Differing Court Decisions Highlight the Importance of Timelines in Medical Treatment Disputes

By Adam Dombchik, Esq.

In this monthly case law update we discuss a current controversy in the law regarding time requirements for reviews of denied medical treatment in a Workers' Compensation case. 

Senate Bill (SB) 863, which was signed into law by Governor Brown and implemented in January 2013, states that medical treatment disputes performed by Independent Medical Review (IMR) shall be completed within certain time frames.  A review of the statutes and regulations indicate that the time frame is 45 days from the insurance company's receipt of a medical treatment request. (For more on Independent Medical Review click here.)

After a work-related injury in California.

So, what rights, if any, does an injured worker have if the IMR process is not completed in this 45-day time frame? Two recent cases have centered around this issue, each resulting in a different outcome.

First is the case of Norberto Arredondo vs. Tri-Modal Distribution Services, Inc., State Compensation Insurance Fund.  In a split-panel decision, the Workers' Compensation Appeals Board (WCAB)—the first court of appeal for a Workers' Compensation decision—concluded that, "An IMR determination is a governmental action performed under the auspices and control of the Administrative Director, distinctly different from Utilization Review, in that given the statutory design of Independent Medical Review, the time frames are not mandatory, and therefore an IMR determination is valid even if it does not issue within 45 days."  One of the three Commissioners assigned to this case disagreed, concluding that the time requirements in the Labor Code must be construed as mandatory in order to uphold basic constitutional and statutory provisions of Workers' Compensation law that require prompt provision of medical care, and opined that such construction is consistent and mandatory with language implemented by SB 863. 

Second is the case of Stacey Saunders vs. Loma Linda University Medical Group. In this contrary decision, from the same WCAB but with a different set of three Commissioners assigned to the case, it was concluded that an untimely Independent Medical Review determination is invalid, such that a Workers' Compensation Judge has the ability to decide the medical treatment dispute based on substantial medical evidence, and that the timelines that apply to the IMR process are mandatory.

As advocates for injured workers, we at Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP are keeping a close eye on this debate. If the conclusion in the Saunders case prevails, it will allow attorneys an opportunity to go to court and ask a judge to order medical care when the State IMR process is untimely. We will continue to update you regarding this issue and any other changes in the Workers' Compensation system. If you would like to speak with an attorney about your legal options, please call 213-739-7000 or click here.

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