Having access to proper medical care in a workers’ compensation claim is vital for injured employees in San Diego. But the process can be difficult. An employer’s insurance company is financially responsible for care. But insurance companies often use their position to work comp cases in their favor.
Without professional representation medical care claims generally follow a predictable scenario where the injured loses out on receiving all rightful benefits. Hiring an experienced workers’ comp attorney in San Diego is invaluable.
The scenario typically unfolds in the following manner…
After a workplace injury or illness, the employee selects a Primary Treating Physician (PTP) from a Medical Provider Network (MPN). A MPN is the insurance company’s organization of chosen doctors. The PTP examines the employee and determines the necessary treatment. Medication, diagnostic tests, physical therapy or surgery are common examples.
Recommended treatment by the doctor is submitted with a Request for Authorization (RFA) to the insurance company. Any approved medical care in a workers’ compensation claim for an injured employee in California is provided by the MPN.
However, the insurance company’s claims adjuster does not automatically approve recommended treatment. Often, they send the RFA to a Utilization Review (UR) doctor for further investigation. This different physician can approve or deny the requested care within five business days.
Interestingly, the UR doctor never physically examines or meets the injured employee. A decision is made solely based on paperwork. Sometimes, the outcome is made from an office cubicle shared with the insurance company. Care can be denied.
If the UR doctor denies the requested treatment, the employee’s only recourse is to file an appeal through the Independent Medical Review (IMR) process. But this process is deeply flawed and biased against the injured worker.
The IMR involves yet another doctor making a decision about the employee’s medical care without ever meeting or examining them. The employee is not entitled to know the name, qualifications, or disciplinary record of the doctor deciding their fate. The physician remains anonymous.
Navigating medical care in a workers’ compensation claim to obtain necessary treatment is an uphill battle. An injured employee is pitted against the profit-driven interests of the insurance company.
Seeking and retaining an experienced San Diego workers’ compensation lawyer is crucial. An attorney with this type of expertise can ensure that an injured or ill employee receives the medical care they deserve.
Thomas DeBenedetto is an accomplished workers’ compensation attorney in San Diego with over 30 years of experience. Securing rightful medical care for employees injured or made ill from the job is one of the firm’s essential responsibilities to their clients.
Attorney Thomas DeBenedetto relays that on medical care claims:
“We will appeal every single denial. I don’t care how big or small they are because each appeal causes the insurance carrier money. And they get sick of it after a while and eventually they concede and you get your benefits. Workers’ comp is a fight to get medical care a fight tooth and nail. You can fight the battle by yourself. Or you could hire an experienced attorney to fight that battle for you.”
Get help with medical care in a workers’ compensation claim with a qualified lawyer. Schedule a free consultation today.
Thomas DeBenedetto
Workers' Compensation Attorney
Thomas DeBenedetto has over 33 years of experience representing injured workers in California workers’ compensation claims. Based in San Diego, he focuses exclusively on workers’ compensation law and regularly publishes educational content to help injured employees understand their rights and benefits under California law.
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