When Employer Disputes Need for Treatment You Must Use Utilization Review

• Posted By: Harvey Brown
• August 1, 2008

This is a significant decision involving interpretation of Labor Code sections 4610 and 4062.

The applicant incurred an admitted industrial injury in 2003. The applicant received medical treatment and the physician requested a magnetic resonance image (MRI). The employer submitted this request for utilization review. The employer did not communicate its decision within the 14 days required by Labor Code section 4610.

The applicant attorney requested an expedited hearing. The Workers’ Compensation Judge (WCJ) found the employer failed to comply and ordered the MRI. The employer filed a petition for reconsideration.

The Workers’ Compensation Appeals Board ( WCAB) heard the case en banc and issued a decision saying that even though the employer missed the deadline for review under 4610, they could still use Labor Code section 4062. Under 4062 the employer could dispute the treating physician.

The employer filed a writ with the Court of Appeal who issued an opinion agreeing with the WCAB. The Court of Appeal indicated that even though the employer was precluded from the utilization review process the employer could still utilize section 4062.

The Supreme Court analyzed Senate Bills 228 and 899and overturned the lower court decision. The Supreme Court determined base on the language of the statutes that you must use the utilization review process of section 4610 and cannot rely on 4062. This is extremely important since you have to react quickly within the time constraints of 4610.

Case: SCIF v WCAB, Sandhagen
This is a Supreme Court decision of monumental proportions.

• Posted In: Work Injury