- Digital Twin Virtual Knee Replica Used to Test Surgical Approacheson May 28, 2026 at 1:23 PM
Hospital for Special Surgery (HSS) in New York City — ranked the number one orthopedic hospital in the United States for 16 consecutive years by U.S. News & World Report — is deploying a technology that could fundamentally change how orthopedic surgical decisions are made, documented, and disputed in workers' compensation cases. The tool is called a "digital twin," and it is moving from the research lab into everyday clinical practice.
A digital twin is a virtual replica of a patient's own anatomy, built from advanced 3D MRI imaging and powered by physics-based computational modeling. In orthopedics, this means a surgeon can create a detailed, patient-specific computer model of an injured knee — including bones, cartilage surfaces, ligaments, and the mechanical relationships between them — and then run simulations on that model before operating.
The surgeon can test different surgical approaches on the virtual knee: tighten or loosen virtual ligaments, reposition virtual implant components, simulate how the joint will behave under load after various types of repair — all without touching the actual patient. The goal, as HSS Digital Twin Program Director Dr. Andrew Pearle has described it, is to move orthopedics beyond one-size-fits-all surgical planning toward truly individualized treatment based on each patient's unique anatomy and biomechanics.
HSS received a $10 million gift in November 2025 from Lauren and Robert Steers to develop the HSS Digital Twin Platform into a four-year clinical program. The institution's stated goal is that within four years, every patient who comes to HSS with a relevant clinical problem will receive a digital twin of their knee. The multidisciplinary team includes orthopedic surgeons, radiologists, biomechanical engineers, and artificial intelligence specialists.
The platform is already being applied to clinical cases. One of the initial applications has been evaluating patients who need ACL revision surgery — a repeat procedure after a prior ACL repair has failed. In these complex cases, surgeons must determine whether the patient would also benefit from a slope-reducing tibial osteotomy, a procedure that reshapes the angle of the shinbone to reduce the mechanical forces that contributed to the original graft failure.
Traditionally, this determination has relied on the surgeon's clinical judgment, standard imaging, and experience. With the digital twin, the surgical team can simulate both options — revision alone versus revision plus osteotomy — on the patient's own virtual anatomy and compare the predicted biomechanical outcomes before making a recommendation.
The platform also integrates additional data beyond imaging: patient gender, activity level, the type of physical demands the patient faces (including occupational demands), and neuromuscular control information. As HSS researchers have described it, the more data fed into the twin, the more precise and personalized the insights become.
HSS is not working alone. The institution is collaborating with other medical centers and organizations to scale the platform, and the underlying technologies — computational modeling, physics-based simulation, AI-enhanced imaging analysis — are advancing rapidly across the orthopedic field. Medscape reported in April 2026 that the platform represents a new frontier in precision orthopedic care that may extend beyond surgical planning into injury prevention.
The trajectory is clear: orthopedic surgery is moving from population-based decision-making toward individualized, simulation-driven planning. For workers' comp, that means the medical evidence supporting — or challenging — surgical recommendations in injury claims is about to become significantly more sophisticated. Adjusters, attorneys, utilization review teams, and medical evaluators who understand what a digital twin is, what data it produces, and what its limitations are will be better positioned to handle the claims that follow.
- Four Drivers Arraigned in Alleged Staged Crash Schemeon May 28, 2026 at 1:23 PM
Four Southern California drivers were arraigned in an alleged staged collision scheme that endangered an innocent driver and is tied to coordinated insurance fraud. The defendants include: Jhoiner Rodriguez Celis, 31, of Anaheim, Melissa Cervantes De La Torre, 30, of Upland, Nailer Mendez Diaz, 35, of Anaheim, and Plata Sampayo, 28, of Upland.
The arraignment follows an investigation by the Inland Empire Automobile Insurance Fraud Task Force, which includes the California Department of Insurance, California Highway Patrol, the San Bernardino County District Attorney’s Office, and the Riverside County District Attorney’s Office.
The investigation, “All You Can Claim,” began after the Upland Police Department contacted the task force after they suspected multiple crashes of being staged for insurance payouts. Detectives determined the defendants were friends and found that on June 8, 2025, they staged a collision in Upland by intentionally crashing into one another. Further investigation revealed, on April 21, 2025, Plata Sampayo and Cervantes De La Torre caused a separate collision in Montclair where they targeted an innocent driver who was not connected to the scheme.
Detectives reviewed body-worn camera footage from the Upland Police Department related to the June 8 collision, which shows officers arriving at the scene after the crash where Plata Sampayo and Cervantes De La Torre were in a vehicle that struck another vehicle occupied by Rodriguez Celis and Mendez Diaz. Detectives determined all four sought medical attention after the crash in an attempt to legitimize their alleged injuries and increase insurance payouts. The estimated loss in this case was $36,000.
The task force, Department of Insurance detectives, Upland Police Department SWAT team, and Riverside County District Attorney’s Office Bureau of Investigation executed search warrants at four locations and arrested the defendants on March 19, 2026. Plata Sampayo also had an outstanding warrant for robbery out of Los Angeles County. All were booked at the West Valley Detention Center.
On May 26, 2026, the San Bernardino County District Attorney’s Office filed felony insurance fraud charges against all four defendants. Cervantes De La Torre and Plata Sampayo were additionally charged with assault with a deadly weapon in connection with the April 21 collision involving the innocent driver.
The Department believes there may be additional victims connected to this group. Anyone who believes they may have been involved in a collision with any of the defendants, or who suspects a staged collision, is urged to contact the California Department of Insurance at 909-919-2200. What may appear to be a routine accident could be part of a coordinated fraud scheme targeting innocent drivers.
- Supreme Court Sets Oral Argument in WCAB Grant for Study Controversyon May 27, 2026 at 10:51 AM
The California Supreme Court has scheduled oral argument in the case of Joseph Mayor v. Workers’ Compensation Appeals Board et.al., S287261 for June 2nd, 2026 at 1:30 pm.
In a triad of published decisions by three separate Court of Appeal panels, namely, Earley v. Workers’ Comp. Appeals Bd., et al., 94 Cal. App. 5th 1 (2023) (“Earley”), Zurich American Ins. Co. v. Workers’ Comp. Appeals Bd., et al., 97 Cal. App. 5th 1213 (2023)(“Zurich”), and most recently in Mayor v. Workers’ Comp. Appeals Bd., et al., 104 Cal. App. 5th 1297 (2024) (“Mayor”), the Workers’ Compensation Appeals Board’s “grant for study” orders pursuant to the former version of Labor Code section 5909 (Section 5909) have been found to be unlawful.
The Mayor court found that the Appeals Board exceeded its jurisdiction when it issued the order granting reconsideration beyond 60 days from the date the petition was filed with the DWC. (Mayor, supra, 104 Cal.App.5th at p. 725.) The court granted a writ of mandate and ordered that the Appeals Board rescind its order granting reconsideration and its January and February decisions. (Id. at p. 731.)
This appears to be a systemic problem with the WCAB. The Amicus Curiae Brief of American Property Casualty Insurance Association stated "[o]ne appellate court noted that, as of November 2021, there were over 500 pending cases in which the WCAB had invoked “Shipley tolling” and issued a boilerplate “further study” order. The practice since then has continued unabated, often ending in simple affirmances in unremarkable cases."
The parties sought review of the Courts of Appeal decisions, and the Supreme Court granted review in Mayor. The Supreme Court is asked to answer the question presented by the essential issue "[m]ay the Appeals Board apply equitable tolling to act upon a petition for reconsideration beyond the 60-day period provided in Labor Code section 5909, when, through no fault of the parties, the Appeals Board did not receive the petition for reconsideration until after the 60-day period has elapsed?" Review was granted on December 11, 2024.
After the Petition for Review was granted, the parties filed briefs with the Supreme Court, presenting their view of the facts and law on the issues presented as follows.
- - Respondent, Workers’ Compensation Appeals Board, Petition for Review Filed on October 7, 2024
- - Petitioner’s Answer to Petition for Review Filed on October 25, 2024
- - Respondent, Workers’ Compensation Appeals Board, Reply to Answer to Petition for Review Filed on November 4, 2024
- - Respondent, Workers’ Compensation Appeals Board, Opening Brief on the Merits Filed on February 10, 2025
- - Petitioner’s Answer Brief on the Merits Filed on March 10, 2025
- - Petitioner’s Notice of Errata Filed on March 11, 2025
- - Respondent, Workers’ Compensation Appeals Board, Reply Brief on the Merits Filed on April 1, 2025
- - Amicus Curiae Brief of American Property Casualty Insurance Association Filed on June 2, 2025
- - Amicus Curiae Brief of Mashallah Ishal Filed on June 3, 2025
- - Respondent, Workers’ Compensation Appeals Board, Response to Amicus Curiae Brief Filed on July 1, 2025
- - Respondent, Workers’ Compensation Appeals Board, Response to Amicus Curiae Brief Filed on July 3, 2025
- - Petitioner’s Supplemental Brief Filed on March 13, 2026
Subsequently, in City of Salinas v. Workers’ Compensation Appeals Board (Miraco) (2025) 113 Cal.App.5th 801 (S293212): Review was granted on November 19, 2025, but briefing has been deferred pending a decision in the lead case of Mayor v. Workers’ Compensation Appeals Board (S287261). No oral arguments are scheduled, and no decision has been issued in Miraco.
In the lead case, Joseph Mayor argues that Labor Code §5909 is mandatory and jurisdictional, and the appeals Board does not have fundamental jurisdiction to consider a petition for reconsideration after the expiration of the 60-day limit set forth in the statute.
The WCAB responds by saying "[f]or 30 years, the courts of this state followed the Fourth District’s decision in Shipley v. Workers’ Comp. Appeals Bd. (1992) 7 Cal.App.4th 1104, 1107 (“Shipley”), holding that because section 5909 is premised upon the Appeals Board having possession of a petition for reconsideration, equitable tolling may apply to extend the 60-day deadline to act in cases where the Appeals Board does not have the petition." It urges the Supreme Court to follow the rationale in Shipley.
The American Property Casualty Insurance Association (APCIA) said it is the primary national trade association for home, auto, and business insurers, with a legacy dating back 150 years. APCIA’s members represent 65 percent of the United States property-casualty insurance market and write more than $65 billion in premiums in the State of California annually, including over 71 percent of the workers’ compensation insurance market.
APCIA said it "is interested in this case because the Workers’ Compensation Appeals Board’s months-long delay in ruling on the petition for reconsideration here is part of a widespread and damaging practice."
- 3 SoCal Residents Convicted for $2B International Prescription Fraudon May 27, 2026 at 10:51 AM
Anthony Santamaria of of North Hollywood was sentenced to 120 months’ imprisonment for his participation in an approximately $2 billion international health care fraud conspiracy. Santamaria is the third member of a Moscow-based criminal organization sentenced this month in connection with the scheme.
Co-defendants Hershel Tsikman of Studio City and Hafizullah Ebady of Parsippany, New Jersey were sentenced earlier this month to 120 months’ and 97 months’ imprisonment, respectively. In addition to the terms of imprisonment, the federal judge ordered Santamaria to forfeit $3.2 million and Ebady to forfeit more than $1.8 million. Additionally, all three defendants were ordered to pay restitution to their victims in an amount to be determined at a later date.
A fourth defendant, Dela Saidazim of Moscow, Russia, was sentenced to time served in December 2022. Three additional co-defendants, David Bishoff and Brycen Millett both from Saint George, Utah and Joshua Alegria of Woodland Hills, California are awaiting sentencing. An eighth co-defendant and the leader of the criminal organization, Brian Sutton of Moscow, Russia, a U.S. citizen who is believed to be residing abroad, remains at large.
According to court filings and proceedings, between 2017 and 2022, the defendants engaged in an international scheme to fraudulently bill private health care benefit programs. They executed their scheme by having call centers they controlled, initially in Utah and later in Russia, contact beneficiaries enrolled with the Private Insurers and offer medications at no cost to the beneficiaries and without any medical exams to determine if the medications were necessary.
Regardless of whether the beneficiaries agreed to receive these medications, the defendants generated fraudulent prescriptions for the medications for these beneficiaries. The defendants also recruited doctors purportedly to review prescriptions by nurse practitioners and physician’s assistants after telemedicine visits. Contrary to what the recruited doctors were told, in most cases there were no telemedicine visits between the beneficiaries and any medical professionals. The defendants generated fraudulent prescriptions under the physicians’ names and National Provider Identifier numbers. Despite the prescriptions, many beneficiaries never received the medications.
The defendants also acquired pharmacies across the United States with pre-existing relationships with the Private Insurers and trained and managed teams of Moscow-based “billers” to input data and remotely submit electronic reimbursement requests for the fraudulent prescriptions through those pharmacies. The defendants submitted over $1.97 billion in fraudulent prescriptions according to third-party billing records. Private Insurers paid over $758 million as a result of those fraudulent submissions.
To conceal their involvement in the scheme, the defendants operated under multiple aliases, funneled hundreds of millions of dollars through pass-through shell companies and straw owners, used end-to-end encrypted communications and moved operations overseas. Specifically, the defendants purchased and operated dozens of existing brick-and-mortar pharmacies through straw owners, including in Brooklyn, Staten Island, Manhattan, Long Island, New Jersey, Pennsylvania, Texas, Michigan and Alabama. The defendants also laundered millions of dollars in fraudulent proceeds from overseas through pass-through shell companies that they used to purchase the scheme pharmacies and conceal the defendants’ involvement.
The government’s case is being handled by the Office’s Business and Securities Fraud Section. Assistant United States Attorneys John Vagelatos, Jessica K. Weigel, Jonathan P. Lax and Tara B. McGrath are in charge of the prosecution, with the assistance of Paralegal Specialist Melina Piatti-Chayan. Assistant United States Attorney Claire S. Kedeshian of the Office’s Asset Forfeiture Section is handling forfeiture matters.
On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs.
- No Duty for Employer to Accommodate Undisclosed Mental Disabilityon May 26, 2026 at 2:32 PM
Target Corporation hired Daniel Husband in October 2020 as a fulfillment expert at its Burbank store. Although Target's new-hire materials explained that the company would attempt to accommodate known physical or mental limitations, Husband did not disclose to any Target official that he had been diagnosed with bipolar I disorder. He worked without incident for approximately 20 months.
Things changed in the summer of 2022. On June 9, 2022, Husband entered the store while off duty and became visibly upset with an employee; the employee reported that Husband used profanity, though Husband denied it. He was verbally counseled and later received a written memo.
On July 7, 2022, Husband arrived for his night shift looking deflated, then suddenly became angry. He recounted hitting himself in the temple and said that his fulfillment workload was "laughing at him." He became highly emotional, pointed fingers, and yelled at a coworker. His supervisor, Daniel Abts, sent him home. Abts found the behavior "somewhat disturbing" and emailed store leadership expressing concern for Husband's "mental state."
The next evening, July 8, Husband arrived shaking, distraught, and breathing heavily. He told Abts he thought he had "killed" his stepmother by speaking a word and asked whether he had killed anyone at the store. Abts found the statements "very irrational" and "very disturbing," believed Husband "needed help," and sent him home with a recommendation that he see a doctor or psychiatric professional. Husband and his father returned to the store that night and again the next morning, July 9, insisting Husband was "fine." During the July 9 meeting with store leadership, managers reported that Husband erupted with profanity directed at Target, though Husband's father denied the outburst occurred.
Later on July 9, Target's store director, human resources lead, and district HR business partner decided to terminate Husband for violating the company's workplace violence policy. At that time, Husband had never informed Target of his bipolar disorder or requested any accommodations. On July 10 — after the termination decision had been made but before Husband was informed — he arrived barefoot at the store, entered the employee-only area, grabbed security keys, ran out, claimed to be someone else, threw the keys at an employee, and began to disrobe. On July 18, Husband submitted a medical note clearing him to return to work but disclosing no diagnosis; he was informed that day of his termination. Subsequent requests for reinstatement, including a September 2022 letter from counsel asserting disability discrimination, went unanswered.
Husband sued Target under the Fair Employment and Housing Act (FEHA) for disability discrimination, failure to provide reasonable accommodation, and failure to engage in the interactive process. Target moved for summary judgment. The trial court granted the motion, ruling that Target had no knowledge of Husband's mental disability when it decided to terminate him because there was more than one reasonable interpretation of his workplace conduct, and that Husband had never disclosed his disability or requested accommodation. The court also found that Target had a legitimate, nondiscriminatory reason for the termination — a genuine belief that Husband had made threats or engaged in violence against coworkers in violation of company policy.
The Second District Court of Appeal affirmed in the published case of Husband v. Target Corporation, -No. B342334 (May 2026).
The opinion addresses a question at the intersection of all three FEHA theories: under what circumstances will an employer be charged with knowledge of an undisclosed mental disability based solely on its own observations? The court held that, as a matter of law, two incidents of aggressive, emotional, and irrational behavior were insufficient to impute such knowledge.
For a FEHA discrimination claim, the court applied the standard from Brundage v. Hahn (1997) 57 Cal.App.4th 228, 237: when an employee has not disclosed a disability, the employer is charged with knowledge only when "the fact of disability is the only reasonable interpretation of the known facts." For failure-to-accommodate and interactive-process claims, the court applied the related standard from Pensinger v. Bowsmith, Inc. (1998) 60 Cal.App.4th 709, 724–725, and Soria v. Univision Radio Los Angeles, Inc. (2016) 5 Cal.App.5th 570, 601: an employer's duty is triggered only when observed symptoms "are so obviously manifestations of an underlying disability" that the existence of a disability "always follows" from them.
The court acknowledged that Husband's conduct was consistent with a mental disability but concluded it was not uniquely indicative of one. His behavior could also reasonably be attributed to the effects of illegal substances, a combination of medications, or sleep deprivation — a point Husband himself conceded during his deposition. Abts's subjective impression that Husband "needed help" and might benefit from seeing a psychiatric professional did not change the analysis. The standard is objective, the court emphasized, and one untrained supervisor's speculation does not establish that a mental disability was the only reasonable interpretation of the facts. Allowing a co-worker's subjective opinion to control would make employer liability turn on the vagaries of individual workplace knowledge and willingness to speculate.
The court rejected Husband's reliance on Ninth Circuit decisions equating conduct caused by a disability with the disability itself, including Gambini v. Total Renal Care, Inc. (9th Cir. 2007) 486 F.3d 1087, 1093. Adopting that framework, the court reasoned, would effectively require every front-line supervisor to have mastered the Diagnostic and Statistical Manual — an unwarranted assumption that would vastly expand FEHA liability beyond its purpose.
- DWC Posts RAND Report on Medical-Legal Processon May 26, 2026 at 2:32 PM
The Division of Workers' Compensation (DWC) announced the release of a comprehensive RAND research report evaluating the effectiveness and long-term sustainability of California’s workers’ compensation Medical-Legal process. The study, conducted by RAND and funded by the California Department of Industrial Relations (DIR), provides a data-driven assessment of the Qualified Medical Evaluator (QME) system and its critical role in resolving workers’ compensation disputes.
A 2019 State audit of the QME system produced several recommendations aimed at increasing the availability of Medical-Legal evaluators within California’s workers’ compensation system. In 2024, DWC adopted regulations intended to improve the functioning of the QME process.
This RAND study was commissioned to assess whether the current Medical-Legal process continues to fulfill its original legislative intent and remains sustainable in its current form. The research examined several key questions, including ten high level questions:
1. Is there a mismatch between the supply and demand of QMEs across specialties and geographic areas?
2. What is the best way to recruit and retain QMEs?
3. How have recent changes to the QME reimbursement structure impacted overall costs to the workers’ compensation system, and should additional changes be considered?
4. What have been the impacts of structural changes to QME selection, and should additional changes be considered?
5. How can medical record delivery to QMEs be improved?
6. How has the quality of Med-Legal reports changed since 2012, and what is the best way to ensure the quality of QME reports?
7. Are the time frames built into the QME process appropriate and being met?
8. Are remote telehealth/remote health evaluations being used appropriately, and should any changes regulating their use be considered?
9. How have litigation practices in the Med-Legal system changed since 2012?
10. What role have medical management companies (MMCs) played in the Med-Legal process?
The findings are expected to help inform future rulemaking efforts aimed at improving the Medical-Legal evaluation system. Some examples of the findings contained in the 172 page report include:
The RAND report stated "[O]ur first high-level recommendation is to increase the number of QMEs with office locations in rural areas and in underrepresented specialties."
It went on to say "we noted substantial increases in the number of follow-up reports and depositions from 2020 to 2021. A follow-up report or deposition generally means that the QME report did not address all of the Med-Legal questions in a case. This could sometimes, but not always, arise from an issue with report quality."
And on the topic of medical management companies the report stated "MMCs can be a valuable resource to the Med-Legal system, performing key administrative functions that allow QMEs to maintain multiple offices. This, in turn, allows IWs to receive QME evaluations closer to their home. Some MMCs also provide mentorship and report review, which, if done well, could contribute to improved quality of reports. MMCs also may help recruit new QMEs."
RAND has posted its report, Qualified Medical Evaluators and the Medical-Legal Process in California Workers’ Compensation, on its website.
- WCIRB Publishes it Quarterly Experience Report Q4 2025on May 21, 2026 at 2:32 PM
The Workers’ Compensation Insurance Rating Bureau of California (WCIRB) has published its latest Quarterly Experience Report, offering an updated view of statewide insurer experience valued as of December 31, 2025. The report reflects recent trends in premium, rates and system costs based on insurer-reported data.
Key findings from the report include:
- - Written premiums in calendar years 2022 through 2025 are relatively stable compared to large swings during the pandemic.
- - Average charged rates have declined steadily since 2014, reaching a historical low in 2025. The smaller decreases in the past two years suggest this trend may be leveling off.
- - The projected loss and allocated loss adjustment expense (ALAE) ratio for accident year 2025 (95%) is generally consistent with 2024 (94%).
- - The combined ratio rose 3 points in 2025 to 129%, its highest level in over 20 years. Recent increases are driven by higher claim frequency and higher loss and loss adjustment expense (LAE) costs, with relatively stable earned premium.
- - Combined ratios have exceeded 110% for the past five years. The last sustained period above 100% was prior to the Senate Bill No. 863 (SB 863) reforms.
- - Closing rates declined beginning in the second quarter of 2020 due to the pandemic and have trended lower since 2023, likely reflecting higher volumes of CT claims and increased litigation, which prolongs the claims process. The closing rate is 32.8% in 2025.
- - Since 2022, increases in indemnity claim frequency have been driven by growth in the frequency of CT claims. Excluding CT claims, recent changes have been more modest.
- - In 2025, overall frequency remains above the long- term trend due to continued elevated reporting of CT claims.
- - After increasing for eight consecutive years, projected total loss and ALAE severity is generally flat in 2025, but remains 29% above 2016.
- - ALAE severities have seen significant increases each year since 2021, with an 11% increase in 2025.
- - Following a modest increase in accident year 2024, projected indemnity severity declined slightly by 1% in accident year 2025. Indemnity severity in 2025 is 27% higher than 2016.
- - Average medical-legal costs per claim have increased sharply since 2022. This reflects both higher utilization and a continued increase in average payment per service, particularly for medical record review.
- - Recent increases are also associated with growth in CT claims, which have higher utilization of medical-legal services, as well as increased use of services involving psychological or psychiatric evaluations. Medical-legal cost increases are also more pronounced in Southern California.
The information presented reflects a compilation of individual insurer submissions of information to the WCIRB. While the individual insurer data submissions are regularly checked for consistency and comparability with other data submitted by the insurer as well as with data submitted by other insurers, the WCIRB wrote it can make no warranty with respect to the information provided by third parties.
- DWC Releases Independent Medical Review Report for 2025on May 21, 2026 at 2:32 PM
The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) have released the annual report on the Department’s Independent Medical Review (IMR) program.
IMR is the medical dispute resolution process for California’s workers’ compensation system that resolves disputes over medical treatment for injured workers. The report summarizes IMR activity in 2025, the thirteenth year since the program was implemented.
The organization that administers the program, Maximus Federal Services, Inc., received 201,037 IMR applications and issued 152,351 final determination letters, each addressing one or more medical necessity disputes. Throughout the year, the organization issued decisions an average of six to seven days after receiving all required medical records.
Highlights from the report include:
Nearly 91% of all unique IMR filings were deemed eligible for review, slightly higher than the percentage in 2024.
Pharmaceutical requests accounted for 31% of all treatment requests submitted for IMR, representing a slightly smaller share of total service requests than in previous years.
Opioids comprised 22% of all pharmaceutical requests.
Treatment request denials were overturned at an overall rate of 10.2%, down from 12.7% in 2024. Program services, behavioral and mental health services, and evaluation had the highest overturn rates.
Guidelines in the Medical Treatment Utilization Schedule continued to serve as the primary resource for determining medical necessity.
The report is posted on the DIR website: 2026 Independent Medical Review (IMR) Annual Report: Analysis of 2025 Data.
DIR’s Division of Workers’ Compensation monitors the administration of workers’ compensation claims and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers’ compensation benefits.
- Stepchild Entitled to Conclusive Presumption of Total Dependencyon May 20, 2026 at 1:11 PM
Scott Eskra was employed by AF Builders, Inc., when he was struck and killed by a falling tree on March 7, 2018. He was survived by his biological daughter, Ariana Eskra, then a minor, and his wife, Brandy Eskra. Also living in his household were Brandy's two children from a prior relationship: Jovie Fischer, who was nine years old and living with Scott and Brandy approximately 20 to 23 days per month, and Austin Evenson, who had graduated high school and joined the Marine Corps but still maintained a room at the family home.
Nearly five years after Scott's death, Ariana Eskra filed an application for death benefits. Brandy Eskra was later joined as an applicant, followed by Jovie Fischer and Austin Evenson. The case required three separate trials to resolve preliminary issues — including statute of limitations questions, evidentiary disputes over a premarital agreement, and the need for additional financial records — before the dependency determinations could be made.
At trial, the evidence established that Brandy Eskra earned approximately $14,000 per year working two to two-and-a-half days per week as a hairdresser. Coworkers at the same salon corroborated that she could not have earned $30,000 per year. Scott Eskra had paid for housing, food, utilities, and other household expenses. Jovie Fischer's biological father had been paying child support until late 2017, and a court-ordered support obligation was issued in December 2017. Austin Evenson was earning roughly $800 every two weeks in the Marine Corps but received occasional financial support from Scott, including gas money, hunting trip expenses, and a plane ticket to visit.
The WCJ issued findings on February 13, 2026, ruling that Brandy Eskra was a presumptive total dependent under Labor Code section 3501(b), which creates a conclusive presumption of total dependency for a surviving spouse who earned $30,000 or less in the twelve months before the employee's death. The WCJ found that both Jovie Fischer and Austin Evenson were partial dependents, reasoning that Jovie did not qualify for the conclusive presumption under section 3501(a) because she was not Scott Eskra's biological or adopted child, and because she had other sources of support including her biological father's child support payments.
The WCAB denied Ariana Eskra's petition for reconsideration and granted Brandy Eskra's petition in the panel decision of Eskra v. AF Builders, Inc., - ADJ17262790 (May 2026). The Board affirmed the WCJ's findings in all respects except one: it amended the decision to find that Jovie Fischer was a presumptive total dependent under Labor Code section 3501(a), not merely a partial dependent. The finding regarding Austin Evenson as a partial dependent was affirmed. Commissioner Razo dissented.
On Brandy Eskra's total dependency, the Board upheld the WCJ's finding without difficulty. The unrebutted evidence — Brandy's own testimony, corroborating testimony from two coworkers, and the 2017 tax return showing gross income of $20,695 — established that she earned well under $30,000 in the year before Scott's death. The Board rejected Ariana Eskra's challenge to the tax return's admission, noting that the WCJ had relied on both documentary evidence and consistent testimony from multiple witnesses.
On the premarital agreement, the Board affirmed its exclusion. The death benefits claim did not exist at the time the agreement was signed, the claim was not the decedent's property to dispose of, and in any event workers' compensation benefits cannot be released without a WCJ's order approving and finding adequacy of consideration — none of which occurred here.
On Jovie Fischer's dependency status, the Board broke from the WCJ. The central question was whether a non-biological, unadopted child living in the decedent's household qualifies as a "child" under section 3501(a), which creates a conclusive presumption of total dependency for a child under 18 living with a deceased employee-parent at the time of injury.
Following its own reasoning in the panel decision Franco, dec'd v. Orange County Plastering Co., Inc., 2025 Cal. Wrk. Comp. P.D. LEXIS 258 (Appeals Board Panel Decision, July 14, 2025), the Board held that the plain and ordinary meaning of "child" includes stepchildren. The Board drew support from section 3503, which lists stepchildren among those who may qualify as dependents, and from section 3202, which mandates liberal construction of workers' compensation law to extend benefits to injured workers and their dependents.
The Board also cited State Compensation Ins. Fund v. Workers' Comp. Appeals Bd. (Asher) (1993) 19 Cal.App.4th 1645, which applied similar reasoning to conclude that minor grandchildren are entitled to extended death benefits. Because Jovie was living with the decedent at the time of his fatal injury, section 3501(a) applied regardless of whether she sometimes visited her biological father or whether that father paid child support.
On Austin Evenson, the Board agreed with the WCJ that he was a partial dependent. Although Austin was a good-faith member of the household under section 3503 and received some financial support from the decedent, he was over 18 and earning his own income in the Marine Corps, so the conclusive presumption of section 3501(a) did not apply. The exact amount of his dependency was deferred.
Commissioner Razo dissented on the Jovie Fischer issue, adopting the WCJ's reasoning. He emphasized that Jovie was not living full-time with the decedent and that her biological father was paying child support, making a finding of total dependency inappropriate in his view. He would have left the WCJ's partial dependency finding in place.
- When Can Treating Physician Use Narrative Report for RFA Forms?on May 20, 2026 at 1:11 PM
The Division of Workers' Compensation (DWC) has adopted updated regulations regarding Utilization Review (UR), which became effective April 1, 2026. These regulations, designed to streamline and standardize the medical treatment authorization process, are available on the DWC website.
In light of these updates, the DWC has received several inquiries regarding whether the use of the DWC Form RFA (Request for Authorization) is mandatory for treating physicians.
Pursuant to California Code of Regulations, title 8, section 9792.6.1, a "Request for Authorization" is formally defined as a written request for a specific course of proposed medical treatment. The regulations mandate that this request be set forth on the DWC Form RFA (as found in section 9785.5) and completed by the treating physician.
The standardized use of the DWC Form RFA is a critical regulatory requirement intended to ensure clear, consistent communication between medical providers and claims administrators, thereby reducing delays in the delivery of necessary medical care.
While the DWC Form RFA is the primary standard, a narrative report may serve as a functional equivalent only under specific conditions outlined in CCR section 9792.9.1(b) and 9792.6.1(u):
- - Mutual Acceptance: The claims administrator (CA) must voluntarily agree to accept a narrative report in lieu of the formal DWC Form RFA.
- - Minimum Content Standards: To be deemed "completed," the narrative report must contain all essential data elements required by law, including:
- - Clear identification of both the employee and the requesting provider.
- - Specific identification of all recommended treatments on the first page of the narrative.
- - Substantiating documentation created no earlier than 30 days prior to the request.
- - Treating Physician’s Signature: The report must be signed by the physician (electronic signatures are permitted by agreement of the parties).
DWC reminds all stakeholders that failure to provide a "completed" request (one that lacks specificity or the required substantiating documentation) may impact the timelines for UR decisions and the overall adjudication of treatment requests.
- Digital Twin Virtual Knee Replica Used to Test Surgical Approacheson May 28, 2026 at 1:23 PM
Hospital for Special Surgery (HSS) in New York City — ranked the number one orthopedic hospital in the United States for 16 consecutive years by U.S. News & World Report — is deploying a technology that could fundamentally change how orthopedic surgical decisions are made, documented, and disputed in workers' compensation cases. The tool is called a "digital twin," and it is moving from the research lab into everyday clinical practice.
A digital twin is a virtual replica of a patient's own anatomy, built from advanced 3D MRI imaging and powered by physics-based computational modeling. In orthopedics, this means a surgeon can create a detailed, patient-specific computer model of an injured knee — including bones, cartilage surfaces, ligaments, and the mechanical relationships between them — and then run simulations on that model before operating.
The surgeon can test different surgical approaches on the virtual knee: tighten or loosen virtual ligaments, reposition virtual implant components, simulate how the joint will behave under load after various types of repair — all without touching the actual patient. The goal, as HSS Digital Twin Program Director Dr. Andrew Pearle has described it, is to move orthopedics beyond one-size-fits-all surgical planning toward truly individualized treatment based on each patient's unique anatomy and biomechanics.
HSS received a $10 million gift in November 2025 from Lauren and Robert Steers to develop the HSS Digital Twin Platform into a four-year clinical program. The institution's stated goal is that within four years, every patient who comes to HSS with a relevant clinical problem will receive a digital twin of their knee. The multidisciplinary team includes orthopedic surgeons, radiologists, biomechanical engineers, and artificial intelligence specialists.
The platform is already being applied to clinical cases. One of the initial applications has been evaluating patients who need ACL revision surgery — a repeat procedure after a prior ACL repair has failed. In these complex cases, surgeons must determine whether the patient would also benefit from a slope-reducing tibial osteotomy, a procedure that reshapes the angle of the shinbone to reduce the mechanical forces that contributed to the original graft failure.
Traditionally, this determination has relied on the surgeon's clinical judgment, standard imaging, and experience. With the digital twin, the surgical team can simulate both options — revision alone versus revision plus osteotomy — on the patient's own virtual anatomy and compare the predicted biomechanical outcomes before making a recommendation.
The platform also integrates additional data beyond imaging: patient gender, activity level, the type of physical demands the patient faces (including occupational demands), and neuromuscular control information. As HSS researchers have described it, the more data fed into the twin, the more precise and personalized the insights become.
HSS is not working alone. The institution is collaborating with other medical centers and organizations to scale the platform, and the underlying technologies — computational modeling, physics-based simulation, AI-enhanced imaging analysis — are advancing rapidly across the orthopedic field. Medscape reported in April 2026 that the platform represents a new frontier in precision orthopedic care that may extend beyond surgical planning into injury prevention.
The trajectory is clear: orthopedic surgery is moving from population-based decision-making toward individualized, simulation-driven planning. For workers' comp, that means the medical evidence supporting — or challenging — surgical recommendations in injury claims is about to become significantly more sophisticated. Adjusters, attorneys, utilization review teams, and medical evaluators who understand what a digital twin is, what data it produces, and what its limitations are will be better positioned to handle the claims that follow. - Four Drivers Arraigned in Alleged Staged Crash Schemeon May 28, 2026 at 1:23 PM
Four Southern California drivers were arraigned in an alleged staged collision scheme that endangered an innocent driver and is tied to coordinated insurance fraud. The defendants include: Jhoiner Rodriguez Celis, 31, of Anaheim, Melissa Cervantes De La Torre, 30, of Upland, Nailer Mendez Diaz, 35, of Anaheim, and Plata Sampayo, 28, of Upland.
The arraignment follows an investigation by the Inland Empire Automobile Insurance Fraud Task Force, which includes the California Department of Insurance, California Highway Patrol, the San Bernardino County District Attorney’s Office, and the Riverside County District Attorney’s Office.
The investigation, “All You Can Claim,” began after the Upland Police Department contacted the task force after they suspected multiple crashes of being staged for insurance payouts. Detectives determined the defendants were friends and found that on June 8, 2025, they staged a collision in Upland by intentionally crashing into one another. Further investigation revealed, on April 21, 2025, Plata Sampayo and Cervantes De La Torre caused a separate collision in Montclair where they targeted an innocent driver who was not connected to the scheme.
Detectives reviewed body-worn camera footage from the Upland Police Department related to the June 8 collision, which shows officers arriving at the scene after the crash where Plata Sampayo and Cervantes De La Torre were in a vehicle that struck another vehicle occupied by Rodriguez Celis and Mendez Diaz. Detectives determined all four sought medical attention after the crash in an attempt to legitimize their alleged injuries and increase insurance payouts. The estimated loss in this case was $36,000.
The task force, Department of Insurance detectives, Upland Police Department SWAT team, and Riverside County District Attorney’s Office Bureau of Investigation executed search warrants at four locations and arrested the defendants on March 19, 2026. Plata Sampayo also had an outstanding warrant for robbery out of Los Angeles County. All were booked at the West Valley Detention Center.
On May 26, 2026, the San Bernardino County District Attorney’s Office filed felony insurance fraud charges against all four defendants. Cervantes De La Torre and Plata Sampayo were additionally charged with assault with a deadly weapon in connection with the April 21 collision involving the innocent driver.
The Department believes there may be additional victims connected to this group. Anyone who believes they may have been involved in a collision with any of the defendants, or who suspects a staged collision, is urged to contact the California Department of Insurance at 909-919-2200. What may appear to be a routine accident could be part of a coordinated fraud scheme targeting innocent drivers. - Supreme Court Sets Oral Argument in WCAB Grant for Study Controversyon May 27, 2026 at 10:51 AM
The California Supreme Court has scheduled oral argument in the case of Joseph Mayor v. Workers’ Compensation Appeals Board et.al., S287261 for June 2nd, 2026 at 1:30 pm.
In a triad of published decisions by three separate Court of Appeal panels, namely, Earley v. Workers’ Comp. Appeals Bd., et al., 94 Cal. App. 5th 1 (2023) (“Earley”), Zurich American Ins. Co. v. Workers’ Comp. Appeals Bd., et al., 97 Cal. App. 5th 1213 (2023)(“Zurich”), and most recently in Mayor v. Workers’ Comp. Appeals Bd., et al., 104 Cal. App. 5th 1297 (2024) (“Mayor”), the Workers’ Compensation Appeals Board’s “grant for study” orders pursuant to the former version of Labor Code section 5909 (Section 5909) have been found to be unlawful.
The Mayor court found that the Appeals Board exceeded its jurisdiction when it issued the order granting reconsideration beyond 60 days from the date the petition was filed with the DWC. (Mayor, supra, 104 Cal.App.5th at p. 725.) The court granted a writ of mandate and ordered that the Appeals Board rescind its order granting reconsideration and its January and February decisions. (Id. at p. 731.)
This appears to be a systemic problem with the WCAB. The Amicus Curiae Brief of American Property Casualty Insurance Association stated "[o]ne appellate court noted that, as of November 2021, there were over 500 pending cases in which the WCAB had invoked “Shipley tolling” and issued a boilerplate “further study” order. The practice since then has continued unabated, often ending in simple affirmances in unremarkable cases."
The parties sought review of the Courts of Appeal decisions, and the Supreme Court granted review in Mayor. The Supreme Court is asked to answer the question presented by the essential issue "[m]ay the Appeals Board apply equitable tolling to act upon a petition for reconsideration beyond the 60-day period provided in Labor Code section 5909, when, through no fault of the parties, the Appeals Board did not receive the petition for reconsideration until after the 60-day period has elapsed?" Review was granted on December 11, 2024.
After the Petition for Review was granted, the parties filed briefs with the Supreme Court, presenting their view of the facts and law on the issues presented as follows.
- - Respondent, Workers’ Compensation Appeals Board, Petition for Review Filed on October 7, 2024
- - Petitioner’s Answer to Petition for Review Filed on October 25, 2024
- - Respondent, Workers’ Compensation Appeals Board, Reply to Answer to Petition for Review Filed on November 4, 2024
- - Respondent, Workers’ Compensation Appeals Board, Opening Brief on the Merits Filed on February 10, 2025
- - Petitioner’s Answer Brief on the Merits Filed on March 10, 2025
- - Petitioner’s Notice of Errata Filed on March 11, 2025
- - Respondent, Workers’ Compensation Appeals Board, Reply Brief on the Merits Filed on April 1, 2025
- - Amicus Curiae Brief of American Property Casualty Insurance Association Filed on June 2, 2025
- - Amicus Curiae Brief of Mashallah Ishal Filed on June 3, 2025
- - Respondent, Workers’ Compensation Appeals Board, Response to Amicus Curiae Brief Filed on July 1, 2025
- - Respondent, Workers’ Compensation Appeals Board, Response to Amicus Curiae Brief Filed on July 3, 2025
- - Petitioner’s Supplemental Brief Filed on March 13, 2026
Subsequently, in City of Salinas v. Workers’ Compensation Appeals Board (Miraco) (2025) 113 Cal.App.5th 801 (S293212): Review was granted on November 19, 2025, but briefing has been deferred pending a decision in the lead case of Mayor v. Workers’ Compensation Appeals Board (S287261). No oral arguments are scheduled, and no decision has been issued in Miraco.
In the lead case, Joseph Mayor argues that Labor Code §5909 is mandatory and jurisdictional, and the appeals Board does not have fundamental jurisdiction to consider a petition for reconsideration after the expiration of the 60-day limit set forth in the statute.
The WCAB responds by saying "[f]or 30 years, the courts of this state followed the Fourth District’s decision in Shipley v. Workers’ Comp. Appeals Bd. (1992) 7 Cal.App.4th 1104, 1107 (“Shipley”), holding that because section 5909 is premised upon the Appeals Board having possession of a petition for reconsideration, equitable tolling may apply to extend the 60-day deadline to act in cases where the Appeals Board does not have the petition." It urges the Supreme Court to follow the rationale in Shipley.
The American Property Casualty Insurance Association (APCIA) said it is the primary national trade association for home, auto, and business insurers, with a legacy dating back 150 years. APCIA’s members represent 65 percent of the United States property-casualty insurance market and write more than $65 billion in premiums in the State of California annually, including over 71 percent of the workers’ compensation insurance market.
APCIA said it "is interested in this case because the Workers’ Compensation Appeals Board’s months-long delay in ruling on the petition for reconsideration here is part of a widespread and damaging practice." - 3 SoCal Residents Convicted for $2B International Prescription Fraudon May 27, 2026 at 10:51 AM
Anthony Santamaria of of North Hollywood was sentenced to 120 months’ imprisonment for his participation in an approximately $2 billion international health care fraud conspiracy. Santamaria is the third member of a Moscow-based criminal organization sentenced this month in connection with the scheme.
Co-defendants Hershel Tsikman of Studio City and Hafizullah Ebady of Parsippany, New Jersey were sentenced earlier this month to 120 months’ and 97 months’ imprisonment, respectively. In addition to the terms of imprisonment, the federal judge ordered Santamaria to forfeit $3.2 million and Ebady to forfeit more than $1.8 million. Additionally, all three defendants were ordered to pay restitution to their victims in an amount to be determined at a later date.
A fourth defendant, Dela Saidazim of Moscow, Russia, was sentenced to time served in December 2022. Three additional co-defendants, David Bishoff and Brycen Millett both from Saint George, Utah and Joshua Alegria of Woodland Hills, California are awaiting sentencing. An eighth co-defendant and the leader of the criminal organization, Brian Sutton of Moscow, Russia, a U.S. citizen who is believed to be residing abroad, remains at large.
According to court filings and proceedings, between 2017 and 2022, the defendants engaged in an international scheme to fraudulently bill private health care benefit programs. They executed their scheme by having call centers they controlled, initially in Utah and later in Russia, contact beneficiaries enrolled with the Private Insurers and offer medications at no cost to the beneficiaries and without any medical exams to determine if the medications were necessary.
Regardless of whether the beneficiaries agreed to receive these medications, the defendants generated fraudulent prescriptions for the medications for these beneficiaries. The defendants also recruited doctors purportedly to review prescriptions by nurse practitioners and physician’s assistants after telemedicine visits. Contrary to what the recruited doctors were told, in most cases there were no telemedicine visits between the beneficiaries and any medical professionals. The defendants generated fraudulent prescriptions under the physicians’ names and National Provider Identifier numbers. Despite the prescriptions, many beneficiaries never received the medications.
The defendants also acquired pharmacies across the United States with pre-existing relationships with the Private Insurers and trained and managed teams of Moscow-based “billers” to input data and remotely submit electronic reimbursement requests for the fraudulent prescriptions through those pharmacies. The defendants submitted over $1.97 billion in fraudulent prescriptions according to third-party billing records. Private Insurers paid over $758 million as a result of those fraudulent submissions.
To conceal their involvement in the scheme, the defendants operated under multiple aliases, funneled hundreds of millions of dollars through pass-through shell companies and straw owners, used end-to-end encrypted communications and moved operations overseas. Specifically, the defendants purchased and operated dozens of existing brick-and-mortar pharmacies through straw owners, including in Brooklyn, Staten Island, Manhattan, Long Island, New Jersey, Pennsylvania, Texas, Michigan and Alabama. The defendants also laundered millions of dollars in fraudulent proceeds from overseas through pass-through shell companies that they used to purchase the scheme pharmacies and conceal the defendants’ involvement.
The government’s case is being handled by the Office’s Business and Securities Fraud Section. Assistant United States Attorneys John Vagelatos, Jessica K. Weigel, Jonathan P. Lax and Tara B. McGrath are in charge of the prosecution, with the assistance of Paralegal Specialist Melina Piatti-Chayan. Assistant United States Attorney Claire S. Kedeshian of the Office’s Asset Forfeiture Section is handling forfeiture matters.
On April 7, the Department of Justice announced the creation of the National Fraud Enforcement Division (Fraud Division). The Fraud Division is laser-focused on investigating and prosecuting those who commit fraud against the American people. The Department’s work to combat fraud supports President Trump’s Task Force to Eliminate Fraud, a whole-of-government effort chaired by Vice President J.D. Vance to eliminate fraud, waste, and abuse within Federal benefit programs. - No Duty for Employer to Accommodate Undisclosed Mental Disabilityon May 26, 2026 at 2:32 PM
Target Corporation hired Daniel Husband in October 2020 as a fulfillment expert at its Burbank store. Although Target's new-hire materials explained that the company would attempt to accommodate known physical or mental limitations, Husband did not disclose to any Target official that he had been diagnosed with bipolar I disorder. He worked without incident for approximately 20 months.
Things changed in the summer of 2022. On June 9, 2022, Husband entered the store while off duty and became visibly upset with an employee; the employee reported that Husband used profanity, though Husband denied it. He was verbally counseled and later received a written memo.
On July 7, 2022, Husband arrived for his night shift looking deflated, then suddenly became angry. He recounted hitting himself in the temple and said that his fulfillment workload was "laughing at him." He became highly emotional, pointed fingers, and yelled at a coworker. His supervisor, Daniel Abts, sent him home. Abts found the behavior "somewhat disturbing" and emailed store leadership expressing concern for Husband's "mental state."
The next evening, July 8, Husband arrived shaking, distraught, and breathing heavily. He told Abts he thought he had "killed" his stepmother by speaking a word and asked whether he had killed anyone at the store. Abts found the statements "very irrational" and "very disturbing," believed Husband "needed help," and sent him home with a recommendation that he see a doctor or psychiatric professional. Husband and his father returned to the store that night and again the next morning, July 9, insisting Husband was "fine." During the July 9 meeting with store leadership, managers reported that Husband erupted with profanity directed at Target, though Husband's father denied the outburst occurred.
Later on July 9, Target's store director, human resources lead, and district HR business partner decided to terminate Husband for violating the company's workplace violence policy. At that time, Husband had never informed Target of his bipolar disorder or requested any accommodations. On July 10 — after the termination decision had been made but before Husband was informed — he arrived barefoot at the store, entered the employee-only area, grabbed security keys, ran out, claimed to be someone else, threw the keys at an employee, and began to disrobe. On July 18, Husband submitted a medical note clearing him to return to work but disclosing no diagnosis; he was informed that day of his termination. Subsequent requests for reinstatement, including a September 2022 letter from counsel asserting disability discrimination, went unanswered.
Husband sued Target under the Fair Employment and Housing Act (FEHA) for disability discrimination, failure to provide reasonable accommodation, and failure to engage in the interactive process. Target moved for summary judgment. The trial court granted the motion, ruling that Target had no knowledge of Husband's mental disability when it decided to terminate him because there was more than one reasonable interpretation of his workplace conduct, and that Husband had never disclosed his disability or requested accommodation. The court also found that Target had a legitimate, nondiscriminatory reason for the termination — a genuine belief that Husband had made threats or engaged in violence against coworkers in violation of company policy.
The Second District Court of Appeal affirmed in the published case of Husband v. Target Corporation, -No. B342334 (May 2026).
The opinion addresses a question at the intersection of all three FEHA theories: under what circumstances will an employer be charged with knowledge of an undisclosed mental disability based solely on its own observations? The court held that, as a matter of law, two incidents of aggressive, emotional, and irrational behavior were insufficient to impute such knowledge.
For a FEHA discrimination claim, the court applied the standard from Brundage v. Hahn (1997) 57 Cal.App.4th 228, 237: when an employee has not disclosed a disability, the employer is charged with knowledge only when "the fact of disability is the only reasonable interpretation of the known facts." For failure-to-accommodate and interactive-process claims, the court applied the related standard from Pensinger v. Bowsmith, Inc. (1998) 60 Cal.App.4th 709, 724–725, and Soria v. Univision Radio Los Angeles, Inc. (2016) 5 Cal.App.5th 570, 601: an employer's duty is triggered only when observed symptoms "are so obviously manifestations of an underlying disability" that the existence of a disability "always follows" from them.
The court acknowledged that Husband's conduct was consistent with a mental disability but concluded it was not uniquely indicative of one. His behavior could also reasonably be attributed to the effects of illegal substances, a combination of medications, or sleep deprivation — a point Husband himself conceded during his deposition. Abts's subjective impression that Husband "needed help" and might benefit from seeing a psychiatric professional did not change the analysis. The standard is objective, the court emphasized, and one untrained supervisor's speculation does not establish that a mental disability was the only reasonable interpretation of the facts. Allowing a co-worker's subjective opinion to control would make employer liability turn on the vagaries of individual workplace knowledge and willingness to speculate.
The court rejected Husband's reliance on Ninth Circuit decisions equating conduct caused by a disability with the disability itself, including Gambini v. Total Renal Care, Inc. (9th Cir. 2007) 486 F.3d 1087, 1093. Adopting that framework, the court reasoned, would effectively require every front-line supervisor to have mastered the Diagnostic and Statistical Manual — an unwarranted assumption that would vastly expand FEHA liability beyond its purpose. - DWC Posts RAND Report on Medical-Legal Processon May 26, 2026 at 2:32 PM
The Division of Workers' Compensation (DWC) announced the release of a comprehensive RAND research report evaluating the effectiveness and long-term sustainability of California’s workers’ compensation Medical-Legal process. The study, conducted by RAND and funded by the California Department of Industrial Relations (DIR), provides a data-driven assessment of the Qualified Medical Evaluator (QME) system and its critical role in resolving workers’ compensation disputes.
A 2019 State audit of the QME system produced several recommendations aimed at increasing the availability of Medical-Legal evaluators within California’s workers’ compensation system. In 2024, DWC adopted regulations intended to improve the functioning of the QME process.
This RAND study was commissioned to assess whether the current Medical-Legal process continues to fulfill its original legislative intent and remains sustainable in its current form. The research examined several key questions, including ten high level questions:
1. Is there a mismatch between the supply and demand of QMEs across specialties and geographic areas?
2. What is the best way to recruit and retain QMEs?
3. How have recent changes to the QME reimbursement structure impacted overall costs to the workers’ compensation system, and should additional changes be considered?
4. What have been the impacts of structural changes to QME selection, and should additional changes be considered?
5. How can medical record delivery to QMEs be improved?
6. How has the quality of Med-Legal reports changed since 2012, and what is the best way to ensure the quality of QME reports?
7. Are the time frames built into the QME process appropriate and being met?
8. Are remote telehealth/remote health evaluations being used appropriately, and should any changes regulating their use be considered?
9. How have litigation practices in the Med-Legal system changed since 2012?
10. What role have medical management companies (MMCs) played in the Med-Legal process?
The findings are expected to help inform future rulemaking efforts aimed at improving the Medical-Legal evaluation system. Some examples of the findings contained in the 172 page report include:
The RAND report stated "[O]ur first high-level recommendation is to increase the number of QMEs with office locations in rural areas and in underrepresented specialties."
It went on to say "we noted substantial increases in the number of follow-up reports and depositions from 2020 to 2021. A follow-up report or deposition generally means that the QME report did not address all of the Med-Legal questions in a case. This could sometimes, but not always, arise from an issue with report quality."
And on the topic of medical management companies the report stated "MMCs can be a valuable resource to the Med-Legal system, performing key administrative functions that allow QMEs to maintain multiple offices. This, in turn, allows IWs to receive QME evaluations closer to their home. Some MMCs also provide mentorship and report review, which, if done well, could contribute to improved quality of reports. MMCs also may help recruit new QMEs."
RAND has posted its report, Qualified Medical Evaluators and the Medical-Legal Process in California Workers’ Compensation, on its website. - WCIRB Publishes it Quarterly Experience Report Q4 2025on May 21, 2026 at 2:32 PM
The Workers’ Compensation Insurance Rating Bureau of California (WCIRB) has published its latest Quarterly Experience Report, offering an updated view of statewide insurer experience valued as of December 31, 2025. The report reflects recent trends in premium, rates and system costs based on insurer-reported data.
Key findings from the report include:
- - Written premiums in calendar years 2022 through 2025 are relatively stable compared to large swings during the pandemic.
- - Average charged rates have declined steadily since 2014, reaching a historical low in 2025. The smaller decreases in the past two years suggest this trend may be leveling off.
- - The projected loss and allocated loss adjustment expense (ALAE) ratio for accident year 2025 (95%) is generally consistent with 2024 (94%).
- - The combined ratio rose 3 points in 2025 to 129%, its highest level in over 20 years. Recent increases are driven by higher claim frequency and higher loss and loss adjustment expense (LAE) costs, with relatively stable earned premium.
- - Combined ratios have exceeded 110% for the past five years. The last sustained period above 100% was prior to the Senate Bill No. 863 (SB 863) reforms.
- - Closing rates declined beginning in the second quarter of 2020 due to the pandemic and have trended lower since 2023, likely reflecting higher volumes of CT claims and increased litigation, which prolongs the claims process. The closing rate is 32.8% in 2025.
- - Since 2022, increases in indemnity claim frequency have been driven by growth in the frequency of CT claims. Excluding CT claims, recent changes have been more modest.
- - In 2025, overall frequency remains above the long- term trend due to continued elevated reporting of CT claims.
- - After increasing for eight consecutive years, projected total loss and ALAE severity is generally flat in 2025, but remains 29% above 2016.
- - ALAE severities have seen significant increases each year since 2021, with an 11% increase in 2025.
- - Following a modest increase in accident year 2024, projected indemnity severity declined slightly by 1% in accident year 2025. Indemnity severity in 2025 is 27% higher than 2016.
- - Average medical-legal costs per claim have increased sharply since 2022. This reflects both higher utilization and a continued increase in average payment per service, particularly for medical record review.
- - Recent increases are also associated with growth in CT claims, which have higher utilization of medical-legal services, as well as increased use of services involving psychological or psychiatric evaluations. Medical-legal cost increases are also more pronounced in Southern California.
The information presented reflects a compilation of individual insurer submissions of information to the WCIRB. While the individual insurer data submissions are regularly checked for consistency and comparability with other data submitted by the insurer as well as with data submitted by other insurers, the WCIRB wrote it can make no warranty with respect to the information provided by third parties. - DWC Releases Independent Medical Review Report for 2025on May 21, 2026 at 2:32 PM
The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) have released the annual report on the Department’s Independent Medical Review (IMR) program.
IMR is the medical dispute resolution process for California’s workers’ compensation system that resolves disputes over medical treatment for injured workers. The report summarizes IMR activity in 2025, the thirteenth year since the program was implemented.
The organization that administers the program, Maximus Federal Services, Inc., received 201,037 IMR applications and issued 152,351 final determination letters, each addressing one or more medical necessity disputes. Throughout the year, the organization issued decisions an average of six to seven days after receiving all required medical records.
Highlights from the report include:
Nearly 91% of all unique IMR filings were deemed eligible for review, slightly higher than the percentage in 2024.
Pharmaceutical requests accounted for 31% of all treatment requests submitted for IMR, representing a slightly smaller share of total service requests than in previous years.
Opioids comprised 22% of all pharmaceutical requests.
Treatment request denials were overturned at an overall rate of 10.2%, down from 12.7% in 2024. Program services, behavioral and mental health services, and evaluation had the highest overturn rates.
Guidelines in the Medical Treatment Utilization Schedule continued to serve as the primary resource for determining medical necessity.
The report is posted on the DIR website: 2026 Independent Medical Review (IMR) Annual Report: Analysis of 2025 Data.
DIR’s Division of Workers’ Compensation monitors the administration of workers’ compensation claims and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers’ compensation benefits. - Stepchild Entitled to Conclusive Presumption of Total Dependencyon May 20, 2026 at 1:11 PM
Scott Eskra was employed by AF Builders, Inc., when he was struck and killed by a falling tree on March 7, 2018. He was survived by his biological daughter, Ariana Eskra, then a minor, and his wife, Brandy Eskra. Also living in his household were Brandy's two children from a prior relationship: Jovie Fischer, who was nine years old and living with Scott and Brandy approximately 20 to 23 days per month, and Austin Evenson, who had graduated high school and joined the Marine Corps but still maintained a room at the family home.
Nearly five years after Scott's death, Ariana Eskra filed an application for death benefits. Brandy Eskra was later joined as an applicant, followed by Jovie Fischer and Austin Evenson. The case required three separate trials to resolve preliminary issues — including statute of limitations questions, evidentiary disputes over a premarital agreement, and the need for additional financial records — before the dependency determinations could be made.
At trial, the evidence established that Brandy Eskra earned approximately $14,000 per year working two to two-and-a-half days per week as a hairdresser. Coworkers at the same salon corroborated that she could not have earned $30,000 per year. Scott Eskra had paid for housing, food, utilities, and other household expenses. Jovie Fischer's biological father had been paying child support until late 2017, and a court-ordered support obligation was issued in December 2017. Austin Evenson was earning roughly $800 every two weeks in the Marine Corps but received occasional financial support from Scott, including gas money, hunting trip expenses, and a plane ticket to visit.
The WCJ issued findings on February 13, 2026, ruling that Brandy Eskra was a presumptive total dependent under Labor Code section 3501(b), which creates a conclusive presumption of total dependency for a surviving spouse who earned $30,000 or less in the twelve months before the employee's death. The WCJ found that both Jovie Fischer and Austin Evenson were partial dependents, reasoning that Jovie did not qualify for the conclusive presumption under section 3501(a) because she was not Scott Eskra's biological or adopted child, and because she had other sources of support including her biological father's child support payments.
The WCAB denied Ariana Eskra's petition for reconsideration and granted Brandy Eskra's petition in the panel decision of Eskra v. AF Builders, Inc., - ADJ17262790 (May 2026). The Board affirmed the WCJ's findings in all respects except one: it amended the decision to find that Jovie Fischer was a presumptive total dependent under Labor Code section 3501(a), not merely a partial dependent. The finding regarding Austin Evenson as a partial dependent was affirmed. Commissioner Razo dissented.
On Brandy Eskra's total dependency, the Board upheld the WCJ's finding without difficulty. The unrebutted evidence — Brandy's own testimony, corroborating testimony from two coworkers, and the 2017 tax return showing gross income of $20,695 — established that she earned well under $30,000 in the year before Scott's death. The Board rejected Ariana Eskra's challenge to the tax return's admission, noting that the WCJ had relied on both documentary evidence and consistent testimony from multiple witnesses.
On the premarital agreement, the Board affirmed its exclusion. The death benefits claim did not exist at the time the agreement was signed, the claim was not the decedent's property to dispose of, and in any event workers' compensation benefits cannot be released without a WCJ's order approving and finding adequacy of consideration — none of which occurred here.
On Jovie Fischer's dependency status, the Board broke from the WCJ. The central question was whether a non-biological, unadopted child living in the decedent's household qualifies as a "child" under section 3501(a), which creates a conclusive presumption of total dependency for a child under 18 living with a deceased employee-parent at the time of injury.
Following its own reasoning in the panel decision Franco, dec'd v. Orange County Plastering Co., Inc., 2025 Cal. Wrk. Comp. P.D. LEXIS 258 (Appeals Board Panel Decision, July 14, 2025), the Board held that the plain and ordinary meaning of "child" includes stepchildren. The Board drew support from section 3503, which lists stepchildren among those who may qualify as dependents, and from section 3202, which mandates liberal construction of workers' compensation law to extend benefits to injured workers and their dependents.
The Board also cited State Compensation Ins. Fund v. Workers' Comp. Appeals Bd. (Asher) (1993) 19 Cal.App.4th 1645, which applied similar reasoning to conclude that minor grandchildren are entitled to extended death benefits. Because Jovie was living with the decedent at the time of his fatal injury, section 3501(a) applied regardless of whether she sometimes visited her biological father or whether that father paid child support.
On Austin Evenson, the Board agreed with the WCJ that he was a partial dependent. Although Austin was a good-faith member of the household under section 3503 and received some financial support from the decedent, he was over 18 and earning his own income in the Marine Corps, so the conclusive presumption of section 3501(a) did not apply. The exact amount of his dependency was deferred.
Commissioner Razo dissented on the Jovie Fischer issue, adopting the WCJ's reasoning. He emphasized that Jovie was not living full-time with the decedent and that her biological father was paying child support, making a finding of total dependency inappropriate in his view. He would have left the WCJ's partial dependency finding in place. - When Can Treating Physician Use Narrative Report for RFA Forms?on May 20, 2026 at 1:11 PM
The Division of Workers' Compensation (DWC) has adopted updated regulations regarding Utilization Review (UR), which became effective April 1, 2026. These regulations, designed to streamline and standardize the medical treatment authorization process, are available on the DWC website.
In light of these updates, the DWC has received several inquiries regarding whether the use of the DWC Form RFA (Request for Authorization) is mandatory for treating physicians.
Pursuant to California Code of Regulations, title 8, section 9792.6.1, a "Request for Authorization" is formally defined as a written request for a specific course of proposed medical treatment. The regulations mandate that this request be set forth on the DWC Form RFA (as found in section 9785.5) and completed by the treating physician.
The standardized use of the DWC Form RFA is a critical regulatory requirement intended to ensure clear, consistent communication between medical providers and claims administrators, thereby reducing delays in the delivery of necessary medical care.
While the DWC Form RFA is the primary standard, a narrative report may serve as a functional equivalent only under specific conditions outlined in CCR section 9792.9.1(b) and 9792.6.1(u):
- - Mutual Acceptance: The claims administrator (CA) must voluntarily agree to accept a narrative report in lieu of the formal DWC Form RFA.
- - Minimum Content Standards: To be deemed "completed," the narrative report must contain all essential data elements required by law, including:
- - Clear identification of both the employee and the requesting provider.
- - Specific identification of all recommended treatments on the first page of the narrative.
- - Substantiating documentation created no earlier than 30 days prior to the request.
- - Treating Physician’s Signature: The report must be signed by the physician (electronic signatures are permitted by agreement of the parties).
DWC reminds all stakeholders that failure to provide a "completed" request (one that lacks specificity or the required substantiating documentation) may impact the timelines for UR decisions and the overall adjudication of treatment requests.