subject: Medical Care Under California and Longshore Work Comp [print this page] Medical Care Under California and Longshore Work Comp
Under the laws of California and Longshore workers' comp, an injured worker has the right to receive medical care at the expense of your employer. The extent of treatment is defined as that which is reasonably required to cure or relieve the effects of the injury and includes all necessary diagnostic, surgical, chiropractic, acupuncture, and other hospital treatment along with any necessary nursing care, medication, crutches, orthotic and prosthetic devices, and other medical services.Under California law, after an injury, within one working day of filing your claim, even while the claims adjuster reviews your claim to decide whether to accept or deny your claim, you are entitled to immediate initial medical care up to a cost of $10,000.00.If your claim is then denied, you will need to file for a hearing at the Workers' Compensation Appeals Board for State claims or the OWCP for Longshore claims, in order to fight for further medical treatment.If your claim is accepted, then you have the right to select a doctor to be your Primary Treating Physician (PTP). Likely, 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.If the claims examiner happens to dislike the doctor that you selected, you may be sent to a Qualified Medical Examiner (QME) for a second opinion on behalf of the insurance company, or you may be offered an Agreed Medical Examiner (AME).An AME is a doctor selected jointly by you and the insurance company. The injured worker participates in this selection. Therefore, California law only allows this option to the parties if the injured worker is represented by an attorney in order to protect the injured worker from selecting an unfavorable AME as a result of inexperience and lack of knowledge of the medical community.Selecting your PTP is one the most important decisions you will make during the course of your claim. Not only do you want to receive the best medical care but also, most of your other benefits will be based on the opinions and reports from your PTP. Your PTP will also determine if you are able to return to work, when you may return to work, and in what capacity you may return to work.Selecting the correct PTP is only half the battle in getting the necessary medical care, however. After you select a doctor and the doctor recommends a course of medical care, under California law, the insurance company then has the option to have these recommendations by your doctor reviewed for approval.This review process is called "Utilization Review" (UR) and is conducted either by the insurance company itself or by an outside company that is paid by the insurance company. Therefore, it is not uncommon for a UR review to result in a denial of treatment by the insurance company.Search for other articles by the same author or visit the author's website to find out more about this subject.
