Attorney Robert McLaughlin fights for a worker's right to reasonable and necessary treatment
In an ongoing case handled by McLaughlin & Sanchez, a California worker is appealing to the 4th District Court of Appeal to have his treatment reviewed within his employer's medical provider network.
The client in question suffered injury to both of his arms at work more than a decade ago and settled his workers' compensation claim in 2004. The settlement included 64% impairment due to the arm injuries as well as the cost of future medical care.
Ten years later, in November 2014, the client's medical provider - who was within the employer's medical provider network (MPN) - requested authorization to provide two prescription topical medications. But the employer disputed this request, submitting it to a utilization review (UR), where only one of the two medications was approved.
Our client appealed the case to an administrative law judge (ALJ), who found in favor of the employer, saying that the matter had been appropriately referred to UR and that our client had the right to appeal for an independent medical review (IMR). We then appealed to the Workers' Compensation Appeals Board (WCAB), which upheld the ALJ's ruling. Meanwhile, our client's requested IMR denied the additional medication.
Our law office has now brought the matter before the 4th District Court of Appeal because we believe that our client's right to an appropriate medical review has not been honored. Specifically, the issue is that California law establishes two different types of independent medical review: the Section 4610 IMR (often known as UR-IMR in the parlance of workers' compensation) and the MPN-IMR.
Staying within a medical provider network is intended to streamline workers' access to care
When an injured worker seeks treatment within a medical provider network (MPN), the network is supposed to make it easier for the worker to get the care he or she needs. If there is a dispute regarding treatment within an MPN, the MPN-IMR process allows the injured worker to seek a second and third opinion. This independent medical review is a robust process that allows the worker to request a physical examination with the doctor providing the second or third opinion; the reviewing doctor can also order diagnostic tests to help reach an informed conclusion.
By contrast, in the UR-IMR process - which our client was instructed to utilize - the reviewing doctor never meets or even speaks to the injured worker. In fact, the worker cannot even learn the IMR doctor's name! This process generally takes much longer than the review process within the MPN, and it is much more likely to deny the injured worker the treatment he or she needs.
The attorneys representing the employer previously argued that because it was the employer, not the injured worker, who disputed the treatment, that the dispute should be handled under the UR-IMR process rather than the MPN-IMR process. However, we take the position that the legislative intent in creating the MPN system was to create a separate, streamlined system with a distinct process for resolving disputes. The worker agrees to seek treatment by physicians who are within the employer's pre-approved network - that is, doctors whom the employer already has confidence in - and in return, the worker has access to a more robust system to appeal any disputed treatment.
We believe that our client has been denied his right to a second and third medical opinion, which are established by statute for a worker treating in an MPN - and we hope that the District Court of Appeal's ruling will follow the original intent of the law: to streamline the delivery of benefits to injured workers.