How Medical Care Is Authorized Under Workers Compensation Insurance

The medical treatment that is provided to injured employees within the California workers compensation system is often much different and of lesser quality than what is provided by general health plans administered by companies such as Anthem Blue Cross & Blue Shield. For starters, industrial care is generally limited to the injured body parts that the insurance company decides to accept as work related. Treatment to other body parts and conditions that are in dispute, even if believed by the injured employee to be job related, will not be paid for by the carrier unless a lawyer gets those parts or conditions admitted through the legal process.This means that in workers’ compensation, most doctors will only treat the body part/health condition that the insurance carrier accepts/admits. Because the carrier is only liable to pay for what it finds to be related to the job, other conditions and parts that need medical attention will be neglected by the primary treating physician. In addition to a lack of holistic medical care, the insurance company has the further ability to reject requests for authorization through the use of a review process known as Utilization Review (or UR for short) for treatments to body parts and conditions that they have chosen to admit as work related. While UR is also used within private health plans, UR is heavily and pervasively implemented in workers compensation plans to block requests for treatments for accepted industrial health conditions. Many believe UR is highly abused by workers comp. companies to deny needed and timely treatment to legitimately hurt workers. Generally, this is probably a true belief. And, when combined with the ability of the adjuster to completely deny body parts and/or conditions at will, the care available is often significantly different and of lesser value than on general health plans.

Medical Care For Denied Body Parts And Health Conditions

Denied Medical Treatment

Denied Medical Treatment

When the insurance company goes ahead and flat out denies liability for a body part or health condition, it means that that no treatment for the denied parts/conditions will be authorized or paid for absent the decision being overturned through the legal process. Payment will be denied to the treating physician and other specialists that should be enlisted to provide treatment. In order to combat injustice, lawyers enlist doctors willing to provide services to denied conditions on a lien basis. This means that the doctor is not taking payment upfront and is instead expecting to collect later when the California workers compensation lawyer wins the court case or settles for an amount that will allow the care provider to collect a portion of their bills. As the laws have been reformed, however, it has become increasingly more difficult for those doctors treating on liens to assert liens and get paid, and when they do get paid, it is often very little. This has led to a mass exodus of legitimate doctors treating on liens within the California work injury scheme. As a consequence, the level of care provided to injured workers not receiving proper treatment from the insurance company to fall further into mediocrity. Oftentimes, an attorney will place a client with a particular physician not because of the standard of care being high, but instead because there is no other choice to obtain the appropriate legal reporting to get the worker benefits under the policy through the legal process, or through State Disability (or SDI). Sadly, this is the truth about California workers’ comp., and its turning worse each new reform. Many applicants, therefore, choose to close their case early for cash to seek treatment outside of the system for on the job accident injury cases in order to heal, get healthy, and get back to the job.

Why Won’t My Doctor Address And Treat All Of My Complaints?

The answer is simple. The insurance adjuster will get upset and/or will refuse to pay the doctor to treat those body parts. If the denied (or not accepted) body parts are addressed by the physician and the doctor decides that they are related to the job accident, the doctor should be putting that in an initial med-legal report and treating those parts as well. Unfortunately, many doctors will refuse to even address and/or write down complaints that are secondary to or outgrowths of the initial work injury. Failing to address all of the injured workers complaints is cause to leave the MPN (Medical Provider Network) and/or switch doctors. If you are not getting the treatment you think you deserve, it is time to look for a California workers compensation attorney in your area to take up your cause and fight for your benefits at the WCAB (administrative law court set up to adjudicate disputes within workman’s comp.). You might need legal advice if:

  • Your case is completely denied and you cannot get proper attention
  • The doctor will not treat denied body parts and/or conditions you believe are related to your accident
  • The physician refuses to address and/or write down all of your complaints
  • The adjuster is refusing to authorize medical care in a timely manner
  • You are not being paid temporary disability benefits even though you are unable to do your job
  • You are being discriminated against for filing a workers compensation claim
  • The adjuster is telling you that you do not have a right to change your doctor
  • You do not want to deal with the adjuster anymore because they are difficult
  • You are interested in maximizing your recovery as part of a lump-sum cash settlement

Contact A California Workers Compensation Lawyer For Advice Immediately

All of the above-stated scenarios happen and they are all cause for concern. There are many other scenarios that warrant getting on the phone with a local attorney to discuss. If you feel you are being treated inappropriately in reference to your injury claim or workers compensation case, call our law office and you will speak to Mr. Napolin, Esq. about your possible workers’ compensation legal matter. He will be able to give you legal advice and advise you on what he believes he could do to forward your interests in a court of law. All consultations are free and are without obligation to hire us for representation. Remember that there are time limits in the law to exercise your legal rights. Do not hesitate. Call today at 909-325-6032. We serve the local communities of Upland, Pomona, Chino, Claremont, La Verne, San Dimas, Glendora, Azusa and West Covina CA.

For more general information on California workers compensation law visit our website at calinjurylawyer.com.

Republished by Blog Post Promoter