In the California workers’ compensation system, as an injured worker, you have the right to receive medical treatment that is reasonably required to cure or relieve the effects of your work related injury or illness, at the expense of your employer (your employer pays the insurance premiums to have work comp insurance which is required by California law).  This medical care or treatment includes all necessary medical examination, diagnostic, surgical, chiropractic, acupuncture, and other hospital treatment along with any necessary nursing care, medication, crutches, orthotic and prosthetic devices, and other medical services that is directly related to the work related illness or injury.  The work comp claims adjuster will review your injury claim and if your work comp claim is then denied, you will need to file for a hearing at the San Diego Workers’ Compensation Appeals Board in order to ask or motion the court for further medical treatment for your work related injuries.

If your San Diego work comp claim is accepted by the insurance adjuster, then you have the right to select a doctor to be your Primary Treating Physician (PTP).  In San Diego, the insurance company will have a network of doctors called a Medical Provider Network (MPN), and if so, you must choose your PTP from this network which is located in the San Diego Work Comp Appeals board building (second floor).  If the work comp insurance claims examiner happens to dislike the doctor that you selected, you may be referred to a Qualified Medical Examiner (QME) for a second medical opinion on behalf of the work comp insurance company, or you may be offered an Agreed Medical Examiner (AME).  You really should have legal counsel at this point to go over your options for your specific work injury case.  

The AME is a medical doctor selected jointly by you (with your work comp lawyer) and the insurance company.  This type of selection requires participation by the injured worker, and California law only allows this option if the injured worker is represented by an attorney in order to protect injured workers from getting tricked into selecting an unfavorable AME by unscrupulous insurance adjusters.  This is one of the many protections California law allows an injured worker to take advantage of in their specific work comp case.  You should know that selecting your PTP is one of the most important choices you will have to make in your worker’s compensation claim anywhere in California.  This is important because you obviously want to receive the best medical treatment for your injury, but also because the majority of your other worker’s compensation benefits will be based on the opinions and reports from your PTP.  Your PTP will also determine if and when you can go back to your employment and in what capacity which means to what degree any job restrictions may be placed on you given your particular work injuries.  Thus, you really want to make sure to pick the best treating physician for all of your medical needs because it affects you both medically, number one, and legally number two.  Your work comp attorney can go over the many details involved with this important choice on your work comp injury case.

But Wait, It Does Not Stop Here:

However, the San Diego workers' compensation legal and medical battle does not stop there, selecting the correct PTP is only half of the battle in terms of getting the necessary medical care.  More specifically, once you have selected your medical doctor for your injury case, and the medical doctor recommends an appropriate course and scope of medical treatment for you, the work comp insurance company then has the right to submit these recommendations for an outside review before they agree to pay for the treatment.  Remember, it is about review, delay and deny with insurance companies, and if they can find a way to legally delay and deny the will most of the time do it because they usually place profits ahead of what is best for you medically speaking.  This work comp insurance review process is called an “Utilization Review” (UR), and is conducted either by the work comp insurance company itself or by an outside company that is paid by the insurance company.  Thus, it is common for a UR review of the treatment recommended by your own medical doctor to end up with the result of a quick denial of that treatment by the insurance company.  Delay, deny, delay, deny becomes the mantra at this point.  However, do not despair - you need a good work comp attorney to navigate this legal and medical process.  Also remember, included with your legal rights to medical treatment is the right to be reimbursed by the insurance company for the distance you travel to get to and from your doctor’s appointments.  Also, if you are called for a deposition at at later date, you get mileage reimbursement for that too - but this is for a different blog posting. Just know that sometimes when you go through California work comp medical care, there can be both "hills and valleys," and you need a good work comp lawyer on your side to help navigate those "hills and valleys."

Mark Blane
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San Diego Personal Injury Lawyer
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