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CAAA Reacts to WCAB's "Dubon 2" Decision on Utilization Review (UR) and IMR Requirements - FOR IMMEDIATE RELEASE: Monday, October 6, 2014  - Sacramento, CA - The California Workers’ Compensation Appeals Board (WCAB) issued its reconsidered decision today in Dubon v. World Restoration, addressing the issue of what insurers are required to provide to Utilization Review (UR) to make the UR valid. The Dubon v. World Restoration case is an excellent example of the widespread failure of claims administrators to provide adequate medical records to the UR reviewer. Without medical records, a UR reviewer's decision is not substantial evidence, and should not be applied to deny an injured worker the right to necessary medical treatment. “The public policy objective of UR and IMR is to expedite medical care, not delay it, but it is used to delay and deny medical treatment millions of times each year,” CAAA President Bernardo de la Torre. “CAAA is disappointed in today’s decision. Our members will continue to fight to protect the rights of California’s injured workers and ensure that injured workers receive medical care in a timely and just fashion.”

Opinion and Order Granting State Compensation Insurance Fund's Petition for Reconsideration in Jose Dubon v. World Restoration, Inc.; State Compensation Insurance Fund
by Diane Worley

The Appeals Board has issued an en banc  Opinion and Order Granting State Compensation Insurance Fund's Petition for Reconsideration in Jose Dubon v. World Restoration, Inc.; State Compensation Insurance Fund, (ADJ4274323, ADJ1601669),filed and served on May 22, 2014.

According to the WCAB: "The Appeals Board granted State Compensation Insurance Fund's petition for reconsideration of the February 27, 2014 Opinion and Decision After Reconsideration (En Banc) wherein the Appeals Board previously held that the Workers' Compensation Appeals Board may determine if a utilization review decision suffered ...  Read More


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Members Only Link.  Noteworthy Case Decision Synopsis: On February 27, the WCAB issued its’ en banc decision in Dubon v. World Restoration Inc, and SCIF, holding, after review of the relevant statutes,
regulations, and case law, that: 1. IMR solely resolves disputes over the medical necessity of treatment requests.
Issues of timeliness and compliance with statutes and regulations governing UR are
... Members Only Resource