I needed spinal surgery, but UR denied it. 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?







About Me:  My name is José Dubon. I’m 56 years old, and I live in Anaheim, in Orange County.

About My Family: My wife and I have two children, ages 20 and 18, who both live with us.

My Job and What Happened: I worked as a laborer for 17 years for World Restoration, a company that repairs and cleans damage to homes and businesses, for example, from flooding. I very much enjoyed my work. In May 2004, I was injured doing my job. I was lifting a 25-pound toolbox and felt a sharp pain in my lower back. The injury damaged my spine, and caused other internal injuries. Multiple MRIs showed bulging discs in my back. I had back pain, numbness, and sometimes pain in both legs. From that day to this, I have been in pain. I wore a back brace and took painkillers. I received many injections in my back while fighting UR and IMR denials. I went through all the treatments available to avoid surgery, but they didn’t work. My doctor recommended surgery, but SCIF’s UR company denied it. I appealed, and it was revealed that SCIF had not sent the UR reviewer most of my medical records. The insurer left out the multiple MRIs showing disc damage. The UR reviewer denied surgery without reviewing my medical records. I appealed to IMR but they upheld the UR denial.

What this has meant to my life: For 10 years, I have lived with the pain from my work injuries. I have had to take painkillers and go through treatments that did not relieve my pain or fix my injuries. When the doctor recommended surgery, the insurance company spent years fighting it. Two different MRIs and other tests clearly showed the need for surgery to repair damaged discs. I can’t drive, bathe or eat without help.

How Utilization Review (UR) Delays and Denials Affect Me: Utilization Review (UR) is to ensure that medical treatment is needed and appropriate for the injury. Instead, UR is used as a roadblock to medical treatment. UR denies care based on incomplete medical records, and then IMR upholds faulty UR denials. It takes years to fight these UR and IMR denials. After three UR denials of my surgery, a 10-year wait, and on the eve of a court-ordered trial, the insurer authorized the surgery. The delay is a penalty that injured workers like me pay for being stuck in a system that is stacked against us. After the surgery, I have gotten worse. I’m still in pain. I can’t even put on my own shoes. I’ll never return to a normal life, to independence, or to the job I loved.

How Workers’ Comp was supposed to help me: Workers’ Compensation 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 have been out of work for 11 years because I couldn’t get the medical treatment to cure my injuries. I have lost many years of my life, unable to do things I love, and also lost a great deal of income to support my family. Insurance companies game the system by withholding the medical records that show the need for treatment. So treatment is denied. How can they get away with that dishonest behavior that harms people like me?