After working for the largest workers’ compensation insurance company in California(quite possibly the entire country!) for over a quarter century, one begins to see the work comp system in a certain way. To begin, most injured workers who navigate the system deal only with the claims examiner for the insurance company and the “company” doctors, who provide these workers with some medical care to get them back to work as soon as possible. The vast majority of injured workers are not represented by legal counsel. Working as Legal Counsel in various capacities for the insurance company, I saw only those cases where an Applicant Attorney had become involved in the case, called a “litigated” case. On occasion I would recieve a call from the Claims Department asking about a problematic “non-represented” claim, but for the most part I dealt with “litigated” cases. You may ask yourself why do most claims go through the workers comp system without an applicant attorney involved? Many injuries are considered non-disabling, “first aid” only type cases that do not result in any disability or time off work. The worker gets patched up and goes back to work in short order. This is actually a good result for the worker. Then there are those cases where the injury is more serious and results in time off work and on-going medical care. The longer the case persists, the more likely something will go wrong: either the injured worker will be sent back to work by the doctor before he or she is ready to return to work and the claims examiner stops paying benefits or the claims examiner will refuse to authorize some form of medical treatment under the guise of Utilization Review. The complexities of the comp system kicks into gear and the result is that the injured worker becomes very frustrated with the whole thing and starts to consider getting legal counsel, and for good reason.
The reality is that the California workers’ comp system is not designed to help injured workers fully recover from their injuries based on the limitations placed on medical care through Utilization Review. Nor is it designed make people “whole” financially when they are injured. In fact, it is not meant to do so. Employers are required to have work comp insurance to do business in California and insurance companies are there to provide that insurance(to make a profit). Even State Fund, which is technically a non-profit entity, puts a lot of effort to keep its costs down in order to keep its operating ratios(expense ratios/loss ratios/combined ratios) as low as possible. One way of doing this is to keep benefits in check, including that ever present cost driver—medical treatment.
So if you are an injured worker, please know that the powers that be don’t always have your best interests at heart when you are going through the work comp process. Proceed with caution.
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