When should the WC adjuster request recs from my PCP?

Question

I injured my arm at work 7 months ago and immediately reported it. 6 months ago, I signed the authorization to release records pertaining to my injuries. I’ve asked my claims adjuster 3x for a copy of those records, which I’m entitled to, and each time he said he’d send them to me, but I still haven’t received them. Because the drs couldn’t find the source, they’ve released me to FD, though I’m still in a lot of pain. 
 
Last week, my PCP finally got the request to release my records. So my WC dr hasn’t had them to refer to. How long does it usu. take for insurance to request medical recs? How long do they legally have to do so? Did it affect my claim negatively that my WC drs haven’t had them?

Ronald Mahurin · Answer

1) challenge the PTP report and request a Panel QME in orthopedics or pain medicine 
 
2) write a formal letter to the adjuster requesting a copy of your records and anything sent to the PTP 
 
3) If you don't receive the medical records promptly request a court date and have the WCJ issue an order that you be provided with your records.

James L. Arrasmith · Answer

In California's workers' compensation system, there are specific rules regarding the exchange of medical information between the injured worker, the claims administrator, and medical evaluators. The claims administrator is responsible for providing relevant medical records to the evaluator. These records include those prepared or maintained by the employee's treating physician and any other medical records relevant to the determination of the medical issue(s) in dispute. The party providing medical and non-medical reports and information is required to serve it on the opposing party at least twenty days before it is provided to the evaluator. If there is an objection to any non-medical records or information proposed to be sent to an evaluator, those records should not be provided to the evaluator unless ordered by a Workers' Compensation Administrative Law Judge. 
 
Regarding your situation, where your primary care physician (PCP) received a request for records seven months after the injury, this delay seems unusual. Typically, the insurance adjuster is expected to make a decision on the claim within fourteen days of the injury being reported, based largely on early medical records. If these records are not available or are insufficient, it can lead to delays or denials of claims. However, as more comprehensive medical records become available, the insurance company may reconsider its decision if the additional records provide necessary information. 
 
The delay in your WC doctors receiving your medical records from your PCP could potentially affect the assessment of your claim. Medical records play a crucial role at all stages of a workers' compensation case. The absence of complete medical documentation can be a common reason for the denial or delay of workers' compensation claims. These records are vital for establishing the cause and extent of your injury and the required treatment. 
 
In your case, it would be advisable to follow up with the claims adjuster for a copy of your medical records. You may also want to consult with a legal professional who specializes in workers' compensation to explore your options and ensure that your rights are protected. If the adjuster continues to be unresponsive, there may be legal avenues to compel the release of the records or address any undue delays in your claim's processing.

Q: When should the WC adjuster request recs from my PCP?