In many cases, an evaluating doctor, AME or Panel QME will require diagnostics to be completed before being able to determine the degree of injury or whether an injured worker is at Maximum Medical Improvement (MMI). Some insurers will deny authorization for these necessary diagnostics, delay to stall the claim and try to starve an Applicant of resources to encourage a lower settlement.
It is important that an injured worker know his/her rights in situations like these. Recently, the WCAB has held that where an insurer refuses to authorize the diagnostics required by the evaluator, the injured worker may still be entitled to temporary disability benefits, also referred to as lost wages. Pribyl v. Acosta Sales and Marketing, 2017 Cal. Work Comp PD Lexis 350.
While this ruling is not binding in other workers' compensation claims, it provides some insight into how the WCAB may rule in other similar matters.
The WCAB has issued an opinion supplementing the Court's prior opinion in Dubon, that a Utilization Review (UR) decision to deny medical treatment must be communicated to the required parties (ie. treating physician, injured worker etc.) within the required time frame or it will be deemed untimely. Bodam v. San Bernardino County (2014) 79 Cal. Comp. Cases 1519.
This means that if an insurer timely completes a UR denial for the treatment requested by an injured worker's treating physician, it still must be communicated to the physician and injured worker within the required timeframes. If the UR is not timely, then the UR is invalid pursuant to Dubon and the injured worker may pursue an order from the WCAB that the treatment be authorized.
It should be noted that this opinion has been designated as a significant panel decision. Therefore, even though it is not binding on lower courts, it is does provide a strong indication as to how the WCAB will decide this particular issue.
The Court, in an en banc decision, held that where an injured worker sustains a new work related injury, he/she is not required to return to the same AME and/or QME's that were utilized to evaluate the prior injury. Navarro v. City of Montebello (2015, Appeals Board en banc) 79 Cal. Comp. Cases 418.
When the Workers' Compensation Appeals Board decides a case en banc, it becomes binding on the lower workers' compensation courts. While the Court's holding in Navarro does not mean an injured worker is entitled to a different AME or Panel QME for every date of injury they sustain, it does mean that an injured worker is not forever shackled to the same one for subsequent distinct injuries.
Many insurers attempt to preclude an injured worker from asserting this right to reduce the potential compensation due for an injury, an injured worker is usually wise to assert this right where applicable.