What to do When Your Insurance Company Says No

There could be a number of reasons why your worker’s comp medications were denied. Medical treatment under worker’s compensation has many rules within the labor code. In my practice, I’ve found that a denial could be as simple as an error in a refill order, or it could be a carrier refusing a claim with no grounds for a denial.

Many workers comp denials fall somewhere in between. An insurer may deny a claim because:

  • They do not think that the medicine is for your work injury.
  • They did not get a copy of a prescription from the doctor (or Request for Authorization), and want to know why you need the medication.

workers-comp-insuranceIf you receive a claim denial you may want to call your claims administrator or attorney. But the rules for workers’ comp medical treatment are not always simple.

The worker’s comp medical treatment denial may be more complicated.

Under the labor code rules, a doctor treats an injured worker and a request for payment authorization is sent. An insurance adjuster may approve the request, or they can deny the payment and ask that the request be sent to a Utilization Review doctor.

If there is a real disagreement over your treating doctor’s opinions, qualified medical evaluators, or agreed medical evaluators examine injured workers, like you. They then determine the benefits you will receive to settle disagreements. They are certified by the Division of Workers’ Compensation Medical Unit to do medical/legal evaluations. These medical evaluators are also physicians licensed to practice in California as:

  • Medical doctors
  • Osteopaths
  • Chiropractors
  • Psychologists
  • Dentists
  • Optometrists
  • Podiatrists
  • Acupuncturists

This Utilization Review is a process that will decide if the insurance company is going to authorize and pay for the treatment requested in your case. They may consider whether the treatment is correct for your type of injury. Or, whether this medication will impair your ability to do your job, if you want to, or have returned to, work.

If you disagree with their decision, you have the right to appeal. Currently, there is a very high rate of worker’s comp medication and treatment denials through Utilization Review. This is having a negative impact on the ability of injured workers to receive appropriate medical treatment.

You have the right to an attorney to assist with your case. Please give me a call so we can discuss your options.