Doctors reviewing treatment requests on behalf of insurance companies in workers’ compensation cases may now be held civilly liable if their recommendations fall below the standard of care required of doctors. In the past, these doctors argued they owed no duty of care to the injured workers. However, the recent appellate court decision of King v. CompPartners held these doctors do indeed owe a duty of care.
By way of background, in 2013, the California legislature made widespread changes to the workers’ compensation system. Among these was the introduction of the Independent Medical Review system. Previously, if the workers’ compensation insurance carrier denied treatment recommended by your doctor, you or your attorney were able to take the issue before the administrative judge. With the change, however, the insurance companies would send the proposed treatment to Utilization Review (UR). UR involved the insurance company sending the request to doctors hired to review the proposed treatment and your medical records. These doctors could be from anywhere and of any specialty, and without any knowledge of the patient’s medical history.
If the doctor denied the medication, it could be appealed only through Independent Medical Review (IMR). IMR is administered by Maximus, which assigns a doctor to review the denial. Neither the injured worker nor his or her attorney ever knows the identity of these doctors. If IMR agrees with the UR doctor and upholds the denial, it effectively ends any further appeal.
Until recently, neither the UR nor IMR doctors were under any obligation or duty to the injured workers who was seeking treatment. These doctors were under no obligation to provide any advice regarding potential negative effects of the treatment not being authorized. King v. CompParters, however, changed that. Here, Mr. King suffered a back injury, and subsequent depression caused by the pain. His physician prescribed him clonazepom (“Klonopin”) in order to treat the depression in 2011. When UR became effective in 2013, the insurance carrier sent the request for this medication to Dr. Naresh Sharma, an anesthesiologist, for review. Dr. Sharma determined the medication was not medically necessary. Therefore, the insurance company stopped paying for the drug, and Mr. King had to stop immediately. Typically when you stop a psychotropic drug such as Klonopin, you must be weaned off. Mr. King had to stop immediately, causing four seizures and further physical injuries.
King sued CompPartners and Dr. Sharma on several grounds including negligence. The defendants in this case felt the proper remedy was IMR, and therefore wanted the case dismissed entirely. The Fourth District Court of Appeal found IMR was the exclusive appeal method for whether or not he needed the medication; however, they found there was indeed a doctor-patient relationship between Dr. Sharma and Mr. King. While the court did not go further, it did say there may have been a duty for Dr. Sharma to warn Mr. King of the potential side effects of stopping the medication immediately.
This is still a developing area of the law, but it is good news for injured workers as now the UR doctor has a doctor-patient relationship with them. Like in the King case, it could potentially open up liability to UR doctors who wrongfully deny medication or treatment. If you have further questions regarding workers’ compensation, do not hesitate to contact Mastagni Holstedt, A.P.C.
About the author: Gerald D. Latasa is an associate in the Workers’ Compensation Department of Mastagni Hosltedt, APC. His practice focuses on all aspects of workers’ compensation litigation, including 132(a) penalties, serious and willful misconduct actions, and representing injured workers before the Workers’ Compensation Appeals Board.
 King v. COMPPARTNERS, INC., Cal: Court of Appeal, 4th Appellate Dist., 2nd Div. 2016