CA Workers' Comp - The insurance adjuster always says that she has not received my doctors requests for treatment,

Asked 4 months ago - Ukiah, CA

the insurance adjuster always says that she has not received my doctors requests for treatment, I've watched the doctor's office staff fax it to her along with the report and RFA form. how can this be handled?

Attorney answers (4)

  1. Scott Douglas Silberman

    Pro

    Contributor Level 12

    4

    Lawyers agree

    Answered . The insurance carrier is subject to strict time limits for performing utilization review from the time they receive the RFA form. If they do not follow the time limits the treatment can be ordered by a workers compensation judge. There are cases that address this including Sandhagen and a recent WCAB case of Dubon v. World Restoration.

    However in order to enforce this you will need to go to court, usually an expedited hearing. It would be wise to seek out a local workers compensation attorney to go over this. In order to prepare and prove that their responses were untimely, i would recommend that you keep copies of the fax confirmation sheets showing that they were successfully sent to the carrier. I would also recommend that you find a local workers compensation attorney to assist you with these issues.

    Disclaimers: Making a false or fraudulent workers compensation claim is a felony subject to up to 5 years in... more
  2. Daniel W Epperly

    Contributor Level 13

    3

    Lawyers agree

    Answered . Get a copy of the RFA and fax confirmation from the doctor. The adjuster only has 5 days to respond. If she fails to authorize the treatment or a UR denial comes more than 5 days after the RFA was sent, you can have the WCAB Information and Assistance Officer help you file for an Expedited Hearing.

    If you claim is not yet settled, you would be wise to consult with an attorney. You can use the following website to help you find an attorney https://www.caaa.org/index.cfm?pg=FindaLawyerDi...

    Good Luck!

  3. Brett A. Borah

    Contributor Level 20

    3

    Lawyers agree

    Answered . I agree with my colleagues. The proof is in the pudding. If you have the RFA and the fax receipt and they blow the strict time limits, you should be able to go to the WCAB and get the judge to Order the treatment.

  4. Michael Amadeo Mazzoni

    Contributor Level 9

    1

    Lawyer agrees

    Answered . I agree with my other fellow attorney's responses, however for starters, I would check to see if your doctor has the correct address and/or fax number that he is sending these RFAs to. If the adjuster isn't claiming she has received them, then that could be the issue. However, if they are in possession of the RFAs and not taking action, you could petition for penalties under Labor Code 5814 for denial of valid treatment. This is usually handled at an Expedited Hearing where you will able to submit evidence and testify under oath to support your claim for denial of treatment. This may catch the adjuster's attention and have him/her either authorize or go through UR in the statutory time frames allotted.

    I would recommend hiring counsel for this however, as the Expedited Hearing is a "mini-trial" of sorts, and with an attorney, it will much easier to navigate through.

    Disclaimer: There is no Attorney-Client relationship created by use of this website. Neither your receipt of... more

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