This sounds like a question for your Attorney to answer/investigate/handle.
We offer general concepts, but you should give ALL your facts to a licensed Attorney in your state before you RELY upon any legal advice.
Verify with your attorney that your doctor belongs to their MPN (medical provider network). However, even if he belongs to their MPN, your doctor's request will first to the UR (utilization review). So, even though you have a life time medical, all doctors' requests will go through the UR first.
Yes, the denials and the UR cost them money. However, it also saves them money if doctors give up on their requests and, basically, go away. I don't know if you were seen by an AME (agreed medical examiner). If yes, your doctors' requests would have to be submitted to the AME instead of UR; at least until July 1, 2013.
As a lawyer, who represents a good number of UFCW members throughout the state, I have come to understand that this is the path many Von's claims adjusters take. Therefore when we experience even the slightest delays, we file for a hearing...or get our client on the very next train to the PQME or AME. You will continue to experience similar delays and denials if you don't stand up to them. Remember, you have an award which entitles you to future medical care...you need to see that this award is enforced.
Michael Ian Rott, Esq., Managing Partner
HIDEN, ROTT & OERTLE, LLP
2635 Camino del Rio South, Suite 306
San Diego, California 92108
Office: 619.296.5884, ext. 14
San Diego - El Centro
Please be advised that the advice provided does not create any attorney/client relationship; that due to the various state laws that the information provided is a general overview of work comp law, which might not be applicable to you, based upon the laws of your state. We will not file anything on your behalf nor protect any statute of limitations which might arise and recommend that you IMMEDIATELY consult legal counsel for advice.
Your story and frustration is shared by injured workers throughout California. For better or worse, workers compensation has become increasingly contentious - and it sounds like your attorney fought hard for you to get this far. You should discuss this with your attorney.
while there may be some legitimate reasons for denial, this unfortunately has become the path of many wc insurers. You will need to fight them on this and request penalties and fees at every opportunity. A documented pattern can be reported to the department of insurance. And, remember your nightmare every time legislation comes around on the ballot - and spread the word.