JOSÉ DUBON: The Human Face Behind WCAB Decision;
Consequences of Insurers Gaming UR System, Withholding Medical Records
CAAA PRESS RELEASE FOR IMMEDIATE RELEASE: Tuesday, October 28, 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 a UR DENIED story on José Dubon, the injured laborer whose case has resulted in three different Workers’ Compensation Appeals Board decisions, addressing what insurers are required to provide to Utilization Review (UR) to make the UR valid. Insurance carriers’ Utilization Review (UR) denies one in five physicians’ requests for medical treatment - up to 3,500,000 per year. 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. “José Dubon’s case has produced a WCAB decision that addresses insurers’ withholding of key medical records. Today, we are releasing the human story behind the Dubon I and II decisions,” CAAA President Bernardo de la Torre. “José waited more than a decade for back surgery for his work injury. That is unacceptable and outrageous and shows what is wrong with the abuse of Utilization Review (UR). The law requires that injured workers receive medical care in a timely and just fashion.”
“I needed spinal surgery, but UR denied it,” said José Dubon, 56, of Anaheim, who was a laborer for World Restoration for seventeen years before hurting his back in 2004 lifting a toolbox. “The insurance adjustor failed to send my medical records to the UR doctor, who therefore saw no need for my surgery. IMR upheld the UR denial. How can UR and IMR deny surgery without seeing my MRIs & medical records?”
“Insurers’ UR companies blatantly and willfully ignore and violate the law by issuing UR denials that fail to comply with the law, yet there are no effective sanctions or consequences for doing so,” said de la Torre. “In José’s case, the key medical records weren’t sent, the records UR reviewed were woefully incomplete, and were not even itemized. José has been left to twist in the wind with no treatment while the interminable and opaque IMR review process allowed insurers to avoid their responsibility to provide the doctor’s recommended treatment.”
The WCAB’s decisions allow 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. “It takes injured workers years 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 – even doing so without examining the key medical records, as in José’s case. If this happened in group health, there would be a patients’ riot,” said de la Torre.
See José Dubon’s story here.
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