Insurer Zurich North America offered a classic example of the bureaucratic absurdity that plagues California’s treatment authorization process, issuing a baffling, time-bound “certification” in response to a physician’s Request for Authorization (RFA).

The treating physician requested authorization to refer the injured worker to a psychologist for counseling. Zurich approved the counseling, but inexplicably limited it to a one-year “Certification Period” from July 11, 2025, through July 10, 2026.

Zurich’s approval made no mention of visit frequency or how many counseling sessions were authorized.

Is the psychologist cleared to see the injured worker weekly? Monthly? During certain phases of the moon?  Without these details, the psychologist has no way to schedule the patient appropriately.

This raises the obvious question: Does it serve California employers and their injured workers well to have Zurich, rather than the treating physician, determine the details of care?

Worse, Zurich’s so-called “authorization” includes language asserting that “ONLY A CLAIM ADJUSTER MAY MAKE A GUARANTEE OF PAYMENT,” in what appears like an attempt to reserve the right to refuse payment for (supposedly) authorized services.

Below, we summarize Zurich’s head-scratching response and share our advice to the psychologist.

Zurich Slaps Time Constraint on Treatment  Approval

The psychologist (a daisyCollect client) reached out with the oddball “certification” document, unsure of how to proceed with scheduling the injured worker since there was no indication of how many counseling sessions Zurich would allow.

Zurich’s response to the RFA (below) offers no specifics. Instead, it vaguely approves “psychological counseling” with the psychologist the treating physician specified in the RFA, but lists a “Certification Period” that closes in a year.

Since Zurich did not specify the amount of treatment or number of sessions it was willing to approve, how is the psychologist supposed to schedule visits?

The vagueness of the UR response adds even more friction to the process of obtaining care for the injured worker that all parties agree is “medically necessary;” the provider needs to send a second RFA requesting clarification as to the count of services authorized.

Authorization Guarantees Payment?

Unequivocally, when a claims administrator authorizes treatment, that authorization is a guarantee of payment. California Labor Code Section 4610.3 states (emphases ours):

“...an employer that authorizes medical treatment shall not rescind or modify that authorization after the medical treatment has been provided based on that authorization for any reason…”

There is no statute, regulation, or rule that permits insurers or their Utilization Review (UR) vendors to impose arbitrary deadlines for rendering authorized treatment. Nor is there any provision that allows them to revoke payment based on such deadlines.

California Labor Code Section 4610 specifies only that “Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment service approved,” while California Code of Regulations (CCR) Section 9792.9.1 states:

“All decisions to approve a request for authorization shall specify the date the complete request for authorization was received, the medical treatment service requested, the specific medical treatment service approved, and the date of the decision.”

Nowhere do these California laws or regulations authorize the payer to subsequently second-guess the treatment or walk back payment. Yet, Zurich’s UR response declares that the document is “NOT AN APPROVAL OF BENEFITS” and states that “ONLY A CLAIM ADJUSTER MAY MAKE A GUARANTEE OF PAYMENT.”

Unfortunately, the California Division of Workers’ Compensation (CA DWC) doesn’t discourage this behavior.

In 2024, the CA DWC quietly deleted a key FAQ from its website. That FAQ previously confirmed a basic, vital truth: when treatment is authorized, payment is guaranteed. With that deletion, the CA DWC sent a chilling message that casts doubt over whether any authorization truly secures payment.

Providers are left twisting in the wind, forced to provide care with no real assurance they’ll ever be reimbursed.

CA Needs Authorization Reform

In California, providers must jump through hoops to submit a perfectly compliant RFA using the official DWC Form RFA. If the provider makes one wrong move, the request can be denied.

Meanwhile, claims administrators face no such scrutiny. There is no standard form or format for responding to RFAs; they can respond with vague, bloated, borderline-illegible documents like Zurich’s mess above, which still counts as a valid UR decision.

This double standard puts providers in a perpetual bind. When the payer’s response is unclear (or nonsensical), providers are left guessing. Guessing wrong can mean no payment.

Our advice to the psychologist is simple:

1. Treat the injured worker for the first counseling session. Zurich technically approved the treatment, even if they refused to say how frequently.
   
2. Then, submit a new RFA clearly and precisely requesting a specific number of sessions (so Zurich has less room to play games).

When it comes to authorization, specifics matter. Otherwise, payers can (and will) claim that treatment wasn’t properly authorized.

Let’s not forget who ultimately pays the price for this bureaucratic gamesmanship: California employers and their injured workers. Employers are stuck with ever-rising workers’ comp premiums while injured workers receive delayed, substandard care dictated by insurers instead of doctors.

Until California ends the double standard and requires claims administrators to issue clear, standardized RFA responses, the system will remain rigged in favor of payers, at everyone else’s expense.

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