CA: Employers 100% Responsible for UR Mistakes

CA: Employers 100% Responsible for UR Mistakes

In a much-anticipated ruling, California’s Supreme Court ruled that a secondary injury derived from an incorrect Utilization Review (UR) decision is compensable under workers’ comp.

The Supreme Court denied the injured worker’s right to sue the Utilization Review Organization (URO) and UR physician in civil court, affirming workers’ comp as the “sole and exclusive remedy” for all injuries that arise out of or occur in the course of employment — including additional injuries that result from improper UR decisions regarding accepted injuries.

King vs CompPartners

The injured worker in question, Kirk King, suffered a compensable back injury in 2008. In 2011, King received a prescription for the psychotropic drug Klonopin to treat anxiety that stemmed from this initial injury.

In 2013, URO CompPartners determined that Klonopin was no longer medically necessary for King. Be that as it may, abruptly stopping use of Klonopin can have serious side effects, including the four seizures King suffered as a direct result of being taken off the medication without adequate weaning.

In addition, the physician conducting UR for CompPartners, an anesthesiologist by trade, failed even to inform King of the risks associated with going “cold turkey.” In 2014, King filed a civil suit, raising the most consequential question for employers, insurers, workers, and providers: who’s responsible when sub-par UR causes a new injury?

“Sole And Exclusive Remedy”

Ultimately making its way to the Supreme Court of California, King became a landmark case in workers’ comp history.

The court ruled that the UR decision to stop Klonopin, and the effects thereof, fall within the scope of workers’ comp, and thus cannot be addressed in civil court. The decision clarifies the “grand bargain” of workers’ comp, more clearly defining the phrase “sole and exclusive remedy” as found in Labor Code Section 3602.

In denying the case’s eligibility for civil court, the court widened and deepened the responsibility of employers and their insurers. Employers are responsible for injuries that occur “in the course of employment,” and also, as the decision states, for injuries that occur “in the course of the workers’ compensation claims process.” 

Providers should carefully document any adverse conditions or ailments which arise when treatment is the denied by the employer’s URO. Employers and their claims administrators are liable for any additional medical treatment, increased disability and other costs resulting from the actions of their UR doctors. Physicians must carefully document any complications that arise from adverse UR decisions in their reports, as these secondary conditions are compensable.

The decision goes on to clarify the scope of the Workers’ Compensation Act:

WCA’s exclusivity provisions preempt not only those causes of action premised on a compensable workplace injury, but also those causes of action premised on injuries “ ‘collateral to or derivative of’ ” such an injury. (Vacanti, supra, 24 Cal.4th at p. 811, quoting Snyder v. Michael’s Stores, Inc. (1997) 16 Cal.4th 991, 997 (Snyder).) Such collateral or derivative injuries include injuries stemming from conduct occurring in the workers’ compensation claims process.

Employers, insurers, URO, providers, and workers take note: any work-related injury, even the secondary variety, is compensable under workers’ comp alone. Proceed accordingly.

DaisyBill’s Billing Software has all the tools you need to properly request authorization, generating compliant RFAs and keeping track of when responses are due. Schedule a free demonstration today.


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