Workers’ Compensation Lawyer San Diego, CA

Seeking Medical Treatment After a Work Accident

Injured workers have rights in California

After an accident in the workplace, your first priority should be your health. Unfortunately, when accidents happen on the job, you may face a process that seems built to save employers and their insurance companies money, not to get you the care you need.

Getting medical treatment can be a difficult and sometimes frustrating part of the workers compensation process. Here's what you need to know.

Get emergency treatment right away

If your accident is serious enough to require you to get emergency medical treatment, your employer is required by law to give you access to emergency services immediately. Go to the emergency room or to another urgent care facility right away. Your employer may tell you where to go to receive treatment.

When you get your emergency treatment - and, for that matter, any other treatment related to your work injury - tell the medical professional treating you that your injury was job-related. Make sure you document everything.

You can switch doctors during the first 30 days of treatment

In California, some employees have the right to predesignate their personal physician to treat work-related injuries. If you exercised that right and predesignated, you can see your own doctor for treatment right away and can switch doctors if needed.

However, if you did not - or could not - predesignate your own physician, your employer's workers' compensation insurance company can choose the doctor who will treat you. Your employer may also have a contract with particular healthcare providers to treat workers hurt on the job. If that's the case, your employer is required to give you written information on the rules governing your choice of care provider.  The employer is required to make a medical appointment for you with one of their contracted healthcare providers within one business day of your requesting the need to see a doctor.  After that initial appointment, you are free to treat with any other healthcare provider contracted with the employer.  You have the right to obtain a list of the healthcare providers under contract with your employer in your geographical area.

If your employer does not contract with healthcare providers and you want to switch doctors during the first 30 days, you need to speak with your employer or claims administrator to try to come to an agreement. Usually, you also have the right to change doctors one time during the first 30 days even if you and the claims administrator cannot agree. However, generally the claims administrator will choose the new doctor as well.

You can use your own health insurance to receive medical care

Within one working day after you file your claim, the claims administrator is required to authorize medical treatment up to $10,000 even while the claim is being investigated. If the administrator does not authorize that treatment, you need to speak to your supervisor or manager right away about the law requiring treatment to be authorized.

In the meantime, you can use your own health insurance to get medical care needed for your injury. If your workers' compensation claim is later approved to cover your injury, your health insurance company can seek reimbursement from the workers' compensation insurance company.  Without health insurance, your only option is to try to find a medical facility that will treat you without immediate payment. Again, the medical facility can seek payment from workers' compensation later if your injury is covered. 

You can challenge denials or modifications of treatment and reviews

Even if you're seeing a doctor who was chosen by the insurance company to treat you, it may be difficult to get the treatment that doctor recommends. When your doctor recommends a treatment, he or she must submit a Request for Authorization (RFA) which will be reviewed by the insurance company. The worker's compensation insurance company will then hire another doctor to conduct a utilization review (UR) and decide whether to accept, deny or modify the requested treatment. Click here for an in-depth explanation of the UR process.

If your requested treatment is denied or modified by the UR doctor, you have the right to request an Independent Medical Review (IMR) to reconsider the decision. To do this, you must send an Application for Independent Medical Review to Maximus - a company that the State of California has contracted to perform IMRs. Maximus will then assign a doctor who is board-certified in the specialty area relevant to your injury to conduct a review of the denial or modification of treatment. Click here for an in-depth explanation of the IMR process.

In most cases, the IMR doctor sides with the original UR doctor and upholds the denial or modification of treatment. You then have the right to appeal the decision to an administrative law judge (ALJ).

In short, getting the medical treatment you need to make a full recovery after a workplace injury can be a complex, difficult and frustrating process. That's why you need experienced legal representation right away. Contact Robert A. McLaughlin, APC today to schedule your free case evaluation. We'll advocate for you and fight for the treatment you need.