Legal Question in Workers Comp in California

I am an anesthesiologist who provided anesthesia services in 2004 to a workers comp injured worker for which the carrier admitted liability. They refuse to pay my claim because they prevailed against the surgeon insisting his back surgery was not necessary. However they paid him a lot of money for office related treatment and the injured worker got paid as well. The patient was in excruciating pain when she came to the surgery center and if I had refused to treat her it would have clearly been patient abandonment. No anesthesiologist is ever in the loop regarding pre-operative authorization. At the first hearing the judge reminded the defendant's attorney that I stand in the shoes of the injured worker ,not the shoes of the surgeon.He also instructed me to give the opposing attorney a copy of the appeals board decision where I had prevailed on a similar case. I added that by failure to preform utilization review and writing a nontimely denial letter any arguments they make regarding medical necessity are moot. The carrier is unmoved. I am due back in court here in California in 1 month. Any pearls of wisdom to offer?


Asked on 11/03/11, 4:46 pm

2 Answers from Attorneys

George Shers Law Offices of Georges H. Shers

Depending on how much you are seeking to recover, you might want an attorney to write a brief to explain in language and include better arguments. You might be entitled to seek a penalty for delay in benefits, interest [which would double your claim], shepardize the case you won to see if it is cited by other cases, raise the argument that the carrier knew others would be involved in the surgery so had to notify them they would not reimburse them, the worker is not penalized for what amounts to malpractice as the carrier should sue the surgeon for the added cost which includes the amount they should have paid you, that the surgery wold have gone forward with or without you but the patient would have been in horrible pain without you being their so your reduces the damages the worker suffered by providing your services, you did nothing wrong but would have been punished or lost your license to practice if you had not induced the medication, etc. I might be able to come up with additional arguments with a little more thought.

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Answered on 11/03/11, 8:55 pm
Ronald Mahurin Law Offices of Ronald Glenn Mahurin

You are in a no win situation. You will be forced to fully litigate the claim, meaning a trial if the carrier does not budge. Your question is contradictory. If the surgeon requested authorization and it was not timely authorized, then under Sandhagen, the surgery must be authorized, end of story. The only situation where an other result could be found is if the parties agreed to an AME or a second opinion issued regarding surgery. However, the timeline under Sandhagen would still apply for the second opinion, so I am at a loss to understand how the surgery was determined to be unnecessary.

Your best bet is to find a lien representative who deals with these types of issues routinely, for example Rios Consulting or MGM lein service and let them litigate the lien for a percentage of the recovery.

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Answered on 11/03/11, 9:59 pm


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