Q: Any options when workman comp administrator not following court settlement?
We are located in Sacramento California. I am researching on behalf of my brother as it's his case. Essentially him and the Hartford insurance company agreed to a settlement where the Hartford agreed to provide him lifetime medical support for his injury. He has been going to all his appointments, check ups, fully compiling on his end. The Hartford is denying him a surgery that his workman comp doctor says he desperately needs. They requested 2nd and 3rd opinions and all say the same thing he needs surgery and medical evidence to support it. The issue is the company is denying his surgery, other treatments and medications for pain. Is it possible to either reopen the case or sue in a new case because they are not complying with the court ordered medical care he was approved for? Any information can be helpful
more info needed
if you had a WC attorney (and you should have had one), then ask him or her.
if not consult with a WC atty.............this is a criminal atty and PI forum
A: If he is still within 5 years from the date of injury, he can reopen his case and this may be to his advantage. However, if the carrier is conducting timely Utilization Review then your only option is to appeal to IMR. Unfortunately, that's the law now. The court no longer has jurisdiction to litigate medical treatment if UR is conducted timely. You can thank WCAB Chair Commissioner Zalewski, a former defense attorney and judge. She drafted the legislation for Director Christine Baker and was rewarded with a comissioner's post for it. Now she is the Chair of the WCAB.
Theodore Allan Greene agrees with this answer
A: The Stipulations With Request For Award agreement does NOT guarantee the insurer will agree to any surgery. Yes, even if the doctor writes he 'desparately' needs it. Your elected officials put in place laws that let a reviewing doctor will never see the injured worker write a report that says the injured worker won't benefit from the requested treatment or surgery, and then the insurance adjuster legally just refuses. It sounds like treatment for life, but all it really is is the right to get denial letters for the rest of the worker's life. It's ridiculous. But we keep re-electing assemblywomen and state senators who take giant donations from comp insurers, and they keep screwing the injured workers with this horrible law. There is a horrific appeal process called the Independent Medical Review, the IMR. 91% of IMR decisions refuse the treatment...and that decision lasts for one full year. And the IMR does not tell you if the request was really reviewed by a real doctor or who that doctor might be... all the worker gets is a short letter saying the appeal was reviewed and the decision to refuse the treatment is upheld. And case law says the only way to appeal that is to return to the same Maximus company and point out what you think the IMR physician may have failed to notice. Someday injured workers will gather together and vote out a state senator and the other state senators will be frightened and change the law. But until then, your brother is stuck with a system that lets the adjuster refuse all requested treatment and leave him to pay for all of his care out of his pocket.
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