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
James L. Arrasmith pro label Lawyers, want to be a Justia Connect Pro too? Learn more ›
  • 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
  • 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.

Justia Ask a Lawyer is a forum for consumers to get answers to basic legal questions. Any information sent through Justia Ask a Lawyer is not secure and is done so on a non-confidential basis only.

The use of this website to ask questions or receive answers does not create an attorney–client relationship between you and Justia, or between you and any attorney who receives your information or responds to your questions, nor is it intended to create such a relationship. Additionally, no responses on this forum constitute legal advice, which must be tailored to the specific circumstances of each case. You should not act upon information provided in Justia Ask a Lawyer without seeking professional counsel from an attorney admitted or authorized to practice in your jurisdiction. Justia assumes no responsibility to any person who relies on information contained on or received through this site and disclaims all liability in respect to such information.

Justia cannot guarantee that the information on this website (including any legal information provided by an attorney through this service) is accurate, complete, or up-to-date. While we intend to make every attempt to keep the information on this site current, the owners of and contributors to this site make no claims, promises or guarantees about the accuracy, completeness or adequacy of the information contained in or linked to from this site.