California Accident Attorneys Blog
People who are injured while they are working are eligible for workers’ compensation benefits through their employers’ insurance carriers. Doctors are able to request specific medical services for injured workers. When employers either change the requests or deny them, the modifications or denials undergo a utilization review by medical experts. In Allied Signal Aerospace vs. Workers Compensation Appeals Board, Cal.Ct. App. Case No. B293080, the California Court of Appeal considered an employer’s petition for review of a decision that was made by the appeals board concerning a utilization review for a woman whose doctor had requested heavy housecleaning assistance.
Factual and procedural background
Maxine Wiggs was an employee of Allied Signal Aerospace who suffered an industrial injury that was cumulative in nature from May 3, 1997, to May 30, 1998. The injury required her to undergo six surgeries between 1998 and 2012. By 2012, Wiggs had to take multiple narcotic and opioid medications to manage her pain. She had three more surgeries from 2014 to 2017. Wiggs requested home health care services. On Oct. 22, 2012, the parties agreed that a registered nurse named Irene Mefford would conduct an in-home assessment of the need for housekeeping services and would write a report and submit it to Wiggs’s doctor for his review.
In her report, Mefford recommended that Wiggs receive housekeeping services two times per month for four hours each for a period of one year. Allied then authorized the home care for one year and paid $5,507 in retroactive care. Wiggs’s doctor submitted a request for home care to Allied on March 7, 2014, and Allied authorized it for four hours twice per month. On June 8, 2015, Wiggs’s doctor submitted a new request, asking that the housekeeping services be increased to four hours per week because of Wiggs’s additional surgeries. Allied denied the increase, and Wiggs did not seek an independent medical review of the denial.
A new request for four hours per week of housecleaning services was submitted on April 6, 2016. Wiggs then requested an expedited hearing, arguing that Allied’s failure to submit her most recent request for a review entitled her to the increased home health care. Allied argued that since Wiggs’s request was identical to one that was previously submitted, it did not need to be submitted for the utilization review because no significant changes had occurred.
On June 1, 2017, Wiggs requested the workers’ compensation judge to issue an order for the parties to return to Mefford. The judge ordered Mefford to prepare a new report after conducting a home assessment and reviewing the medical records of what had occurred from 2012 to 2016. Allied petitioned the court for reconsideration and removal, arguing that the court did not have jurisdiction to consider the issue of home health care. The judge recommended that the reconsideration and removal request be denied.
The Workers’ Compensation Appeals Board affirmed the decision of the workers’ compensation judge’s decision to order the parties to return to Mefford. Allied then appealed the decision of the Appeals Board to the California Court of Appeal.
Issue: Whether the workers’ compensation judge had jurisdiction to address a medical treatment issue?
Allied argued that the court did not have jurisdiction to order the parties to return to Mefford or to make determinations of medical treatment issues because they are supposed to be handled by the utilization review process. Allied also argued that Mefford was only hired to perform a single assessment and was not to be deferred to on an ongoing basis. Wiggs argued that the parties had stipulated to let Mefford make the decision regarding her need for increased housekeeping services, which Allied denied.
Rule: When an employer denies or modifies a request for medical care services, the denial or modification goes through the utilization review process that is conducted by medical experts.
In California, denials or changes that are made by employers to requests for medical care from the doctors of injured workers who receive workers’ compensation benefits are subject to review by medical experts through the utilization review process. Workers’ compensation judges and the Workers’ Compensation Appeals Board do not have jurisdiction over this process unless one of two exceptions applies. Workers’ compensation judges and the Appeals Board can only review writs of review when it is a final order or when a review of a threshold order will end the proceedings.
Analysis
The Appeals Board had considered the stipulation that Mefford would be hired for an assessment and agreed with Wiggs that it was for continuous and ongoing service. When the Court of Appeals looked at the stipulation, it disagreed with the Appeals Board and found that the stipulation between the parties was only for Mefford to perform the initial in-home assessment and to write a report before Wiggs was initially granted home care services.
The Court of Appeals looked at the orders of the workers’ compensation judge for a new assessment to be performed by Mefford along with a review of the medical records since 2012. The court found that this order would not terminate the proceedings as required under the exception to the threshold issue rule but would instead leave the decision of whether Wiggs should receive increased housecleaning services up to the judge or to the Appeals Board instead of the utilization review process. The court determined that Wiggs’s home care issue should be decided by the utilization review process. The court then considered whether the appeals board had jurisdiction over the threshold issue of Wiggs’s home health care services.
The Appeals Board found that there was evidence of an agreement for ongoing services by Mefford. The stipulation simply stated that Mefford was the nurse that the parties had agreed would perform a home assessment. The stipulation did not say that she would also perform assessments in the future or that she would be in a position to resolve future disputes between the parties. The court noted that several requests in the intervening period were sent to the UR process instead of to Mefford, indicating that the parties understood that they had only stipulated to using her services to complete the initial assessment and report. The Court of Appeals found that the idea that the stipulation contemplated ongoing services from Mefford was not supported by substantial evidence. As a result, the Appeals Board did not have jurisdiction to review the writ of review regarding Wiggs’s need for increased home health care services.
Conclusion
Since the Court of Appeals ruled in favor of Allied, the decision of the Appeals Board was reversed. The case was returned to be submitted through the utilization review process instead of through the workers’ compensation judge or Appeals Board since they did not have jurisdiction to consider the issue.
Talk to an experienced workers’ compensation lawyer in Los Angeles
When people suffer occupational injuries because of their jobs, they are entitled to recover workers’ compensation benefits to pay for their medical care and related services. However, some requests may be denied. Requests that are denied must be handled by the utilization review process before they can be appealed to a workers’ compensation judge for a review of the final decision. If you need additional services that have been denied, you might want to talk to an experienced workers’ compensation lawyer at the Law Offices of Steven M. Sweat. Contact us today to schedule a free consultation by calling (310) 592-0445.
Sources
https://law.justia.com/cases/california/court-of-appeal/2019/b293080.html