California Worker’s Comp Reform Has Hurt Injured Workers

P R E S E N T E D B Y

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© 2015 Berman More Gonzalez, Attorneys at Law. All rights reserved. Design and editorial services by FindLaw, part of Thomson Reuters.

A workplace accident and serious

injury can quickly change your life.

Accessing needed care, medications

and home modifications can become

a drawn-out battle.

At Berman More Gonzalez, we felt it was important to

provide an update on the effects of California’s recent

workers’ compensation reforms.

In our white paper, we explain:

•  Why workers’ comp insurers deny requests for

treatment or medication

•  What you can do to fight a denial of benefits

•  How the California workers’ compensation appeals

process works

All California employers must purchase workers’

compensation insurance that pays for medical

expenses if an employee suffers an on-the-job injury.

Generally, workers’ comp is the only available remedy

for an injured worker. Obtaining needed medical care

through the system has become more difficult as

insurers deny more requests.

A story illustrates the frustrating nature of the process. A

quadriplegic, injured when his tanker truck crashed on an

off-ramp, has fought for years to move back home with his

family. His home needed modifications, such as a ramp,

enlarged doorways and an additional bathroom to

accommodate his specialized wheelchair.

Over the three years he waited on appeal after appeal, his

wife commuted an hour each way to visit him at a care

facility. With help from a dedicated attorney, the insurer

finally agreed to modify his home. This grandfather will

soon be able to live with his family.

In the most serious workplace accidents

that involve spinal cord injuries, survival

is the initial concern. Medical costs can

mount quickly to pay for the following:

 

•  Multiple surgeries

•  Physical and occupational therapy

•  A specialized wheelchair

•  Long-term care costs for an assisted

living facility

•  Personal attendants and caregivers

 

Immediately

speaking with a

workers’

compensation

attorney can

ensure your loved

one gets treatment

from the best

available doctors

in the insurer’s

network.

!

After your doctor recommends a course of action, he

or she will send a request for authorization to the

workers’ comp insurer. The insurance company uses a

utilization review (UR) process to decide if the

request is medically necessary. Unfortunately,

insurers often ask a doctor in a different specialty

outside of California to review the claim.

The recent workers’ comp reforms put in place a

new appeals process. Now to challenge an UR denial,

you need to request an independent medical review.

A company called Maximus runs the program for

the state of California. Since this new system went

into place, the denial rate of IMR appeals is

Almost 80 percent.

Recent cases from the Workers’ Compensation

Appeals Board have limited the right to seek review

from a Workers’ Compensation Judge. The courts are

limited to deciding issues related to the timeliness of

an UR decision. Other issues, for example medical

necessity, will still need to be resolved through IMR.

After the recent reforms, denials of treatment have

increased leading to delays and frustration.

The best strategy is to avoid a denial of benefits in the

first place is a well-written and documented request

for authorization.

DENIED

It is more critical than ever to seek the help of

a workers’ compensation attorney to ensure

you or a family member receives all necessary

care following a serious workplace injury.

To learn more about workers’ compensation

reform and recent cases interpreting the appeals

process, please read our full white paper.

Share the white paper

© 2015 Berman More Gonzalez, Attorneys at Law. All rights reserved. Design and editorial services by FindLaw, part of Thomson Reuters.