There was a time when an injured worker hurt on the job in California was entitled to receive medical care; and DID! That time has since passed. With the passing on SB 863 in 2013, we are now seeing the fallout of this "solution." More medical treatments are being denied than we have ever seen.
Utilization Review (UR) is now the nemesis of all injured workers. It is easier for them to deny the treatment and let an applicant file an appeal with Independant Medical Review (IMR), than for them to waste money approving treatment. IMR has even gone as far as to brag about their 85% (ish) uphold rate of UR.
Where there were once QME or AME doctors who would see the injured employee, comment on the requested or denied medical treatment, now there are faceless/ nameless doctors in Independent Medical Review who play God with an applicant's treatment with no system to hold them accountable. They review medical records, not always all of them, and make a determination affecting the patients care without ever actually seeing the applicant. The California Appellate Court has found this is, in fact, due process, and there is very little one can do about it. Note: There appears to be a case headed to the CA Supreme Court on the issue.
The question then becomes what to do about getting medical treatment? Currently, there are several options:
Theoretically you can get treatment through Workers Comp, however the assumption of this piece is you’re not getting that treatment. Or the claim has been denied.
Second, you can seek treatment for denied care on your own or through private/ public insurance.
Third, you go without treatment or spotty treatment as some approvals do come in on a patch work basis.
But what if the treatment is denied and you don’t have private insurance? This is becoming the conundrum in work comp. Often you may have insurance through your employer, but when you went out on work comp the employer cut off your medical insurance. Currently, the options come down to fighting the system or resolving your claim so you can seek treatment on your own or through purchasing health insurance.
Often when closing your claim with a Compromise and Release, you can settle out your future medical treatment. No, it’s not paid at the highest possible expense possible. No, it’s not as much as you were hoping. However, it sometimes is the best option to resolve a possible claim. Once the claim is closed, you can seek medical treatment on your own, or through any number of types of insurance and actually get the treatment you need.
The biggest question here is how to settle your claim. (see our blog post on this issue) For more information on how to best handle your claim, please contact a Redding or Eureka Workers Compensation Attorney for a free consultation. We are happy to assist you in better understanding your options, and helping to devise the best plan for your treatment. Our job is to assist you in getting you the treatment you need and are entitled to receive.