Legal Question in Workers Comp in California

The insurance company failed to render a UR decision within 5 working days and is still refusing to authorize the requested treatment. Since Dubon II states that "a UR decision is invalid and not subject to independent medical review if it is untimely" what are my options besides requesting an expedited hearing (which I am doing) and getting the judge to rule on the treatment request? Does 5814 apply and can I get a 25% penalty? Are there other penalties and sanctions I can ask for?


Asked on 2/21/17, 1:13 pm

1 Answer from Attorneys
Nancy Wallace Nancy Wallace Atty at Law

Options BESIDES the Expedited Hearing? Other than writing the defense attorney or insurance adjuster with threats of sanctions, no. The rule is that THE REQUESTING PHYSICIAN must get the notice in 5 WOrking days; the injured worker ad her attorney can receive them one more day after, 6 working days (8 calendar days, typically). Maybe if you can prove -- not just assert, but actually prove -- to the adjuster the date the doctor delivered the RFA and the prove the date the UR Decision wwas delivered was 9 days later, they may then wish to avoid a judge making that finding on the record and quietly approve that one requested procedure without an Expedited.

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Answered on 3/01/17, 3:55 pm


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