA Guides, and was an AME whose opinion the WCAB could credit | Court held substantial evidence supported the WCAB’s reliance on Dr. King’s objective findings and impairment ratings |
| Whether restitution from criminal conviction precludes further benefits | Restitution and conviction should prevent future benefits or require offset | Restitution order did not constitute a determination that Hernandez could not receive further benefits; unrelated benefits are protected | Court held restitution did not bar future benefits and did not require denying the award |
| Standard of review for WCAB findings | N/A (challenging legal application and sufficiency) | WCAB factual findings are reviewed for substantial evidence; legal questions de novo but with deference to WCAB interpretation | Court applied substantial-evidence review and deferred to WCAB on credibility and medical weighing |
Key Cases Cited
- Tensfeldt v. Workers Compensation Appeals Bd., 66 Cal. App. 4th 116 (Cal. Ct. App.) (framework: §1871.5 bars benefits "owed or received as a result of" fraud; permits recovery when independent compensable injury shown)
- Farmers Ins. Group v. Workers' Comp. Appeals Bd., 104 Cal. App. 4th 684 (Cal. Ct. App.) (fraud-related restitution may be limited to benefits directly stemming from the fraud; unrelated benefits may remain)
- Milpitas Unified Sch. Dist. v. Workers' Comp. Appeals Bd. (Guzman), 187 Cal. App. 4th 808 (Cal. Ct. App.) (AMA Guides are mandatory but not a rigid protocol; clinical judgment allowed)
- Power v. Workers' Comp. Appeals Bd., 179 Cal. App. 3d 775 (Cal. Ct. App.) (AME opinions are entitled to deference and should be followed absent persuasive reason)
- Green v. Workers' Comp. Appeals Bd., 127 Cal. App. 4th 1426 (Cal. Ct. App.) (WCAB may rely on AME and give weight to explained departures from Guides)
- Braewood Convalescent v. Workers' Comp. Appeals Bd., 34 Cal. 3d 159 (Cal. 1983) (definition of substantial evidence in WCAB review)