Depending on the type of settlement and/or if you have a Findings and Award (“F&A”) from the judge, you may have additional rights under the California workers’ compensation (“WC”) system. If you settled your WC case by a Stipulated Award with open future medical care, and/or if you have a F&A from the judge for future medical care, then you are entitled to lifetime future medical care for the medical condition(s)/body part(s) listed in the Stipulated Award and/or F&A. In order to use the lifetime future medical care, you will need to find a doctor(s) that is willing to treat you under the California WC system. This often means finding an injured worker friendly doctor within the WC insurance carrier’s Medical Provider Network (“MPN”).
The Utilization Review Process
Future medical care is subject to the WC insurance carrier’s Utilization Review (“UR”) process and the State of California’s Independent Medical Review (“IMR”) appeal process.This means that requests for treatment by your WC doctor(s) must be submitted by the WC doctor(s) on a Request For Authorization (“RFA”) form to the WC insurance carrier. The RFA will then be reviewed through the WC insurance carrier’s UR process. UR will make a determination to either authorize the requested treatment, or delay, or deny the requested treatment. If the treatment request by your doctor(s) is denied by UR, then an appeal of the UR denial must be timely submitted to the State of California’s IMR appeal process within 30 days of the date of the UR denial. The decision by IMR is presumed correct and can only be challenged in very limited circumstances that involve showing fraud, improper bias (race, religion, sexual orientation etc.), plainly erroneous mistake of fact, conflict of interest, or that the Administrative Director (“AD”) of the State of California acted in excess of the AD’s powers. Assuming IMR upholds the denial of treatment, the denial of treatment remains in effect for one year from the date of the UR denial, unless your doctor can show there is a significant change in your condition justifying re-requesting the treatment prior to the expiration of one year from the date of the UR denial. Having a WC doctor(s) on your side is crucial for treatment, but also because the doctor’s findings may be the basis for: (1) eventually negotiating a monetary settlement with the WC insurance carrier to close out/buyout the lifetime future medical care by a Compromise and Release (“C&R”) settlement; and (2) pursuing additional disability and WC benefits based on the deterioration and/or worsening of your medical condition(s)/body part(s).
Filing a Petition To Reopen (“PTRO”)
If you have a Stipulated Award and/or F&A, AND your medical condition(s)/body part(s) deteriorate and/or worsen within five (5) years of your date of injury and/or within 5 years of the end date of your cumulative trauma (“CT”) injury, then you have the right under the WC system to file a Petition To Reopen (“PTRO”) for new and further disability. The PTRO must be filed with the Workers’ Compensation Appeals Board (“WCAB”) within 5 years of your date of injury and/or end date of your CT injury and a doctor must state in a report that your condition is worse within 5 years. You may be entitled under the PTRO for additional WC benefits including e.g., a higher level of permanent disability (“PD”), additional payments of temporary disability (“TD”), a supplemental job displacement benefit voucher (“SJDBV”), and treatment for existing and/or new medical condition(s)/body part(s) that developed as a consequence of your original injury(ies). For this reason, if you are still within 5 years of your date of injury and/or end date of your CT injury, it is extremely important that you monitor your medical condition(s)/body part(s) to determine whether you need to immediately file a PTRO with the WCAB. Ford & Wallach will not reopen your WC case unless you timely set up a phone appointment with us. You may also have a new, subsequent WC injury(ies) that you can purse in the WC system and collect additional WC benefits, even IF you already settled your original WC case by closing out/buying out your future medical care by a C&R; it is more than 5 years from the date of injury and/or end date of your CT injury; and/or you previously filed a PTRO etc. If you continue to get worse and you have worked since your last date of injury and the work has made you worse, you may have a new injury(ies).
I have questions and may need legal help with my denied workers’ comp claim…
If you have already settled your workers’ compensation case and want to know what benefits you may have, you should consult with an attorney. Ford & Wallach offers a free consultation and will determine the best course of action that will protect your rights. Our workers’ compensation attorneys will fight for all of the benefits you are entitled to. Contact us by email or call 213.380.3140.