This brief synopsis is intended only to provide an outlandish example of how frustrating it is to obtain proper medical treatment in the present workers’ compensation system.
The unnamed individual in the following scenario was injured in the late 1990’s and settled the permanent disability portion of his claim, leaving future medical treatment open. As a result of his injury he had one leg amputated just below the knee.
His doctor put in a request for a wheelchair which was denied by Utilization Review. Amongst the reasons cited for denial was there was no evidence that the man could not use a walker. Really? He didn’t have a leg to stand on. This illustrates one of the problems with the UR system. When the treater puts in a request the doctor normally submits the RFA with the report but that report is usually not a narrative report outlining the entire history. Therefore, the UR doctor is missing important factors that should be considered.
Following the denial the issue went to Independent Medical Review and the denial was upheld. It was then appealed to the WCAB and set for Expedited Hearing on one of the very limited issues that allows an appeal from IMR. The parties agreed to resubmit it to UR as all parties agreed that the man should have the wheelchair, however, the claims adjuster apparently lacked the authority to overrule UR. This same scenario went on for a second and third UR denial and IMR uphold. Finally on the fourth UR denial, Applicant attempted to set the UR doctor’s deposition which resulted in a phone call from the doctor. After explaining the situation, the doctor took a second look and finally issued an approval for the wheelchair. Quite likely it cost the carrier much more in legal fees than the wheelchair itself and the entire process took about nine months.
Bottom line is that the present system is devoid of all common sense. It now focuses on form over substance, process and procedure over just results with little regard for the injured person who has been sucked into the system.
