Supreme Court Hears Utilization Review Case

Posted by admin at 12:04 PM on Jun 13, 2018


The California Supreme Court is now pondering two questions: Whether injured workers can sue the physicians making utilization review determinations in court, and if so, whether liability (if any) for injuries that arise from those UR determinations is or is not covered solely by the workers’ compensation act’s exclusive remedy provision.

The Supreme Court justices heard oral arguments and are now deliberating about the issues.

The defense argued that allowing such civil actions would drive thousands of medical treatment disputes straight to the courts rather than through the independent medical review process the Legislature intended. It notes that the Legislature has repeatedly amended the statutes governing the UR and IMR processes and has never created a tort remedy outside the workers’ comp system for any situations.

Plaintiff’s attorneys in the case counter that allowing the civil tort action is not a new class of liability at all as the Legislature has already allowed injured workers to sue their treating physicians for malpractice. Additionally, they note that carriers are free to seek recovery from providers for unnecessary treatment costs. Here they say they are merely asking for a case-by-case review to determine if the UR reviewer met the duty of care.

Importantly, defense argues that an outside UR review company is not a party to the workers’ comp grand bargain between employees and employers.

The case King v. CompPartners stems from a UR determination by a CompPartners’ physician, Naresh Sharma, that a prescription for Klonopin was not medically necessary. The drug is used to treat anxiety and depression and carries warnings that patients should be weaned off the drug. Sudden withdrawal can lead to seizures.