Round 5: Sedgwick v. Juan Jose Gonzalez

Sedgwick vs. The People
“Deny & Delay Care to Drive Injured Workers Away”

X-Ray Technician’s Injury Tests Insurer, Sedgwick Fails: Defies Judge’s Order, Refuses to Provide Medical Care

CAAA PRESS RELEASE FOR IMMEDIATE RELEASE: Friday, February 7, 2014

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

Sacramento, CA – The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today released the fifth in their “Sedgwick vs. the People” series detailing Utilization Review (UR) abuses by insurance companies. The largest workers’ compensation insurer in North America, Sedgwick Claims Services, has failed to provide needed medical treatment and disability compensation to an injured X-Ray technician, despite a judge’s order finding his injury was work-related. Radiologic technologist Juan Jose Gonzalez, of Perris (Riverside County), worked for twenty-five years at several area hospitals. The hospitals loved his work. But when he tripped and fell in 2008 while moving an x-ray machine, the hospital’s insurer denied and delayed needed medical care, sent an investigator to demand the injured technician re-enact his fall, and then rejected his claim. His nightmare had begun, and it has not yet ended, despite a judge’s order in 2011 finding he was injured at work. “Sedgwick delayed and denied the care I needed for my work injury. They treated me like a criminal, not an injured professional hurt doing his job,” said Mr. Gonzalez. “Despite a court order finding my injury was work-related, Sedgwick has refused to provide any medical care. They are experts at giving injured workers the runaround, and have delayed my care for more than 5 years. How can they get away with that?”

CAAA has called for sanctions against insurance carriers like Sedgwick Claims Services, who consistently delay and deny doctors’ recommended care. On April 6, 2011, the Workers’ Compensation Appeals Board (WCAB) found that Mr. Gonzalez’s injuries were caused by his work. Yet, Sedgwick has refused for nearly three years to provide any medical treatment for Mr. Gonzalez’s injuries. The insurer still refuses to do so, ensnaring Mr. Gonzalez in an endless series of expert medical opinions, which they then dispute and contest. Sedgwick faces no effective penalties for its mistreatment of Mr. Gonzalez.

“On October 16, 2008, I was moving an x-ray machine, with many tubes connected, and I tripped. I didn’t want to damage the x-ray machine equipment, so I twisted awkwardly so as not to fall and knock over the x-ray machine. As I twisted, I bent over awkwardly, injuring both of my shoulders, my left elbow, my finger and my middle and lower back. I immediately contacted my house supervisor, who sent me to the emergency room. I was put on work restrictions, diagnosed with a back sprain and rotator cuff tear. I continued to work on light duty while waiting for approval for medical treatment,” said Mr. Gonzalez.

“One day, I got a call to go to a building at Inland Valley Hospital, where an investigator for Sedgwick was waiting for me. He said he wanted me to replicate the accident so he could film it. I had received no notice of this interview, and it made me very concerned. I was very reluctant to try to do what I’d been doing when I had injured myself. I told the investigator I couldn’t re-enact the injury, as I was concerned about further injuring myself. He told me I was refusing, and that it would have ‘serious consequences in your case. You don’t want to cooperate.’ A few days later, Sedgwick denied my case for refusing to “cooperate” with their investigator. Even though the MRIs showed labrum and rotator cuff injuries, Sedgwick refused to provide needed medical treatment. I took Sedgwick to court in 2011, and after a two and a half year delay, they agreed to a judge’s order finding my injury was work-related. Yet they have still refused all medical treatment.

“I was left on my own. It has been a nightmare for my family and me. I’ve had to get what care I could outside Sedgwick’s network. I’ve had three shoulder surgeries, all on my group health plan, and still need more. I’m in pain from my back injury,” said Mr. Gonzalez. “How did I go from being a valued and trusted employee of many years at Mercy and Scripps and Sharp Hospitals, to being painted as a monster?” Juan’s story is available here.

CAAA President Jim Butler said, “Insurers’ Utilization Review (UR) routinely delays and denies doctors’ legitimate requests for appropriate medical treatment. CAAA estimates, based on DWC data, that more than 3,500,000 doctors’ recommendations per year are denied. This is outrageous and expensive, and has got to change. Mr. Gonzalez shows how this business practice impacts everyday working Californians who just want to heal and get back to work. The lack of effective penalties enables insurers to unjustifiably delay and deny medical care for people like Juan, who are injured simply doing their jobs. It’s time to bring UR to heel, and stop insurance carriers from using it as a routine roadblock.”

For more information, visit: www.caaa.org

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