Denied Medical Treatment? - The Martin Newsletter

Volume 1, Issue 4 The Martin Newsletter February 2006

Denied Medical Treatment?

"Utilization Review" - just an excuse to deny medical treatment?

"Utilization Review" is routinely being used as a weapon by insurance adjusters to unreasonably delay and even deny an injured worker necessary medical treatment. This only serves to prolong recovery times, reduce the likelihood of a full recovery, frustrate the treating physician (a growing number of physicians won't even treat injured workers anymore), and overload the Workers Compensation Appeals Board (WCAB) with hearings.

What's Needed: Reasonable Medical Treatment

Reasonable medical treatment for a work injury is supposed to be provided by the employer and its workers’ compensation insurance company whenever a worker is injured on the job. Yet, despite the fact that both the California State Constitution and Labor Code clearly obligate insurance companies to promptly authorize reasonable medical treatment, there has been a shocking increase in insurance adjusters refusing to honor the law, and instead misusing the "Utilization Review" process.

Since Arnold Schwarzenegger's "reform" of workers’ compensation on April 19, 2004 included provisions that all but eliminated meaningful penalties for insurance company misconduct, injured workers in California have needlessly suffered (and even died) waiting for "Utilization Review" to allow critical treatment to proceed.

The Abuse of Utilization Review

Labor Code Section 4610 allows insurance adjusters to challenge any (and every) treatment recommendation by the treating physician by sending it to "Utilization Review" (UR), a process by which records are selected by the insurance adjuster, sent to a "reviewer" who is often out of state, and may not even be a physician (often nurses and chiropractors are used to "critique" a Board Certified Orthopedic surgeon!). No examination of the injured worker takes place. The "Utilization Review" company then sends a report to the insurance adjuster, which usually contains a cursory explanation of why the treatment should be denied, or reduced. The strict time limits by which the "Utilization Review" is supposed to occur are rarely observed by insurance companies and their adjusters, and even more rarely are the UR reports ever sent to the injured worker, who is left wondering why they cannot get the needed treatment or testing.

There are steps that can be taken to remedy this type of interference and abuse by the insurance company, including subpoenaing information, and setting emergency/expedited hearings at the WCAB. Once the insurance adjuster learns that the worker is not going to tolerate unreasonable interference with the treatment process, the injured worker and treating doctor can focus on getting the worker back on the road to recovery.

Let's End the Abuse!

Insurance adjusters abuse and overuse "Utilization Review" when they challenge every treatment recommendation made by the treating doctor in every case. The sooner this abuse is put to an end by the State Legislature, and signed into law, the better for injured workers and the already over-burdened workers’ compensation system.

Fighting For Injured Workers' Rights in California

Thomas F. Martin
Professional Law Corporation
2107 North Broadway, Suite 206
Santa Ana, California 92706
(714) 547-5025
www.thomasfmartinplc.com

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