In a recent case before the California Court of Appeal, the court addressed an injured employee’s claim that the workers’ compensation process of independent medical review (IMR) was unconstitutional. The court reviewed the legislative reforms to the workers’ compensation system and analyzed the history of an injured employee’s challenge to a denial of a request for medical treatment. Ultimately, the court determined that injured workers were provided more opportunity for review of their medical claims through constitutional state reforms to the workers’ compensation system.
Frances Stevens injured her right foot while working as an editor for Outspoken Enterprises. After undergoing three surgeries on her foot, she was unable to return to work. The pain in her feet forced her to use a wheelchair, leading to low back and shoulder pain, as well as eventually severe depression. After a trial in 2013, a workers’ compensation judge held that Ms. Stevens was permanently totally disabled.
Outspoken Enterprises was insured by the State Compensation Insurance Fund. They accepted responsibility for her medical care and covered extensive medical care for her. Ms. Stevens’ physician requested approval for her to receive four prescription medications to alleviate her pain. He also sought approval for home health aide services, eight hours a day, five days a week. His request was processed under utilization review (UR) and reviewed by another doctor. This doctor eventually denied the request and maintained that a home health aide was not warranted because the evidence did not show that Ms. Stevens was home-bound or that she required home medical care.
Ms. Stevens then requested another review for approval of her treatment. Again, she was denied. She requested an IMR and submitted further documentation in support of her treatment request. The IMR determined that the services and items were not medically necessary and appropriate. Ms. Stevens appealed this determination, claiming that her due process rights were violated.
On appeal, Ms. Stevens alleged the IMR process violated the California Constitution’s separation of powers clause, as well as principles of due process.
The appellate court reviewed the 2004 and 2013 legislation providing reform of the process for considering injured workers’ requests for treatment. Prior to 2004, the worker’s treating physician recommended treatment. If an employer wanted to challenge a recommendation, it was through a lengthy dispute resolution process. In order to streamline the process, employers were to establish a UR process that reviewed and approved, or delayed or denied, medical treatment services. Only a competent reviewer had the authority to modify or deny a request for treatment.
In 2013, the Legislature enacted reforms that established the IMR process in order to resolve challenges brought by workers to adverse UR decisions. Now, a worker’s treating physician submits their recommendation, and that is reviewed under the employer’s UR process.
If the UR decision modifies, delays, or denies a request for treatment, the worker can seek review through an IMR. In other words, it gives the worker a second chance to obtain a favorable decision.
In short, the court stated that the reforms benefited workers because treatment requests would not be modified, delayed, or denied except by a physician. Workers were also guaranteed that UR decisions in their favor could not be challenged by employers on grounds of medical necessity. This curtailed the employer’s rights and also ensured faster final resolution of decisions.
The court next rejected Ms. Stevens’ claim that the California Constitution limits the power of the Legislature over the workers’ compensation system. The Legislature is vested with power, unlimited by any provision of the Constitution, to create and enforce the workers’ compensation system by legislation. Furthermore, the court stated that the Legislature has broad power over workers’ compensation matters.
Significantly, the court rejected Ms. Stevens’ claim that her due process rights were violated, especially since she was provided ample process. Workers seeking treatment under the workers’ compensation laws receive much more process, including through UR, than that provided in the IMR procedure. The court explained that the IMR process is a review of the UR determination, and the IMR determination is subject to review, even though the Workers’ Compensation Board cannot change medical necessity determinations. The Board can review an IMR determination to make sure it was adopted with authority and based on fact.
Notably, the court stated that the Workers’ Compensation Board in this case failed to appreciate their power to review the IMR determination denying Ms. Stevens the home health aide services. The court rejected Ms. Stevens’ contention that the IMR process does not provide a means to address conflicts about the definition of medical treatment.
The court affirmed the Workers’ Compensation Board’s decision but remanded to determine whether the director acted in excess of his authority when deciding that a home health aide was not medically necessary for Ms. Stevens.
At Sharifi Firm, we represent injured workers in their claims for compensation. Our workers’ compensation attorneys are experienced in all facets of the process, including appealing an adverse decision. Contact our office for a free, confidential consultation by calling 866.422.7222.
More Blog Posts:
California Court of Appeals Holds Cumulative Injuries within the State Provide Legitimate Relationship to Invoke Worker’s Compensation Laws, Southern California Injury Lawyer Blog, October 7, 2015
California Court of Appeals Applies Premises Line Rule to Determine Employee is Entitled to Workers’ Compensation Benefits, Southern California Injury Lawyer Blog, >August 10, 2015