“Utilization Review”(UR) is the first process in denying medical to the injured worker. The insurance basically uses this process to deny medical care-especially expensive medical care in Workers’ Compensation cases most notably home care and assistance.
Once there has been a “denial” of care to the injured worker, there is an “Appeal” process with “Independent Medical Review” (IMR) is conducted by Sedgewick, a large insurance adjusting entity in California Workers’ compensation, which does not allow for a Hearing or notify the Applicant or the Applicant’s attorney of who the judge is and the exact bases of the “Decision” ( usually to “uphold”, on occasions to “modify,” and, on rare occasions to “overturn”).
In the past, the doctors who are responsible for the UR review have been able to render their “findings’ without any repercussions. In addition, appeals of that actual process itself have not been successful, with the Courts finding that “Due Process” is not violated in this “Administrative Process.”
A recent case, King v. Comppartners (1/15/16 81 Cal Comp Cases 10 Court of Appeal) has quite likely provided ammunition for the injured worker in California to actually institute a Civil Suit as against a doctor, although he may be reporting for UR. That case involved an Applicant who injured his spine in Los Angeles, California, and became addicted to Klonopin. When his primary treating physician requested a refill, it was denied without any “weaning period” which caused him to suffer multiple seizures. This case found that there may be a malpractice claim as against the insurance adjusting entity (Comppartners) and/or the doctor, in that there was a duty of the Utilization Review doctor in that a “physician-patient” relationship existed.
It is hoped by the Applicants attorneys in California that this case may cause UR doctors to be more liberal in their allowance of medical care. In fact, what has occurred, especially in Workers’ Compensation in Los Angeles, California, is that there is now usually an allowance of a “weaning period” to occur so as to “taper-off” medications rather than denying the drug altogether.