When an employee develops a job-related health issue, they may qualify for workers’ compensation coverage. Most people in California dealing with medical challenges have to worry about finances. Even if they have health insurance, they may need to pay a sizable deductible before they get any coverage and may still be responsible for 30% or sometimes even more of their treatment costs due to coinsurance.
Workers’ compensation frees employees from the responsibility of paying for medical treatment. They potentially qualify for full coverage regardless of whether they need surgery or months of physical therapy. However, they do not have as much control over their own care as they would when seeing their own doctor. The doctor overseeing their care will determine what treatment they require.
Sometimes there is a disagreement about the necessity or appropriateness of certain types of treatment. What happens during a disagreement about treatment for a work-related health issue?
The worker may need to undergo an evaluation
California has thousands of sizable workers’ compensation claims to manage every month, and therefore the state has a very robust system in place to deal with all kinds of challenges. There is a very straightforward solution for disputes about the need for treatment or if it is appropriate.
If an employer claims that the treatment a physician recommended is not necessary or would not improve a worker’s condition, the employee may need to undergo an independent medical review (IMR). Workers can also request the review of an unfavorable treatment decision through an IMR. At an IMR, a physician not currently involved in the worker’s treatment would do an in-depth review of their current physical abilities and treatment history. They would then determine what functional limitations exist and what course of treatment would likely be appropriate.
The report authored after an IMR can lead to quick approval for a worker’s treatment or a need to rework the existing care plan. Although it can be frustrating to need to obtain an outside opinion and wait to undergo treatment, an IMR can often help someone secure the care that they require.
