Woodbridge, VA asked in Insurance Bad Faith and Workers' Compensation for California

Q: What grounds is it legal for a state insurance agency to prevent an injured worker from being evaluated to treatment?

I reported a psychological injury in February, and I still have not even been evaluated. My claims adjuster has been avoiding both my emails and phone calls. It is almost June.

2 Lawyer Answers
James L. Arrasmith
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Answered
  • Insurance Claims Lawyer
  • Sacramento, CA
  • Licensed in California

A: Under California law, an insurance company is required to authorize medical treatment that is reasonably required to cure or relieve the injured worker from the effects of their work-related injury, and they must do so in a timely manner.

The claims administrator is required to authorize treatment within one working day after receiving a request for treatment from a physician, unless additional information is needed. If additional information is required, they must communicate this to the physician within 5 working days.

Injured workers are entitled to an evaluation within 3 working days of a request, or longer if agreed to by the injured worker.

Some permissible reasons an insurance company may delay or deny treatment:

1. They have evidence the injury is not work-related.

2. They require additional medical information to determine if the proposed treatment is medically necessary.

3. The requested treatment does not fall within evidence-based treatment guidelines.

However, they must promptly communicate the reasons for any delay or denial to the injured worker and physician. Failing to respond to requests for authorization in a timely manner without a valid reason would be a violation of the law.

If you have not received a response after repeated efforts to contact your claims adjuster over a prolonged period, you may want to consider filing a complaint with the California Department of Insurance. You can also request an expedited hearing before a workers' compensation administrative law judge to address the issue of medical treatment.

It's advisable to consult with a workers' compensation attorney to discuss your specific situation and get guidance on the best course of action to ensure you receive the evaluation and treatment you need in a timely manner as provided by law.

Gary Alan Jackson
Gary Alan Jackson
Answered
  • Workers' Compensation Lawyer
  • Huntington Beach, CA
  • Licensed in California

A: That AI answer is just annoying. Anyway you should call an attorney, one that breathes, and get a real consultation about your rights in your particular situation.

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