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Investigation finds few overturned workers’ comp claim denials

On Behalf of | Sep 22, 2016 | workers' compensation

By law, those who are eligible for workers’ compensation benefits should receive them. A recent investigation by the NBC Bay Area news, however, reveals that this may not always be the case in California. Instead, many injured workers face denials of their claims for their treatment claims and very few denials overturned during the appeals process. 

The California workers’ compensation system was reformed in 2013 as part of Senate Bill 863. As a result, applicants who have their treatment claims denied no longer appeal in front of a judge. Instead a private, for-profit corporation holds what are called Independent Medical Reviews (IMR) on behalf of the state.

This process has created an insurmountable obstacle for many injured workers seeking care. According to records, of the nearly 600,000 appeals for medical treatment between 2013 and 2015, the IMR doctors upheld the initial denial by the state. Proponents of this system see this as evidence that the correct decisions are being made earlier in the process, while others, including workers and their doctors, think the data shows that the process is flawed. 

Part of the controversy is related to the doctors selected to conduct the IMRs. The company awarded the contract to conduct these reviews, Maximus Federal Holdings, keeps the names of the doctors they employ confidential. Additionally, a significant percentage of those doctors are out of state.

Potentially most alarming is that the doctors never physically examine the injured workers. Instead, they are supplied with medical histories pertaining to the case and make determinations based on a set of standard guidelines. Decisions regarding the course of treatment are either a yes or a no – no alternative treatment options are suggested for denied claims.

Given the uphill battle many injured workers face, it may be in your best interests to obtain representation from a workers’ comp attorney. With legal advice, counsel and advocacy, you may stand a better chance in obtaining the medical treatment you need for a work injury.


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