Get to the Bottom of Why Your Medical Treatment is Being Denied
Have you filed a workers’ compensation claim in California, only to have your medical treatment denied? One of the most frustrating parts of being injured at work is dealing with the red tape and complications of workers’ compensation. When it leads to a victim not being able to get the medical treatment they need, it can be a truly difficult situation.
The good news is that you are not alone. You can contact DLC Law at (626) 285-8815 now to request a free legal consultation with a Board Certified Workers’ Compensation Specialist by the State Bar of California.
You have little choice in doctors in the first 30 days following a workplace accident
For the first 30 days after a work-related accident, your medical care is usually under the authority of the insurance company. This means you are obligated to see the doctor they choose. After the 30-day period has passed, you may choose a main treating physician of your choice to continue your medical treatment.
This primary treating physician may refer you to other specialists for treatment, but the primary doctor will be in charge of your job status, among other things. You won’t be able to see other doctors without a recommendation from your primary care physician.
Steps to take if the insurance company refuses to authorize medical treatment
In most cases, the insurance company has Five days from the date of a request for medical treatment authorization to approve or refuse the requested treatment or therapy. This deadline is flexible and may be extended for a variety of reasons.
Treatment can be refused for a variety of reasons, the most common of which is that the insurance carrier’s medical assessment determines that the proposed treatment is neither reasonable nor required. Because these determinations are subjective, the carrier is given a lot of leeway in making these decisions.
There are a few possibilities if a certain therapy is rejected. First, if your private health insurance coverage covers the treatment, you can proceed with it, and once your case is resolved, your insurance carrier will likely file a lien against your claim for payment.
Another alternative is to proceed with the treatment directly with the medical provider on a lien basis. In such situations, the medical practitioner agrees to hold payment until your claim is completed. The third step is to request a Workers’ Compensation Appeals Board hearing.
You or the insurance carrier can seek a qualified medical examiner for a medical/legal assessment
The opinions of the treating physician, including opinions on permanent disability, temporary disability, medical therapy, and so on, can be challenged by either you or the insurance carrier. If this happens, any party can seek a Qualified Medical Examiner to conduct a medical/legal assessment.
A qualified medical examiner (QME) is a physician who has met all of the state’s standards for obtaining such a license. This QME is referred regarded as a “Panel QME”. If you are not represented by an attorney then you should not choose a Panel QME on your own. You might need the assistance of an attorney to guide you through this process. However, the insurance company may still require you to visit a doctor of their choosing for this mandatory examination.
We recommend that you do not pick a “Panel QME” and instead seek an attorney for prospective representation if you also disagree with your treating physician’s recommendations. The reason for this is that once you choose a “Panel QME,” the doctor’s opinions become legally obligatory on you for the rest of the case, even if you retain an attorney. Many attorneys also have their own list of preferred medical/legal assessors.
You must attend certain examination set up by the defendants, and you may be forced to attend more than one test with the QME chosen. An attorney will help guide you regarding which medical examinations to attend. To learn more about the best way to handle your specific case, contact DLC Law at (626) 285-8815 for a consultation.