California employees who are injured on the job get to take advantage of the California workers’ compensation system to obtain compensation for their medical bills, lost earnings, and certain other related expenses. Unlike other areas of law, this system offers a significant advantage – you don’t need to prove that your employer was at fault to win! Worker’s Compensation rules are complex. An experienced Thousand Oaks Medical Treatment Attorney from the Law Office of Kenton D. Trigger can help guide you through the process and fight for your rights.
HOW IT WORKS:
Perhaps the most valuable benefit available to an employee who has been injured on the job is that of medical treatment. In California, the claims administrator is required to authorize and pay for any and all medical care that is “reasonably required to cure or relieve” the effects of the injury. This means care that follows scientifically based medical treatment guidelines that were designed to help physicians give appropriate treatment.
If it’s an emergency, the employer must ensure the injured worker has access to treatment right away. For non-emergencies, the claims administrator is required to authorize medical treatment within one working day after a claim form has been filed with the employer. While investigating the claim, the claims administrator must authorize necessary treatment up to $10,000.00.
DESIGNATING A PRIMARY TREATING PHYSICIAN:
You have the right to select your own treating physician so long as certain procedures are followed. If you “predesignated” your personal physician, you may see that doctor right away. This means you gave your employer the name and address of your personal physician in writing before you were injured. If you did not predesignate your personal physician, then the claims administrator may tell you where to go for treatment.
Regardless of whom the claims administrator originally designated as the treating physician, after 30 days the injured worker may switch to a physician of their choice so long as they are still in need of medical care. However, if there has been a validly established medical provider network (MPN), the injured worker must find a physician within the network, subject to a few exceptions. This network consists of doctors chosen by the insurance company and limits whom the injured worker may treat with. If an injured worker treats outside of the network they can be forced to change their treating physician to one within the MPN.
APPEALING TREATMENT DENIALS:
There are a few options available to an injured worker who is having trouble getting the appropriate care. If the injured worker disagrees with their doctor about necessary treatment, they have a right to get another doctor’s opinion. If the treatment recommended by treating physician has been denied, the injured worker has the right to challenge that decision and seek penalties if the denial was unreasonable. Lastly, if the claims administrator won’t authorize treatment, an injured worker can use their own private health insurance to get the medical care they need. The health insurer will then seek reimbursement from the insurance company.
Once it has been found that there has been a valid workplace injury, any and all treatment arising from that injury is covered under the employers’ workers’ compensation policy. Because this treatment remains covered for the remainder of the injured worker’s life, it is often the most valuable benefit available to them.
Medical treatment as part of worker’s comp is a complicated area. I am a knowledgeable Thousand Oaks Medical Treatment Attorney for worker’s compensation cases. If you have questions about how this will affect your case, please call us at (805) 430-3300
Frequently Asked Questions (FAQs)
Can I see my own doctor?
It depends. If you designated your own doctor before the injury occurred, you can use your own doctor as long as he is your primary care physician, and as long as your employer offers group health coverage. Otherwise, your employer will likely be able to choose your doctor for you or you will be limited to who you treat with by their medical provider network (MPN).
The insurance company is being cooperative. Why do I need an attorney?
No matter how cooperative the insurance company may appear to be, they are still ultimately representing their own financial interests, which are adverse to yours. The determination of your claim amount is complex, and you can be certain that they have lawyers representing them. Hiring an aggressive Westlake Village medical treatment lawyer to fight for your rights is a prudent decision.
What is the difference between a “Stipulated Finding and Award” settlement and a “Compromise and Release” settlement?
- Stipulated Finding and Award settlement: In a Stipulated Finding and Award settlement, you agree with certain findings (your PD rating, for example) and you are awarded an amount (typically a certain payment for a certain number of weeks). If the administrative law judge approves the settlement, it is legally binding.
- Compromise and Release settlement: This is a lump-sum payment. Once it is paid, the insurance company will be under no further obligation to you. A Compromise and Release settlement must also be approved by an administrative law judge.
How can I find out who provides workers’ compensation insurance for my employer?
You can look up this information on the website of the Workers’ Compensation Insurance Rating Bureau. Remember that California law allows some employers to self-insure against workers’ compensation liability.
What is a QME?
A QME, or Qualified Medical Evaluator, is a medical professional (typically a doctor), who has been qualified by a state examination to evaluate a workers’ compensation claimant’s degree of disability. A QME is intended to act as a neutral third party to resolve disability disputes.
What is the DWC Medical Unit?
The DWC Medical Unit is a part of the California Division of Workers’ Compensation. Among its many functions, the DWC Medical Unit appoints Qualified Medical Evaluators (QMEs) to resolve disputes about the medical condition of workers’ compensation claimants.
What is “Maximum Medical Improvement” (MMI)?
“Maximum Medical Improvement” means the same thing as “Permanent and Stationary.” It means that your condition has already improved as much as it ever will, in the estimation of your doctor. You may need to reach this point before Permanent Disability benefits can be calculated.
Are prescription drugs and medication covered?
Yes, they are. To claim them, you must send the insurance company a bill together with a letter signed by your doctor confirming that the medication was necessary for your treatment and that they were prescribed under the direction of your doctor.
What is an Independent Medical Review (IMR)?
An Independent Medical Review (IMR) is an examination of your injury or illness by a neutral third party physician. You can request an IMR if your doctor recommends a certain course of treatment and the insurance company refuses to pay for it on the grounds that it is medically unnecessary.
Can I appeal an adverse IMR decision?
You can as long as your appeal is based on certain grounds, such as:
- The administrative director (AD) exceeded the scope of his legitimate powers
- The determination was based on fraud
- The reviewer had a conflict of interest that likely affected his decision
- The determination was based on discrimination based on race, religion, sexual orientation, etc.
- Based on the evidence submitted, a mistake of fact occurred
If You Don’t Win, My Legal Services are Free
I don’t like to lose, and I am sure that you don’t like to lose either. That is why I set up my fee structure the way I did. If I fail to bring home compensation for you, my total legal bill (for the entire case) will be zero. If I do win compensation for you, my fees will be calculated as a percentage of your recovery. I couldn’t afford to do this unless I won the overwhelming majority of my clients’ cases. Have a proven workers compensation law firm working for you.
Act Decisively by Contacting a Skilled Medical Treatment Workers’ Comp Lawyer
Pursuing a workers’ compensation claim on your own, or with the help of a lawyer without experience in workers’ compensation claims, is likely to give you the kind of headache you just don’t need right after suffering a workplace injury. That is where I come in, should you choose to retain me. As a skilled and passionate Thousand Oaks Medical Treatment Lawyer, I will stand by you through this time and fight for the compensation and medical treatment you are entitled to.
Call me at (805) 430-3300, or contact me online, so that we can set up a free, no risk case consultation. I will listen to your story, answer your questions and discuss your options. As a dedicated, supportive Westlake Village medical treatment attorney I offer that if you are too injured to come to me, I will come to you.