What happens when a workers’ compensation claims administrator disagrees with a primary doctor and rejects a medical treatment? This scenario is not uncommon: employee hurt at work, employee needs medication, employee’s doctor prescribes medication, employee’s treatment is evaluated by a workers’ compensation doctor, treatment is denied, treatment ceases, and employee becomes even sicker. A recent decision by the California Court of Appeal highlights this ongoing tension in the workers’ compensation context, where medical needs don’t always align with administrative efficiencies.
In the case of King v. CompPartners, Inc., Kirk King suffered a back injury at work in February 2008. In July 2011, Mr. King was diagnosed with anxiety and depression due to chronic back pain resulting from his injury. Later in 2011, Mr. King’s physician prescribed him Klonopin, an anti-anxiety medication, provided through his company’s workers’ compensation program.
But in July 2013, CompPartners conducted a “utilization review” of Mr. King’s medication. A utilization review (known as a UR) is a process required by law for employers and workers’ compensation claims administrators to review and evaluate the medical diagnoses underlying claims of injured employees to ensure that treatment is medically necessary. CompPartners was the UR company used by Mr. King’s employer to review his Klonopin prescription. A CompPartners doctor reviewed Mr. King’s treatment, concluded that the Klonopin prescription was unnecessary, and decertified its use by Mr. King.
As a result, Mr. King was denied further workers’ compensation coverage for Klonopin, and he was forced to immediately stop taking the drug. This had tragic consequences for Mr. King because it is unsafe to abruptly cease taking Klonopin. Like many medications, it requires a gradual reduction in dosage (or “weaning off”). The immediate termination of Klonopin led Mr. King to suffer four seizures, causing him further physical injury. A second UR took place in October 2013, and a different CompPartners doctor also concluded that Klonopin was medically unnecessary. Neither of the UR doctors examined Mr. King in person or warned him of the serious risks of abruptly stopping Klonopin.
Mr. King and his wife sued CompPartners, Inc., the UR doctors, and other parties (the defendants) in superior court in California for medical malpractice, negligence, infliction of emotional distress, and loss of consortium. The defendants asked the court to throw out the Kings’ claims for a variety of reasons, including that the Kings’ exclusive remedy should be through the workers’ compensation system and the Labor Code, not the tort system, because the claims made by the Kings originated from a UR of a workplace injury. They also argued that the doctors never personally examined Mr. King or treated him, so they did not owe him a duty of care, and they could not be liable for medical malpractice. The court agreed, and threw out the Kings’ lawsuit “with prejudice,” meaning that the court would not allow the Kings to re-file their lawsuit with new facts.
But the Kings appealed the decision to the California Court of Appeal. As to the “preemption” argument, the Court of Appeal agreed with the lower court that if Mr. King was harmed as a result of the UR doctor’s determination that Klonopin was medically unnecessary, when in fact the drug was medically necessary until Mr. Kirk was properly weaned from it, such an injury would be considered part of the UR determination and within the course of the workers’ compensation process, and a claim could only be brought through the workers’ compensation system. This is because the workers’ compensation system is intended to cover injuries occurring in the course of the employee’s job and that are proximately caused by the employee’s job, which include collateral or derivative injuries that arise from a UR.
However, the Court of Appeal also held that if the defendants harmed Mr. King by failing to warn him of the dangers of abruptly ceasing Klonopin, it would constitute a new injury, separate and apart from the UR determination and the workers’ compensation process, and could be the basis for a lawsuit in court.
As to whether the defendants owed Mr. King a duty of care, the Court of Appeal followed existing precedent and held that, although the doctors claimed that they did not personally treat Mr. King, under certain circumstances a doctor-patient relationship can exist between a UR doctor and the person whose medical records are being reviewed. This is because a UR doctor is acting as a health care provider as to the medical aspects of his or her decision, and these functions must be carried out by exercising medical judgment and applying clinical standards. The scope of the UR doctor’s duty of care, however, depends on the facts of the case. Accordingly, more facts were needed to determine if a duty of care to Mr. King was breached, such as how Mr. King learned of the decertification decision or if other doctors were involved.
The Court of Appeal ultimately returned the case to the lower court so that the Kings could amend and re-file their complaint with additional facts.
The King case is a cautionary tale for workers’ compensation claims administrators and workers alike. For claims administrators, the decision illustrates the dangers of second-guessing medical treatment decisions in the name of efficiency and the protection of workers’ compensation funds, which could lead to serious injuries and expose a claims administrator and its UR doctors to expensive medical malpractice claims. Given this inherent tension and the potential for significant risk, a review of the California workers’ compensation program, including the UR process and the review and licensing of UR doctors, might be on the horizon.
For workers who are injured on the job, it is a good reminder that you need to be in control when it comes to your treatment and recovery, that you should carefully question any employer or claims administrator’s decision to overrule your doctor’s orders, and you should consult with an experienced workers’ compensation attorney early and often to make sure that your rights are being protected.
The Poirier Law Firm has over 15 years of experience representing injured Georgia employees in workers’ compensation cases. If you or a family member has been hurt at work, call Poirier Law today for a free consultation.