Help for CA IW's after being denied medications 2018 (Califo

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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby mytwocents on Tue Jan 16, 2018 1:22 pm

You may be thinking of an old case from 1974 called Silberg v. CA Life Insurance Co., 39 CCC 947, where the group health insurance policy excluded treatment for “injury or sickness for which compensation is payable under any Workmen's Compensation Law.” The Court held that the insurance company was liable up to the policy limits for anything that the workers’ comp carrier didn’t pay.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby Barney5 on Wed Jan 17, 2018 10:12 am

I have not seen any instances where injured workers had difficulties with obtaining treatment through their private insurance except for 2 injured workers, and they both had "K" private insurance.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby jpod on Wed Jan 17, 2018 11:28 am


I read the Silberg case but don’t think that fact pattern applies in this hypothectical. The claims manager for the health insurer said it didn’t pay the hospital bills b/c it was awaiting the outcome of the WC proceeding on compensability. The Court faulted the insurer for not paying and filing a lien against the employee’s compensation to recoup what it paid if the WC court found the injury to be compensable. The issue of reasonableness was not a factor.

In Silberg the hospital care insurance policy exclusion language was found to be ambiguous. The IW’s was a self-employed dry cleaner but had agreed to do some limited work for his landlord who had a dry cleaning store next door when he was injured. The WC case settled via C&R and the health insurer took that finding as a basis for applying the exclusion in hospital insurance contract. The court ruled the exclusion language to be ambiguous and that the insurer should have picked up the bills while the WC case was pending. That was the basis for a bad faith finding b/c if the claim was found to be not AOE/COE the health insurer would have paid the hospital bills anyway; conversely if the injury was found to be compensable it could recoup via the lien.

But that fact pattern is not what we are discussing. In this hypothetical the injury is compensable; IMR found the treatment to be unreasonable/unnecessary as defined by LC 4600 and the employee’s doctor (or the IW) submitted the unpaid bills to the employee’s health insurer for payment. There is no ambiguity issue about the exclusion language as there was in Silberg. There are no disputes remaining: the injury is AOE/COE and the matter of reasonableness was already resolved via IMR. What obligates the health insurer to pay the bills? Resolution of the reasonableness issue does not affect compensability.

Again I do not see how in practice a health insurer is contractually obligated to pick up treatment costs which have already been adjudicated as unreasonable for an admitted WC claim. Is the gap in my thinking that while IMR is pending the insurer has to pay b/c the issue of reasonableness was still pending even when the health insurance policy excludes coverage for work related injuries? Even if contractually obligated wouldn’t the health insurer just adopt the IMR ruling of unreasonableness?

How would the health insurer ever prevail that the WC insurer, or the IW, owed them money if it picked up the costs for IMR denied treatment on an accepted claim? Can a WCJ allow a lien against the IW’s compensation when IMR found the treatment to be unreasonable? Does the WCJ even have jurisdiction to order the WC insurer or the health insurer to pay the medical bills if IMR rules the treatment is unreasonable? LC 4903 seems to only allow the WCAB to award a “reasonable expense” for a lien filed against a claim for compensation.

I just don’t see how the health insurer is contractually obligated to pick up bills, or portions of bills that are not payable in the WC system when the underlying injury is covered under WC statutes. In practice isn’t it the doctor that files a lien b/c both the health and WC insurers will not pay?
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby Barney5 on Wed Jan 17, 2018 2:51 pm

Private insurance has a different system of what is considered medically necessary.
Last edited by Barney5 on Thu Jan 18, 2018 11:21 pm, edited 1 time in total.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby vampireinthenight on Wed Jan 17, 2018 3:14 pm

Yeah, Silberg was the one I was thinking of.

jpod, if the results of UR under each coverage denies the treatment, then I suppose there isn't much a patient could do other than follow the dispute process for each coverage they have. HMOs operate differently than other insurance, so the coverage could differ. If IMR (in WC) upholds the denial, then it is very likely that there would be no recoverable lien for the provider or insurer to recover on. But that doesn't mean the other coverage does not have to provide the treatment if it meets their protocols.

I've never researched it in depth. I suspect if you want to look further into what an HMO or health insurer has to provide, you might want to look at the Insurance Code and the Knox-Keene Act. There are regulatory minimums when it comes to providing types of care. For instance, I think they have to provide certain cancer screenings, orthotics, alcohol treatment, etc, etc. There's a huge list if you combine all the regulations and insurance codes.

Oh, and keep in mind, Knox-Keene Act was 1975 and there have been many additional legislative actions since that may have changed some of the things the Silberg case alluded to as possibly reasonable.

Let us know what you find out!
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