“Medical treatment” is statutorily defined as care to cure or relieve the effects of the industrial injury. The California Labor Code Sec. 4600 et. seq. defines medical care and the scope of treatment covered.
The law states that the employer/carrier must pay all “reasonable and necessary” cost of medical care related to the industrial injury (ASSUMING THE CARRIER HAS ACCEPTED YOUR CLAIM). This means that even if a certain part of the body was not industrially injured but if it is reasonable and necessary to treat the industrially injured body part by treating the non-industrially injured body part, then the employer/carrier must pay for it as well. It is illegal for a doctor or a medical facility to charge an injured worker for the cost of treatment if they know that the injury was work-related. See Cal. Lab. Code Sec. 3751(b).
Mr. Lonely Long is an overweight man and works as a janitor. One night he slipped and fell on the wet floor while working the night shift and hurt his lower back (lumbar spine). The carrier has “accepted” his claim. As a result of the lower back injury, the primary treating surgeon said that he needs a lumbar fusion (to close the two discs in his back at the L4-L5 levels), but because he is overweight (a condition not caused by work), the surgeon first wanted him to undergo a weight loss program before the surgery. Under these circumstances, the carrier must pay for both the weight loss program and the surgery even though the obese condition was not related to work, because the weight loss was a form of reasonable treatment which is a necessary precondition to having industrial back surgery.
A law requiring the workers’ compensation insurance carrier to create a “medical provider network” (or MPN) was passed in 2005. See Cal. Lab. Code Sec. 4616 et. seq. The purpose of the law was to create a network of doctors with sufficient specialties in the MPN so that when the worker is injured, he or she can simply go online to the carrier’s website and find an MPN doctor in the particular field quickly so that the worker can be swiftly treated. However, due to the ever growing complexities of workers’ compensation laws, navigating the MPN has made things difficult because not all doctors inside the MPN are going to favor the worker and also not knowing which specialty or which doctor to choose from has made it hard for the worker. To make matters worse, if the carrier rejects liability of the claim (i.e, has issued a letter of “denial of claim”), it will not give any treatment inside of the MPN and thus asking the carrier for help will be futile and a total waste of time.
Often the carrier will deny the workers’ compensation claim in whole or in part.
A “partial denial” of claim means that the carrier has agreed that certain body
parts were injured on the job while others were not injured on the job. For
example, if the carrier says that you have injured your back and rejects liability
for the neck, then it will only pay for care related to the back and not the neck.
This means that the carrier will only allow the MPN doctor to give you care for
the back and not the neck. It sounds ridiculous but it can happen!!!!!
A “whole denial” of the claim means that according to the carrier all body parts
were not injured on the job. If the carrier said that we reject liability for the
entire claim, then it means that all body parts are rejected and that it will pay
no benefits including medical care. So, don’t waste time by trying to ask for or
look for a doctor inside of the MPN for treatment as the carrier will not grant it.
FORTUNATELY, help is only a phone call away!!!! If your claim has been denied in whole or in part, call the Fong brothers and we can help you by finding a doctor outside of the “medical provider network” at no cost to you as we have doctors in our system who will accept your case on a “lien” which means that the doctors will not charge you and will seek payment from the carrier once your case settles.
Even if your case is fully accepted, we can still help you find a doctor inside of the MPN who will help you!!!!! So, DON’T WAIT, because not seeking or waiting too long for medical care is gambling with your own health.
“Utilization Review” (or UR) is a process used to determine the usefulness of the medical care being recommended by the treating physician. Cal. Labor Code Sec. 4610 et. seq. governs the “utilization review” process. The law recognizes that sometimes patients receive unnecessary medical care. So, the purpose of the UR process is to enable the patient(s) to receive all the “reasonable and necessary medical care” under the law. In general, whenever the physician makes a recommendation for a certain type of medical care, the insurance carrier can have its doctor review the request to determine if the recommended care is useful or not to the injured worker. If the carrier’s “utilization review” department agrees that it is useful, then the recommendation is approved and the worker receives the care. If the department does not agree, then the recommendation is denied and the worker does not receive this type of medical care. This process is called “utilization review.”
What is “independent medical review”? The law recognizes that at times the insurance company through its UR department may unreasonably deny the requested medical care from the treating doctor. So, the remedy to the injured worker is to file an appeal to the “Independent Medical Review Board”. This process is called “independent medical review” or IMR. The time deadline to file IMR is 30 days from the time the UR denies or modifies the doctor’s recommendations.
SOUNDS COMPLICATED AND CONFUSING? Absolutely! We do NOT recommend that you go through this process alone. Given the ever increasing complexity of the law, you should not handle this by yourself. Help is only a phone call away!!! FREE CONSULTATION! NO OBLIGATION FREE PHONE CALL! Call the Fong brothers as we both Board Certified Specialists in workers’ compensation laws and we can help by answering your question(s) for free.