4903.1
. (a) The appeals board or arbitrator, 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 or a self-insured employee welfare
benefit plan, and its award or approval shall provide for
reimbursement for benefits paid or services provided under these
plans as follows:
(1) 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, subject to the provisions described in
subdivision (b).
(2) 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, 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) (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
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. 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.
(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) 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 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) 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.
(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 payer to conduct utilization review pursuant to Section
4610.
(3) Any party in complying with the requirements under Section
4903.