Most people would say that treatment for a work-related injury or illness should be based on what medical professionals recommend – not on what employers and their workers’ compensation insurers are willing to pay for. That doesn’t mean, however, that those who are footing the bill for this treatment won’t try to limit it.
California Labor Code Section 4600 addresses employer responsibilities. Section 4600 states in part that medical care “that is reasonably required to cure or relieve the injured worker from the effects of the worker’s injury shall be provided by the employer.” If an employer wants to discontinue coverage for an employee’s authorized medical and rehabilitative treatment, they need to provide medical evidence that it’s no longer needed.
An example of how protracted a battle can be
Let’s examine one case in which the employee finally prevailed. The man, who had worked as an electrician, suffered orthopedic injuries to multiple parts of his body – including his knees, back and fingers — as well as a traumatic brain injury (TBI). The TBI left him with cognitive issues and severe anxiety that prevented him from caring for himself.
He was approved for a month-long stay at a Southern California residential rehabilitation program. When he submitted a request for authorization (RFA) to extend his stay, the request was denied by the reviewer for the employer. They claimed that there had been no “clinically meaningful improvement” during the time he’d been in the facility.
When he sought a reconsideration, a workers’ compensation administrative law judge ruled that under Section 4600 of the California Labor Code, his employer had no right to deny this care without a change in circumstances that would have to be determined in what’s known as a utilization review like the one conducted before the care was initially approved. That decision was upheld by a Workers’ Compensation Appeals Board panel when it was appealed.
Moving forward
When someone suffers serious, long-term, debilitating work-related injuries, the road to recovery (even partial recovery) can be a long and arduous one. Having to deal with employers and insurers who fight you at every turn as you continue to seek compensation for your treatment is the last thing you need. Seeking experienced legal guidance can help protect your rights under California law so that you can better focus on your recovery.