Question

How Do I Get Treatment After A California Work Injury When Medical Requests Are Denied?

Keith Philip More

Answered by:
Keith Philip More

Located in Newport Beach, CA
Bentley & More LLP

Keith Philip More - Workers' Compensation - Super Lawyers

Answered by: Keith Philip More

Bentley & More LLP
Newport Beach, CA
Phone: 949-783-8479

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Answer

Medical request denial after a work accident can leave you feeling hopeless and desperate. When it seems obvious that workers’ compensation should apply, hearing that your medical bills will not be covered can be a shock. This is not the final answer to your situation, however. There are certain steps that you can take to fight for the approval of your claim, which could include taking the issue to court.

Reasons The Insurance Companies May Choose To Deny Your Claim

No matter what: Always file a claim after being injured at work. Even if you are unsure if the insurance company will cover damages or unsure if your case has enough evidence, having a claim on file is essential. Your human resources department may tell you that workers’ compensation coverage is through a specific insurance company that has likely set up a network of doctors to treat you. If you seek a medical diagnosis from a doctor outside of this approved network, the insurance company may deny your claim on the grounds that the provider is unauthorized.

Getting medical requests approved through workers’ compensation is notably difficult for many clients I have worked with. Insurance companies are known for denying parts or all of the medical treatment a person has requested under workers’ compensation coverage. This can leave you asking what the point of workers’ comp coverage is when you don’t seem to be getting any benefit from it.

Insurance companies can also deem the suggested treatment unnecessary. Also, and quite unfortunately, insurance companies may deny you just because they can. Often the rejected claims are not protested, and there are no consequences for refusing your request the first time — even if a judge orders them to approve the request. With no consequences and the chance to save their company money by denying this help, it can be a no-brainer for insurance companies to deny your claim.

Fighting Back For Your Claim

I once represented a person who had been crushed between heavy industrial spools of wire. The person ended up with balance problems, multiple fractures and severe brain injury. Right off the bat, the insurance company denied them physical therapy for their balance issues. After falling three times since the accident, the accident victim’s doctor reported that physical therapy was necessary to avoid further injury. However, after the insurance company’s “utilization review,” they still deemed physical therapy as unnecessary.

Hearing cases like this can make you want to go to court to face the insurance companies and just say, “Are you kidding me!?” If you have a similar story to this, the only way to get to your case to court is an “untimely review” on the insurance company’s utilization review. Untimely reviews are handled by the courts while timely reviews are handled by the insurance company’s medical review board. Getting your case in front of the courts with an experienced attorney at the helm gives you the opportunity to fight for your medical request claim away from the biased insurance companies.

Your Claim Denial Isn’t The End Of The Road

Another client I represented had radiating pain and numbness in their fingers. The request for authorization (RFA) for medical attention was sent to the adjuster while the client was treating the issue with their doctor. When the claim was denied, I submitted the claim to a utilization review. By the end of the case, it turns out that the adjuster was sending the claim review to a doctor in another location, and not a California-licensed doctor. I was able to fight the denial and help my client get coverage.

Another issue to be aware of is adjusters not utilizing all the information you provide. You can give organized, detailed information for your case but the adjuster can still choose to send only what they deem “relevant” to be reviewed. I have found that about 90 percent of adjusters do not provide adequate records to the doctors doing these reviews. Think of it like a “denial” rubber stamp used when the insurance company tells them to. The case could also be sent to review by a doctor who is not in the right medical provider network, which may result in a noncertification of the request.

As you can see, there are ambiguities in the workers’ comp and insurance company systems. To get the treatment you need, you may need to try:

  • Investigating their tactics
  • Maneuvering your case through the legal system
  • Getting the insurance adjuster on the phone with a lawyer and your doctor
  • Asking your doctor’s office to send a Form WC-205 to force the insurance company to give you a timely answer
  • Filing a Form WC-PMT which will schedule a call with a workers’ comp judge
  • Seeking a hearing with a workers’ comp judge to present your case

An experienced lawyer can assist with all of the above and find solutions to the unique holdups in your case. An attorney is your best advocate for getting the treatment you need—and for obtaining an approved medical request covering your claim.

Disclaimer: The answer is intended to be for informational purposes only. It should not be relied on as legal advice, nor construed as a form of attorney-client relationship.

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