Why Insurance Companies Deny Worker’s Compensation Treatment Requests

Understanding Why Insurance Companies Deny Worker’s Compensation Treatment Requests in California


Workers’ Compensation provides crucial benefits to employees suffering work-related injuries or illnesses. However, obtaining necessary medical treatment can be challenging. One common obstacle in California is the denial of treatment requests by insurance companies. This article explores the reasons behind these denials and sheds light on this complex issue.

Cost Containment:

Insurance companies aim to minimize costs and maximize profits. Their loyalty is to the shareholders, not you the injured worker. Denying treatment requests helps contain expenses and generates profit. They may claim certain treatments are unnecessary or not directly related to the work injury to save on medical expenses.

Lack of Medical Evidence:

Insurance companies require comprehensive medical evidence to support treatment requests. If the documentation is insufficient or doesn’t clearly link the treatment to the work injury, they usually deny the request.

Preexisting Condition or Alternative Causes:

Insurers might attribute the worker’s condition to preexisting injuries, medical conditions, or other non-work-related causes. They may argue the treatment isn’t warranted because the condition existed before the work injury or was caused by unrelated factors like age, weight, race etc.

Disputes Over Causation:

Establishing a direct link between the work injury and the requested treatment can be difficult. Insurance companies may dispute this causal relationship, requiring additional medical opinions or evaluations to validate the treatment’s necessity.

Utilization Review (UR) Process:

In California, the utilization review process determines the medical necessity of requested treatments. Insurance companies use this process to evaluate and potentially deny treatment requests, arguing that the treatment isn’t medically necessary or that cheaper alternatives could achieve the same results. UR denies treatment about 90% of the time.

Independent Medical Review (IMR):

If an injured worker disagrees with a treatment denial, they can request an independent medical review. However, the IMR process is complex and time-consuming. Insurance companies may exploit this complexity, delaying the review and leaving the worker without necessary treatment. IMR appeals uphold denied treatment decisions about 90% of the time.

Legal Strategies and Tactics:

Insurance companies employ skilled defense attorneys familiar with Workers’ Compensation law. These attorneys use strategies to challenge treatment requests, such as questioning the credibility of medical providers or disputing the injury’s extent. These tactics aim to weaken the worker’s case and justify treatment denials.

Conclusion: Denials of Workers’ Compensation treatment requests by insurance companies in California can be frustrating and detrimental to injured workers. Understanding the reasons behind these denials and seeking legal assistance when necessary is crucial. Consulting with an experienced Workers’ Compensation attorney can help injured workers navigate the complex claims process, gather strong medical evidence, challenge denials, and secure the medical treatment they deserve.

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