Five years ago, while cleaning an industrial machine at work, our client lost his arm when it became trapped in that machine. Because this accident occurred while he was on the job, our client was required by law to file a workerâ€™s compensation claim, where the insurer is supposed to provide medical treatment for the various conditions and ills associated with an injury of this severity, including the daily psychological trauma and physical pain. Chiefly, with an amputation like this, neuromas develop. A neuroma is a growth or tumor of nerve tissue that tends to be benign (i.e. not cancerous), and can be caused by trauma to the nerve. Traumatic neuromas particularly tend to be painful and, as in this case, cause the individual to have major sensitivity in the area. In addition, amputees often experience “phantom limb pain.” Phantom limb pain (PLP) refers to ongoing painful sensations that feel as though they are coming from the part of the limb that is no longer there. The limb is gone, but the pain is real. Our client was diagnosed with these and other conditions, and has suffered with them for half a decade.
Unfortunately, under the current workerâ€™s compensation system in California, none of this matters. Instead of prioritizing treatment, the law confines an injured worker to a doctor within the medical provider network set up by the workerâ€™s compensation insurance carrier. Those recommendations by the treating physicians are subject to review by a Utilization Review (â€œURâ€) doctor. The UR doctors never examine the injured worker, never see the injured worker, and never get the opportunity to speak with the injured worker. Yet that UR doctor’s opinion on the recommendation carries more weight thanâ€”and can veto–the very doctor chosen by the insurance company to treat you.
In this case, Bentley & More‘s client was provided with a recommendation for a new prosthetic arm by his treating doctor. Yet Travelers Insurance Company denied the prosthesis by using a UR doctor from Texas. Poignantly, insurance carriers are using doctors who are unlicensed in California to veto the treatment recommended by a California doctor, and deny care without examining, seeing, or even speaking to the injured worker. And similar tragedies happen every day. Insurance carriers like Travelers, AIG, and State Compensation Insurance Fund have been saving money by providing subpar care to injured workers, hiding behind the UR process to do it. These shady tactics have resulted in a savings of over one billion dollars to these carriers, according to Work Comp Director Christine Baker. Savings translate to profits since employers have seen increases in their premiums.
That’s what we Californians must deal with if we are unlucky enough to be injured on the job. Insurers who compound one tragedy by causing anotherâ€”all to save their bottom line.
Even an appeal of the UR decision is fraught with challenges. To try to get our client his prosthesis, we have to follow an appeal process that is murky and secretive at best. Itâ€™s called â€œindependent medical review,â€ yet is anything but â€œindependent.â€ Instead, an anonymous company reviews the UR recommendation and makes its decision relying on a secret doctor who never sees, examines, or speaks to the injured worker. Despite calling itself â€œindependent,â€ the process upholds denied care for injured workers at an astounding rate of 86%. The insurance companies have rigged the playing field, and get to reject care recommended even by their chosen treating doctors 86% of the time.
Imagine losing your right to choose a doctor by his credentials or a friends’ recommendation. In a country that is supposed to enshrine civil liberties and protect our right to privacy, you lose the most sacred right to choose a doctor just because you were injured on the job. To compound that loss, even care recommended by that doctor is likely to be rejected by a system the insurance companies have designed to favor profits over injured workers. There are countless cases of injured workers who suffer like our client or, even worse, have been provided with substandard care causing paralysis or other crippling results.
This is not a system that protects workers or provides proper care. It is certainly not one that belongs in California. But itâ€™s what the insurance companies have been able to rig in their favor so far. Accordingly, I will continue to fight for my client’s right to have the prosthesis and will pursue the appeal in this unfair, one-sided system. If you are outraged, please share this piece with your friends and family or write to the Director of Workers Compensation, Christine Baker, at the Department of Industrial Relations.
The system must change. We must make that change. And finally protect workers across California.