Three New Decisions are providing a tiny little light at the end of the Workers' Compensation Treatment Nightmare Tunnel, and now maybe we can show the Workers Comp Judges how needed treatment is repeated being unfairly refused.
DUBON V WORLD RESTORATION: YOU don't have to go through the worthless Independent Medical Review -- IMR -- process when the insurer refuses ( non-certifies ) treatment.
INSTEAD you find a DEFECT in the Utilization Review. What exact date did your Doc provide the REquest? count 5 business days, and if the UR wasn't provided by that 5th day, it's late and defective. What kind of medical professional reviewed your Doc's Request for Authorization? We just had a Plastic Surgeon review a request for Orthopedic Surgery... NOT a 'peer' as required, so that's defective. Did the reviewing physician lack studies and reports the adjuster should have provided but failed? Defective non-certification.
A DEFECTIVE UR should not be submitted to a IMR. DUBON let's us take a defective UR directly to the Workers Compensation Judge. Get your Expedited Hearing set (with your Declaration of Readiness to Proceed), show the judge how your doctor explained very clearly how the requested treatment would relieve the effects of the industrial injury and how the UR non-certification was defective, and skip the IMR.
GOMEZ V FACILITIES SUPPORT: The board reminds us the Treating Doc's Request for Authorization must clearly support and show how this treatment will relieve the effects of the industrial injury... just showing the court the UR is defective isn't quite enough.
STRATEGY: before filing for the Expedited Hearing, make certain the Treating doc's reporting clearly shows exactly how the condition being treated is industrial and how the treatment will clearly relieve that industrial injury effects. HINT; A SUPPLEMENTAL REPORT addressing the UR doc's complaints is always a good idea.
WEILMAN V TIG INSURANCE: It's crucial that the treatment requested be PROVEN to be 'reasonable and necessary' together with a defective UR denial. YOu can't just show the UR non-certification was defective and expect the WCAB judge or order the treatment.
PLUS: the attorney can get attorney's fees for the hours spent fighting for the continuing treatment unreasonably denied (something that stopped attorneys from filing on cases closed by Stipulations With REquest For Award, because hours and hours would disappear and the payment for your hours would take more hours to get some payment).
IMR FACELESS, NAMELESS DOCTORS should be avoided: we're advised 80% of IMR decisions deny requested treatment... so if there is ANY way to avoid the IMR, AVOID THE IMR PROCESS and use these new decisions.