Authorizations of Immediate Medical Care Do NOT Need to Be in Writing
LC 5402(c) requires authorization of all treatment (up to $10,000) consistent with applicable treatment guidelines for the injury within one working day of filing of the claim form, but there is no current statute or regulation requiring that such authorization be in writing.
The issue arose recently after an Institute member received a call from a local WCAB informing them that they must add language to their delay notices authorizing up to $10,000 in medical care until the employer accepts or denies the claim. In this case, an unrepresented worker had taken their delay letter to the WCAB and met with an Information & Assistance Officer. The I&A officer told the claimant that the notice failed to indicate that the insurer would cover up to $10,000 in immediate medical care and that a revised notice with this language needed to go out immediately, even though workers are already informed of their rights under LC 5402(c) in the Notice of Potential Eligibility (cover sheet to the DWC-1), on the posting notice and in the new hire pamphlet.
When the I&A officer called the insurer, the claims administrator told her that treatment had been authorized, but the I&A officer said the authorization must be in writing. CWCI contacted the I&A Unit Manager at the DWC and confirmed that there is no existing statute or regulation requiring that the authorization of treatment during the delay period be in writing or be included in a delay letter. The I&A Manager agreed to alert the I&A officers, but did note that proposed benefit notice regulations drafted by the Division would require delay and denial notices to include the following 5402(c) language.
DWC’s draft language for the delay notice: For claims reported on or after April 19, 2004, regardless of the date of injury, if you submitted a claim form to your employer or claims administrator, Labor Code section 5402(c) provides that within one working day after you file the claim form, the employer shall authorize the provision of all medical treatment, consistent with the applicable treatment guidelines, for the alleged injury and shall continue to provide such medical treatment until the claims administrator accepts or denies liability for the claim. Liability for medical treatment under this Labor Code section shall be limited to a maximum of ten thousand dollars ($10,000).
DWC’s draft language for the denial notice: If you reported your claim on or after April 19, 2004, regardless of the date of injury, you may be entitled under Labor Code section 5402(c) to payment up to $10,000 for medical treatment, consistent with the applicable treatment guidelines, from one working day after you filed your DWC-1 claim form until the date of this notice denying liability for the claim. Unless you have done so already, you should send me all your medical treatment bills services obtained during this period for consideration of payment. Labor Code section 5402(d) provides that payment for this treatment shall not give rise to a presumption of liability on the part of the employer.
An advisory committee provided input on the draft benefit notice regs at the end of October, but they still must go through public hearing and OAL approval, and are subject to change. Notably, even with this additional language, there would still be no statutory or regulatory requirement that claims administrators issue a written authorization for initial treatment, though nothing would preclude them from doing so.
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