BILL NUMBER: SB 1105 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY AUGUST 29, 2012
AMENDED IN ASSEMBLY AUGUST 24, 2012
AMENDED IN ASSEMBLY JUNE 13, 2012
AMENDED IN SENATE MAY 2, 2012
AMENDED IN SENATE APRIL 16, 2012
INTRODUCED BY Senator Lieu
FEBRUARY 16, 2012
An act to amend Section 4903.1 of the Labor Code, relating to
workers' compensation.
LEGISLATIVE COUNSEL'S DIGEST
SB 1105, as amended, Lieu. Workers' compensation: liens.
Existing law establishes a workers' compensation system,
administered by the Administrative Director of the Division of
Workers' Compensation, to compensate an employee for injuries
sustained in the course of his or her employment. Existing workers'
compensation law authorizes the Workers' Compensation Appeals Board
to determine and allow specified expenses as liens against any sum to
be paid as compensation. Existing law requires, before issuing an
award or approval of any compromise of claim, the determination of
whether any benefits have been paid or services provided by specified
entities.
This bill would require the appeals board to allow a lien for
loss-of-time benefits paid by a self-insured employee welfare benefit
plan, as defined.
This bill would incorporate additional changes in Section 4903.1
of the Labor Code proposed by SB 863 that would become operative only
if SB 863 and this bill are both chaptered and become effective on
or before January 1, 2013, and this bill is chaptered last.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 4903.1 of the Labor Code is amended to read:
4903.1. (a) The appeals board, arbitrator, or settlement
conference referee, before issuing an award or approval of any
compromise of claim, shall determine, on the basis of liens filed
with it pursuant to subdivision (b) or (c), whether any benefits have
been paid or services provided by a health care provider, a health
care service plan, a group disability policy, including a
loss-of-income policy, a self-insured employee welfare benefit plan,
or a hospital service contract, and its award or approval shall
provide for reimbursement for benefits paid or services provided
under these plans as follows:
(1) When the referee issues an award finding that an injury or
illness arises out of and in the course of employment, but denies the
applicant reimbursement for self-procured medical costs solely
because of lack of notice to the applicant's employer of his or her
need for hospital, surgical, or medical care, the appeals board shall
nevertheless award a lien against the employee's recovery, to the
extent of benefits paid or services provided, for the effects of the
industrial injury or illness, by a health care provider, a health
care service plan, a group disability policy, a self-insured employee
welfare benefit plan, or a hospital service contract.
(2) When the referee issues an award finding that an injury or
illness arises out of and in the course of employment, and makes an
award for reimbursement for self-procured medical costs, the appeals
board shall allow a lien, to the extent of benefits paid or services
provided, for the effects of the industrial injury or illness, by a
health care provider, a health care service plan, a group disability
policy, a self-insured employee welfare benefit plan, or a hospital
service contract. For purposes of this paragraph, benefits paid or
services provided by a self-insured employee welfare benefit plan
shall be determined notwithstanding the official medical fee schedule
adopted pursuant to Section 5307.1.
(3) (A) When the referee issues an award finding that an injury or
illness arises out of and in the course of employment and makes an
award for temporary disability indemnity, the appeals board shall
allow a lien as living expense under Section 4903, for benefits paid
by a group disability policy providing loss-of-time benefits and for
loss-of-time benefits paid by a self-insured employee welfare benefit
plan. Such lien shall be allowed to the extent that benefits have
been paid for the same day or days for which temporary disability
indemnity is awarded and shall not exceed the award for temporary
disability indemnity. No lien shall be allowed hereunder unless the
group disability policy or self-insured employee welfare benefit plan
provides for reduction, exclusion, or coordination of loss-of-time
benefits on account of workers' compensation benefits.
(B) For purposes of this paragraph, "self-insured employee welfare
benefit plan" means any plan, fund, or program that is established
or maintained by an employer or by an employee organization, or by
both, to the extent that the plan, fund, or program was established
or is maintained for the purpose of providing for its participants or
their beneficiaries, other than through the purchase of insurance,
either of the following:
(i) Medical, surgical, or hospital care or benefits.
(ii) Monetary or other benefits in the event of sickness,
accident, disability, death, or unemployment.
(4) When the parties propose that the case be disposed of by way
of a compromise and release agreement, in the event the lien
claimant, other than a health care provider, does not agree to the
amount allocated to it, then the referee shall determine the
potential recovery and reduce the amount of the lien in the ratio of
the applicant's recovery to the potential recovery in full
satisfaction of its lien claim.
(b) When a compromise of claim or an award is submitted to the
appeals board, arbitrator, or settlement conference referee for
approval, the parties shall file with the appeals board, arbitrator,
or settlement conference referee any liens served on the parties.
(c) Any lien claimant under Section 4903 or this section shall
file its lien with the appeals board in writing upon a form approved
by the appeals board. The lien shall be accompanied by a full
statement or itemized voucher supporting the lien and justifying the
right to reimbursement and proof of service upon the injured worker,
or if deceased, upon the worker's dependents, the employer, the
insurer, and the respective attorneys or other agents of record.
(d) The appeals board shall file liens required by subdivision (c)
immediately upon receipt. Numbers shall be assigned pursuant to
subdivision (c) of Section 5500.
(e) The changes made to this section by Senate Bill 457 of the
2011-12 Regular Session do not modify in any way the rights or
obligations of the following:
(1) Any health care provider to file and prosecute a lien pursuant
to subdivision (b) of Section 4903.
(2) A payor to conduct utilization review pursuant to Section
4610.
(3) Any party in complying with the requirements under Section
4903.
SEC. 1.5. Section 4903.1 of the Labor Code is
amended to read:
4903.1. The appeals board, arbitrator, or settlement conference
referee, before issuing an award or approval of any compromise of
claim, shall determine, on the basis of liens filed with it pursuant
to Section 4903.05, whether any benefits have been paid or services
provided by a health care provider, a health care service plan, a
group disability policy, including a loss-of-income policy, a
self-insured employee welfare benefit plan, or a hospital service
contract, and its award or approval shall provide for reimbursement
for benefits paid or services provided under these plans as follows:
(a) When the referee issues an award finding that an injury or
illness arises out of and in the course of employment, but denies the
applicant reimbursement for self-procured medical costs solely
because of lack of notice to the applicant's employer of his or her
need for hospital, surgical, or medical care, the appeals board shall
nevertheless award a lien against the employee's recovery, to the
extent of benefits paid or services provided, for the effects of the
industrial injury or illness, by a health care provider, a health
care service plan, a group disability policy, a self-insured employee
welfare benefit plan, or a hospital service contract.
(b) When the referee issues an award finding that an injury or
illness arises out of and in the course of employment, and makes an
award for reimbursement for self-procured medical costs, the appeals
board shall allow a lien, to the extent of benefits paid or services
provided, for the effects of the industrial injury or illness, by a
health care provider, a health care service plan, a group disability
policy, a self-insured employee welfare benefit plan, or a hospital
service contract.
(c) (1) When the referee issues an award finding that an injury or
illness arises out of and in the course of employment and makes an
award for temporary disability indemnity, the appeals board shall
allow a lien as living expense under Section 4903, for benefits paid
by a group disability policy providing loss-of-time benefits and for
benefits paid by a self-insured employee welfare benefit plan. The
lien shall be allowed to the extent that benefits have been paid for
the same day or days for which temporary disability indemnity is
awarded and shall not exceed the award for temporary disability
indemnity. A lien shall not be allowed hereunder unless the group
disability policy or self-insured employee welfare benefit plan
provides for reduction, exclusion, or coordination of loss-of-time
benefits on account of workers' compensation benefits.
(2) For purposes of this subdivision, "self-insured employee
welfare benefit plan" means any plan, fund, or program that is
established or maintained by an employer or by an employee
organization, or by both, to the extent that the plan, fund, or
program was established or is maintained for the purpose of providing
for its participants or their beneficiaries, other than through the
purchase of insurance, either of the following:
(A) Medical, surgical, or hospital care benefits.
(B) Monetary or other benefits in the event of sickness, accident,
disability, death, or unemployment.
(d) When the parties propose that the case be disposed of by way
of a compromise and release agreement, in the event the lien
claimant, other than a health care provider, does not agree to the
amount allocated to it, then the referee shall determine the
potential recovery and reduce the amount of the lien in the ratio of
the applicant's recovery to the potential recovery in full
satisfaction of its lien claim.
SEC. 1.5. Section 4903.1 of the Labor
Code is amended to read:
4903.1. (a) The appeals board , or
arbitrator, or settlement conference referee,
before issuing an award or approval of any compromise of claim, shall
determine, on the basis of liens filed with it pursuant to
subdivision (b) or (c) Section 4903.05 , whether
any benefits have been paid or services provided by a health care
provider, a health care service plan, a group disability policy,
including a loss of income loss-of-income
policy , or a self-insured
employee welfare benefit plan, or a hospital service
contract, and its award or approval shall provide for
reimbursement for benefits paid or services provided under these
plans as follows:
(1) When the referee If the appeals board
issues an award finding that an injury or illness arises out of
and in the course of employment, but denies the applicant
reimbursement for self-procured medical costs solely because of lack
of notice to the applicant's employer of his or her need
for hospital, surgical, or medical care, the appeals board shall
nevertheless award a lien against the employee's recovery, to the
extent of benefits paid or services provided, for the effects of the
industrial injury or illness, by a health care provider, a health
care service plan, a group disability policy ,
or a self-insured employee welfare benefit plan, or a
hospital service contract subject to the provisions
described in subdivision (b) .
(2) When the referee If the appeals board
issues an award finding that an injury or illness arises out of
and in the course of employment, and makes an award for
reimbursement for self-procured medical costs, the appeals board
shall allow a lien, to the extent of benefits paid or services
provided, for the effects of the industrial injury or illness, by a
health care provider, a health care service plan, a group disability
policy , or a self-insured employee
welfare benefit plan, or a hospital service contract
subject to the provisions of subdivision (b) .
For purposes of this paragraph, benefits paid or services provided by
a self-insured employee welfare benefit plan shall be determined
notwithstanding the official medical fee schedule adopted pursuant to
Section 5307.1.
(3) When the referee
(3) (A) If the
appeals board issues an award finding that an injury or illness
arises out of and in the course of employment and makes an award for
temporary disability indemnity, the appeals board shall allow a lien
as living expense under Section 4903, for benefits paid by a group
disability policy providing loss of time benefits. Such
loss-of-time benefits and for loss-of-time benefits
paid by a self-insured employee welfare benefit plan. The lien
shall be allowed to the extent that benefits have been paid for the
same day or days for which temporary disability indemnity is awarded
and shall not exceed the award for temporary disability indemnity.
No lien shall A lien shall not be
allowed hereunder unless the group disability policy or
self-insured employee welfare benefit plan provides for
reduction, exclusion, or coordination of loss of time
loss-of-time benefits on account of workers'
compensation benefits.
(B) For purposes of this paragraph, "self-insured employee welfare
benefit plan" means any plan, fund, or program that is established
or maintained by an employer or by an employee organization, or by
both, to the extent that the plan, fund, or program was established
or is maintained for the purpose of providing for its participants or
their beneficiaries, other than through the purchase of insurance,
either of the following:
(i) Medical, surgical, or hospital care or benefits.
(ii) Monetary or other benefits in the event of sickness,
accident, disability, death, or unemployment.
(4) When If the parties propose that
the case be disposed of by way of a compromise and release
agreement, in the event the lien claimant, other than a health care
provider, does not agree to the amount allocated to it, then the
referee appeals board shall determine
the potential recovery and reduce the amount of the lien in the ratio
of the applicant's recovery to the potential recovery in full
satisfaction of its lien claim.
(b) When a compromise of claim or an award is submitted to the
appeals board, arbitrator, or settlement conference referee for
approval, the parties shall file with the appeals board, arbitrator,
or settlement conference referee any liens served on the parties.
(c) Any lien claimant under Section 4903 or this section shall
file its lien with the appeals board in writing upon a form approved
by the appeals board. The lien shall be accompanied by a full
statement or itemized voucher supporting the lien and justifying the
right to reimbursement and proof of service upon the injured worker,
or if deceased, upon the worker's dependents, the employer, the
insurer, and the respective attorneys or other agents of record.
(d) The appeals board shall file liens required by subdivision (c)
immediately upon receipt. Numbers shall be assigned pursuant to
subdivision (c) of Section 5500.
(b) Notwithstanding subdivision (a), payment or reimbursement
shall not be allowed, whether payable by the employer or payable as a
lien against the employee's recovery, for any expense incurred as
provided by Article 2 (commencing with Section 4600) of Chapter 2 of
Part 2, nor shall the employee have any liability for the expense, if
at the time the expense was incurred the provider either knew or in
the exercise of reasonable diligence should have known that the
condition being treated was caused by the employee's present or prior
employment, unless at the time the expense was incurred at least one
of the following conditions was met:
(1) The expense was incurred for services authorized by the
employer.
(2) The expense was incurred for services furnished while the
employer failed or refused to furnish treatment as required by
subdivision (c) of Section 5402.
(3) The expense was necessarily incurred for an emergency medical
condition, as defined by subdivision (b) of Section 1317.1 of the
Health and Safety Code.
(e)
(c) The changes made to this section by Senate Bill 457
of the 2011-12 Regular Session do not modify in any way the rights
or obligations of the following:
(1) Any health care provider to file and prosecute a lien pursuant
to subdivision (b) of Section 4903.
(2) A payor payer to conduct
utilization review pursuant to Section 4610.
(3) Any party in complying with the requirements under Section
4903.
SEC. 2. Section 1.5 of this bill incorporates all of the
substantive amendments to Section 4903.1 of the Labor Code proposed
by both this bill and Senate Bill 863. It shall only become operative
if (1) both bills are enacted and become effective on or before
January 1, 2013, (2) each bill amends Section 4903.1 of the Labor
Code, and (3) this bill is enacted after Senate Bill 863, in which
case Section 1 of this bill shall not become operative.