CA Supreme Court Issues Decision That Brings Into Focus Utilization Review and the "No-Fault" Nature of the Workers' Compensation System

By Amy C. Leung
The California Supreme Court recently issued a highly anticipated decision in Kirk King et al. v. CompPartners, Inc., et al.  In King, the injured worker had been taking the medication Klonopin to treat his work-related injury.   As per the Labor Code provisions, the employer (through its insurance agency) submitted the doctor's prescription through the Utilization Review (UR)process, whereby a UR doctor reviews the treatment request for medical necessity.  The UR doctor denied the Klonopin as not medically necessary, and thus the employer abruptly ceased authorizing the medication.  As a result of the abrupt termination of medication, Mr. King tragically suffered seizures. 

Utilization Review and No Fault System

One of the cornerstones of the workers' compensation system is that it is the "exclusive remedy" for workers sustaining an on-the-job injury.   The workers' compensation system was established as a "no fault" system, meaning that injured workers do not have to prove an employer's negligence caused the injury, and in exchange employers are not allowed to be sued separately in civil court under tort law.

Mr. King wanted to pursue a civil lawsuit against the doctor asserting the doctor committed medical malpractice.  The attorney for Mr. King argued that the UR physician was negligent in deciding that the prescription was not medically necessary, and in failing to recommend a gradual weaning plan instead of abrupt cessation.  King argued that "exclusive remedy" did not apply to the UR doctor who was liable under civil law, like any other doctor who provided medical treatment to a patient. 

The Supreme Court concluded that UR organizations and their physicians are not subject to civil lawsuits when acting on behalf of the employer, and that the exclusive remedy protection applied.  In so ruling, the Court essentially held that the UR doctors are not personally liable to the injured employee, and may not be sued for malpractice.

However, the Court did affirm that any consequences and worsening of a worker's condition and disability due to treatment for an industrial injury is covered by the workers' compensation system.  The Justices pointed out some "significant problems" with the UR system.   The Court acknowledged the large impact and role that UR plays in an employer's duty to provide medical treatment to injured workers.  In a concurring opinion, Justice Liu said "the Legislature may wish to examine whether the existing safeguards provide sufficient incentives for competent and careful utilization review."

We are hopeful that with the Court's input, the California Legislature will re-evaluate the effectiveness of the UR procedure in properly caring for injured workers. 

The attorneys at Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP continue to fight for the rights for injured workers both through individual representation of our clients, as well as with continued input in the administrative process and legislative advocacy.

 

 

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