Getting Medical Care in a Workers' Compensation Claim

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 benefitsHiring an experienced workers’ comp attorney in San Diego is invaluable.

The scenario typically unfolds in the following manner…

A Primary Treating Physician (PTP) is Chosen

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.

The Utilization Review Process

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.

Appealing Denied Care through Independent Medical Review (IMR)

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.

The Importance of Legal Representation

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.

Get Help Today

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.

Testimonials from Clients on Medical Care

Had a heat stroke in August 2021 and it completely changed my life for the worst. Unfortunately, I was not receiving the medical care or attention I needed at the time so I had to retain an attorney. Once I did, things changed immediately. Thomas and his crew were on it from the start. They sent me to medical professionals that were able to actually help me. Teresa was my medical coordinator and ALWAYS got right back to me via text or by phone with any questions or concerns I had. She is awesome!!! The entire staff was amazing. The process was long but in the end I was happy with the result and I would definitely recommend Thomas and his firm to anyone injured on the job. Thanks again.
Joe
★★★★★
I highly recommend the Law Offices of Thomas Debenedetto to anyone in need of a worker's compensation attorney. I have full trust in his abilities. Thomas represented me twice with worker's compensation claims. The first one took place in 2008. At the beginning of this claim I did not have legal representation; I was interacting directly with the insurance "carrier" - my employer's insurance company. After several months of examinations and treatments by the insurance company's doctors - going from one doctor to another - my condition had not improved and no diagnosis had been reached as to the nature and extent of my injuries. At this point I decided to seek legal representation. I searched the yellow pages for worker's compensation attorneys in my area. I consulted with several attorneys before contacting the Law Offices of Thomas Debenedetto. I found Thomas is to be knowledgeable of worker's compensation law, and experienced in handling worker's compensation claims. I felt confident with his representation. Thomas is personable. I felt comfortable and relaxed talking to him. Thomas immediately arranged for me to be seen by one of the best orthopedic surgeons in San Diego, and from that point forward I received excellent medical care - my injuries were diagnosed and I was provided with a plan for treatment. It was reassuring to know that I was in great hands medically and legally, When the insurance carrier delayed on approving physical therapy after my first surgery, one call to Thomas got the ball rolling right away! I was very satisfied with Thomas' representation, from the excellent medical care, to keeping the insurance carrier on task, and to the monetary award I received at the end of the claim. In 2014, I was injured again on the job. I telephoned Thomas' office. It had been over three years since I had any contact with his law office and I was very pleased with the reception I received. I was able to get an appointment right away. Thomas arranged for me to be seen by the same orthopedic surgeon as with the previous claim - which is what I was hoping for. My injuries were not as extensive as with the first claim, so after the completion of a couple of months of physical therapy Thomas settled my case with the insurance carrier. I was, once again, very pleased with the results. If you are in need of a worker's compensation attorney, call the law offices of Thomas Debenedetto. Thomas will see to it that you get excellent medical care, fair treatment from the insurance carrier, and the best settlement your claim merits.
Willetta
★★★★★
Thomas DeBenedetto, San Diego workers’ compensation attorney

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.