Treatment Was Denied By Utilization Review and I Want To Sue The Doctor

California Supreme Court

I Want to Sue the Doctor That Denied the Treatment – What Lawsuit Can I File?

In King v. CompPartners, the California Supreme Court dealt with this very issue. In King, the injured worker was denied via utilization review of a medication called Klonopin that he had been taking on a continued basis. When the medication was denied, the injured worker suffered seizures which resulted in a worsened condition.

Generally, someone injured on the job in California is limited to workers’ compensation benefits as the exclusive cause of action to obtain indemnity and medical treatment. So, an injured worker cannot sue the employer directly for matters stemming from a work injury and only has the insurance claim following an industrial accident.

Workers’ Compensation and Utilization Review

But, the situation in King, presented an instance where the individual who suffered the additional damages following the seizures filed a lawsuit against the utilization review physician for denying the medication that resulted in the seizures. This makes sense as medical practitioners possess a specialized knowledge of medicine and have a duty to provide a certain standard of care to patients. But, what complicates this issue in workers’ compensation cases is a utilization review physician is not directly treating the patient. Instead, they are reviewing a treating doctor’s request for medical necessity.

It appears the reviewing physician in King certainly made a mistake by denying ongoing authorization of Klonopin. Klonopin is prescribed to treat seizures, so logically it follows that failure to provide the medication resulted in the seizures. So, could the injured worker in King sue the utilization review doctor directly? That’s what he tried to do.

The CA Supreme Court said no. The court found utilization review entities are afforded the same protection as insurance carriers and claims administrators who stand in the shoes of the employer, shielded from liability for anything other than the workers’ compensation claim.

We Find This California Supreme Court Decision to Be in Error

Of course, medical doctors who perform utilization review services cannot be held to the same standard of an employer or insurer or administrator. Physicians spend years in medical school and residency before they can become licensed. The specialized knowledge doctors have should not be used to deny reasonable medical treatment requests. This is simply against public policy and is now made all the worse as these physicians are insulated from any additional civil claim that may be brought against them for their failure to provide the necessary standard of care.

The King decision also appears to be contrary to the ability of an injured worker to bring a medical malpractice lawsuit against a treating doctor directly where that doctor’s treatment has fallen below the standard of care required.

If you or someone you know is having problems obtaining reasonable medical treatment denied by utilization review, we are happy to help. Give us a call today at (619) 528-9800.