Insurance companies use Utilization Review (UR) to deny and delay needed medical care. The care is usually recommended by the company’s own chosen doctor. Without consequences or effective penalties, insurers’ UR is out of control. It has real impacts on injured workers.
About Me: My name is Doug Lee. I’m 51 years old, and I live in Magalia, just east of Chico, in Butte County.
About My Family: I am married with three grown children. My wife and I come from a long line of timber workers.
My Job and What Happened: I worked for Quality Timber as a logger. I felled trees on most days. In July 2003, I had felled a sugar pine, which pushed over a smaller tree that was now leaning at a dangerous 45° angle. I was sawing off the danger- ous limbs when my saw got stuck in the tree. As I yanked it loose, I strained my back.
I continued working, but a few weeks later I injured it worse. I fell into a hole while felling trees, landing on my lower back on top of my equipment and some tree limbs. I heard a snap, crackle and pop, and the pain was unbearable. My head started spinning and I threw up. My boss called me at home the next day and fired me.
I underwent two back surgeries; both of which failed. I walked into the first surgery, but had to use a cane after it. After the second surgery, the insurer cut off my physical therapy. I had to relearn to walk all on my own. I just want to heal and return to work.
What this has meant to my life: I’ve always been a hardworking person, but I haven’t been able to work since my injury. The insurer refuses to pay for any gym, or aquatherapy, or other therapy that would help. I can’t even get up in the morning without pain relief medication. Now, the insurance company delays and denies the pain medication. I have to have pain relief to be able to do what I can to live my life.
The Care I've been denied: I hurt my back felling trees. My saw got stuck and I fell into a hole on top of my equipment and tree limbs. I’ve had two failed back surgeries. I’ll never do my job again. I live with pain. The insurance company cuts off my pain medication for no reason, with no warning. Then approves the next month. Then denies the next. And so on. How does that help?
How Utilization Review (UR) Delays and Denials Affect Me: The insurance company arbitrarily denies filling my pain medica- tion prescription. Sometimes they approve it; sometimes they modify it; sometimes they deny it. Their Utilization Review doctor, who has never examined, or even met me, believes I am a drug addict who needs to be weaned off pain medication. I am no addict, and I take the minimum of the least potent pain medication. How does it help a person in pain to have their medication approved one month, denied the next and approved then denied for three months. It is a roller coaster that has me in pain most of the time.
How Workers’ Comp was supposed to help me: Workers’ Compensation insurance is supposed to provide medical care necessary to cure or relieve the effects of my work injury. I would love not to need pain medication to get through the day, but my back is not going to heal - ever. The insurer denies therapy, exercise and also pain medication. Utilization Review lets faceless, nameless company-hired doctors deny the treatment and medication recommended by treating the doctors who examine me. What sense does it make to approve, then deny, then modify, then approve, then deny pain medication?