California Applicants' Attorneys Association (CAAA) Reacts to WCAB's "Dubon 2" Decision on Utilization Review (UR) and IMR Requirements
WCAB Backpedals, Lets Insurers Game System by not Sending Medical Records

Contact: Steve Hopcraft 916/457-5546,; Twitter: @shopcraft

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.”

“The decision allows UR companies to blatantly and willfully ignore and violate the law by issuing UR denials that fail to comply with Labor Code section 4610 or Rule 10451.2 just as long as they do so quickly.” Said de la Torre. “No matter that the medical records weren’t sent, or were woefully incomplete, or not even itemized (as in Dubon), nor that the physician is in the wrong field of medicine and isn’t qualified. The patient will twist in the wind with no treatment while the interminable and opaque IMR review process takes months and months to rubber stamp the UR denial.”

The WCAB’s new decision allows insurers to game the system by failing to send UR reviewers adequate medical records to support the doctor’s recommended medical treatment, so UR denies the claim. That despicable practice was clearly outlawed by the original Dubon decision. Now, the board has backpedaled and reopened the door for insurance carriers to deny treatment by ignoring the medical records of patients. It will now take injured workers months and months to go through the maze of UR and IMR obstacles. At the end of the maze IMR Reviewers continue to uphold 84% of the UR denials of doctors’ recommended care. If this happened in group health, there would be a patients’ riot,” said de la Torre.

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