California to Insurers: Don’t Use Workers’ Comp Law to Deny Approved Care

Special Report from ProPublica

by Michael Grabell, ProPublica

California labor officials have issued a warning to insurance companies that a new workers’ compensation law shouldn’t be used to reopen old cases and deny previously approved home health care to injured workers.

The notice follows a ProPublica and NPR investigation earlier this month that featured a worker paralyzed in an on-the-job accident whose home health aide was abruptly taken away by his company’s insurer, leaving him to sit in his own waste for hours at a time.

In addition, the state’s Senate Labor and Industrial Relations Committee has called a hearing Wednesday to discuss “the progress and remaining questions” surrounding the 2012 legislation.

The investigation by ProPublica and NPR found widespread cutbacks nationwide in benefits for injured workers. Since 2003, more than 30 states have slashed compensation for workers hurt on the job, created barriers to getting medical care, or made it more difficult for injured workers to qualify. The changes, often driven by business and insurers, are often labeled as “reforms” to existing workers’ comp systems.

As part of its 2012 reforms, California instituted a new medical review process while restoring some benefits that had been severely cut years earlier. Under the new process, the final arbiters of disputes over medical treatment changed from judges to anonymous outside doctors who never see the injured workers and can only be overruled in limited circumstances.

The law also applied retroactively, which means that all requests for medical treatment—including those involving older injuries—are now subject to reviews by insurance company doctors and more rigid medical treatment guidelines.

Insurers and state regulators say this has provided a check on inappropriate medical care, such as the over-prescription of addictive painkillers. But injured workers and their lawyers say insurance companies have used this provision to seize on minor treatment requests as an excuse to revise agreed-upon treatment plans.

In the case profiled by ProPublica and NPR, warehouse manager Joel Ramirez was paralyzed when a 900-pound crate fell on him in 2009. Travelers Insurance provided 24-hour home health care for several years. But it withdrew the aide last summer, and, according to a judge, asserted that the law allowed it to revisit the treatment and require the new medical review process.

The decision left Ramirez, 48, and his family to fend for themselves. He fell several times trying to transfer to and from his wheelchair and had to wait for hours for a relative to get home to help him clean himself because he was unable to control his bowels. His wife was forced to quit her job to look after him, and his daughter left college to help make up the lost income. After four months, Travelers reinstated the aide under orders from the state Workers’ Compensation Appeals Board.

In the notice issued Thursday, the Department of Industrial Relations and its Division of Workers’ Compensation said:

“agreed-upon medical treatment must be honored.”

The notice said:

“Under the 2012 reforms,” such care can’t be modified “unless a treating physician provides medical evidence of a change in the injured workers’ condition.”

Rupali Das, the division’s medical director, previously said in an interview that the state is planning to update the home health guideline after determining that it was too narrow and “does not meet what we want to have in California.”

Wednesday’s oversight hearing will review whether the law is living up to its goals of reducing costs while still ensuring that injured workers receive the medical care they need quickly.

Tthe committee wrote in its news release:

“Many of the reforms have drawn praise from stakeholders, but others have raised concerns.”

Lawmakers will hear from state administrators as well as insurance, labor, business and medical industry representatives.

State Sen. Tony Mendoza, a Democrat from Los Angeles County who heads the labor committee, said the hearing will explore whether the 2012 law:

“lives up to its commitment of increasing injured worker benefits, speeding up the provision of medical help for injured workers and decreasing workers’ compensation costs for California’s employers.”

Related coverage: See photos of what Joel Ramirez’s life is like after the warehouse accident that left him paralyzed from the waist down. And read the rest of Michael Grabell’s reporting on workers’ comp.

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