California Workers’ Compensation Medical Care Benefits
In California, workers’ compensation (WC) insurance helps workers who get hurt or sick on the job by paying for medical care, replacing lost wages (called “indemnity“), and other benefits. Workers’ compensation insurance ensures that people who get sick or hurt can get the care they need quickly and without proving their employer was at fault. The expense of workers’ compensation insurance is borne entirely by employers. If you become hurt or sick on the job, you can get the medical attention you need without worrying about out-of-pocket costs, but only when the treatment is deemed “reasonable and necessary.”
Examples of covered benefits include:
- Visits to specialists
- Inpatient treatment
- Surgery
- Ambulance fees
- Emergency room care
- Doctors bills
- Physical therapy
- Diagnostic procedures
- Laboratory testing
- X-rays and other imaging
- Pharmaceuticals
Division 4 of the California Labor Code and the rules and regulations enacted by the California Department of Industrial Relations’ Division of Workers’ Compensation (DWC) oversee the provision of WC medical treatment to injured workers in California. Remember that unless the claims administrator gives written approval, Workers’ Comp will only cover up to 24 visits to the chiropractor, 24 visits to physical therapy, and 24 visits to occupational therapy for your injury.
How Does the Insurance Company Decide What Kind of Treatment is “Reasonably Necessary?”
The insurance provider handling your workers’ comp claim will have high expectations that your doctor adheres to norms in care. The (ACOEM) American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines, Second Edition, is what is followed. According to these recommendations, workers who sustain injuries or illnesses on the job may seek therapy, which has a positive impact.
Suppose you require therapy or treatment that is not in the guidelines. In that case, your doctor will have difficulty convincing the insurance company to cover the procedure unless they can provide evidence that it is consistent with other scientific recommendations accepted by the medical community.
What Criteria Does the Insurance Company Use to Determine Whether or not to Cover a Procedure?
It is the responsibility of each insurance provider offering workers’ comp benefits to institute a usage review procedure to ascertain whether or not a particular therapy is essential. The claims administrator may only give the green light to your doctor’s recommended course of treatment, not change it in any way. Only a second doctor familiar with your condition and the proposed therapy should decide whether or not to reject the first recommendation.
Suppose you’ve been hurt on the job, and the utilization review doctor refuses to approve treatment. In that case, your attorney in California may request an independent medical review to have another doctor evaluate the UR doctor’s decision and determine whether or not the treatment should be approved.
What to do if Your Company Uses an MPN or Does not Have One?
Several companies and insurance companies have begun to contract with medical provider networks (MPNs) to manage better the costs of treating injured employees. State Division of Workers’ Compensation authorization is required for MPNs. Each MPN has both occupational medicine specialists and primary care physicians. You may get a list of MPN physicians in your area from the claims administrator. If unsatisfied with your first MPN doctor, you can switch after your initial visit.
In the first 30 days after your employer learns of your injury, the claims administrator may choose your treating doctor if you haven’t predesignated and the company doesn’t have an MPN. As long as they are within a reasonable distance, you may see any doctor or go to any hospital after the first 30 days.
After the 30 days, you may be entitled to switch to your chiropractor or acupuncturist if you provided your employer with their name and address in writing before your accident or sickness.No chiropractor can treat you as your primary care physician once you’ve had 24 visits.
What Options do You Have If your Workers’ Compensation Claim Is Rejected?
To ensure that your claim is considered seriously, you must move quickly. An experienced California workers’ compensation attorney can assist you in filing an adjudication of claim with the California State Division of Workers’ Compensation to challenge the rejection of your claim and have your case heard by a WC judge. In addition to speeding up the procedure, a skilled workers’ compensation attorney will advocate on your behalf to guarantee a positive outcome.
It is against the law for a doctor or medical practitioner to charge a worker for emergency care if they suspect the injury or sickness is work-related. A medical practitioner may ask you to sign a “lien” form, which states that payment for services rendered will be withheld until the matter is resolved.
California employment cases can be complex. Your employer will likely fight back. You need someone on your side to protect your rights and get the money you deserve.
Call Setyan Law at (213)-618-3655 for a consultation.
