Workers Compensation Lawyers Blog: Victims of San Bernardino Terror Attack Denied Claims for Medical Treatment
As if the trauma of being attacked and seriously injured in the workplace and experiencing the trauma of watching co-workers shot and killed wasn’t enough, victims of the San Bernardino shootings have been reporting that they were having trouble getting medical treatment. According to a report in The San Bernardino Sun, the state Division of Workers’ Compensation recently concluded its investigation into the county’s handling of cases involving victims of the Dec. 2, 2015 terror attack at the Inland Regional Center.
What investigators found was that denials for the treatment were mainly due to physicians failing to submit the appropriate information. In an eight-page report, state officials concluded that a significant number of cases involved a provider’s failure to provide “adequate clinical rationale or appropriate documentation to justify requests for extended or new prescriptions,” other types of therapies or medical equipment. Officials also noted that as claims matured, the county increased its scrutiny of treatment requests, leading to modifications and denials.
The Independent Medical Review Process
California’s workers’ compensation system uses a process called independent medical review (IMR) to resolve disputes about the medical treatment of injured workers. As of July 1, 2013, medical treatment for all dates of injury was to be resolved by physicians through this process rather than through the court system. A request for medical treatment in the workers’ compensation system must go through a “utilization review” process to confirm that it is medically necessary before it is approved.
If the utilization review denies, delays or modifies a treating physician’s request for medical treatment because it is not medically necessary, the injured employee can ask for a review of that decision through IMR. The costs of the IMR are paid by employers, who are required under the law to provide injured employees with all medical treatment that is reasonable and necessary to cure or relieve the effects of a work-related injury. These costs are based on the nature of the medical treatment dispute and the number of medical professionals needed to resolve the dispute. Injured workers must take a number of steps as part of the IMR process including:
- Enclose a copy of the complete utilization review (UR) determination with the IMR application form that was provided by the claims adjustor.
- Sign the IMR application form before submitting a request for IMR.
- Send the signed IMR application and the UR determination within 30 days of receiving the UR determination to the address of the form.
High Rate of Denials
Until, mid-April 2016, apparently, the county was routinely approving nearly all requests. The requests began running into issues because doctors failed to properly document or fully explain their requests, the report said. And of course, survivors of the attack who were still suffering and expected their doctors’ recommendations to be followed were frustrated by the denials. The report added that better documentation might have reduced the number of denials and independent medical review requests.
Serving seriously injured and traumatized survivors of a terror attack is unchartered territory for the county, for doctors and for the survivors, county officials said. Of the 2,146 requests for medical and psychological treatment and prescription medications for the 58 survivors, 2,000 or 90 percent were approved while two cases were neither approved nor denied. Three percent of the requests received modified approval. Of the 144 treatments that were denied, only nine were overturned on appeal. In all, 68 appeals were filed by 11 employees.
Traumatized Victims Denied Care
The county denied claims of 25 employees alleging psychological injury from the terror attack. A common factor in these denials was that the employees were not present at the training center when the gunman opened fire. One of the survivors said she was shot twice and had a colostomy as a result. She underwent four surgeries since the incident. She was denied prescription of the pain medication oxycodone and has also been denied physical therapy. In fact, she was left waiting days in the hospital before she was provided the necessary antibiotics she needed before going home.
Navigating the workers’ compensation system has been a nightmare for this employee and many others. When victims of such incidents are denied the care they desperately need, they naturally become more distraught and give up on the system because it’s tough to navigate and simply overwhelming to deal with. The amount of time and energy it takes is more than what these individuals have because they are struggling physically, psychologically and financially.
Can New Laws Solve This Issue?
Assemblywoman Eloise Reyes (D- San Bernardino) introduced legislation in December 2016 to help survivors of the San Bernardino terrorist attack by removing the roadblocks that keep workers who have survived such injuries from receiving treatment for post-traumatic stress disorder (PTSD) and other disorders. Assembly Bill 44 essentially removed a step in the workers’ compensation process called a “utilization review,” which requires a secondary physician to approve the medical treatment plan that has already been prescribed by the patient’s primary care physician.
This extra step has unfortunately created unnecessary delays that cause undue hardship, pain and delay of recovery. AB 44 also authorizes treating physicians to pursue the medical treatments necessary for patients to quickly return to work. A Nov. 20 article in The Sun told stories of survivors of the attack being cut off cold turkey from antidepressants or anti-anxiety medication by utilization review doctors. AB 44 is still awaiting referral to an Assembly policy committee. But, hopefully, this law will eliminate the roadblocks victims of terror attacks face when it comes to getting the care they need after a traumatic, life-changing event.
Contacting a Workers’ Compensation Lawyer
Whether you are the victim of a terrorist attack or a violent incident on the job, or if you have been injured in a workplace accident, it is important that you contact an experienced California workers’ compensation lawyer who will remain on your side, fight for your rights and help you obtain the critical care you need to recover physically and emotionally. Call the ODG Law Group at 818-230-2428 for a free consultation and comprehensive case evaluation.
Photo credit: The San Bernardino Sun