Sacramento, CA (WorkersCompensation.com) – The California Supreme Court has ruled that an injured worker further injured by a utilization reviewer can only look to the Workers’ Compensation Administration (WCA) for relief.
In a decision handed down Thursday, the Supreme Court found unanimously that in the case of King vs. CompPartners, Inc., relief from misdiagnosis or errors from utilization reviewers can only be found through workers’ compensation.
The case involves Kirk King, an employee who sustained a back injury at work in February 2008. King suffered from chronic pain as a result, which led to depression and anxiety. King’s primary treating physician placed him on psychotropic drugs, including Klonopin, to treat the anxiety and depression.
In July 2013, Dr. Naresh Sharma was employed by CompPartners, and conducted a utilization review of King’s prescription. Sharma found the Klonopin medically unnecessary, and decertified the prescription. Sharma’s decertification of the prescription did not include any directions for weaning off the medication or any warning to King of what abruptly stopping the medicine could do.
Due to the decertification, King immediately stopped taking the medication and suffered from a series of seizures as a result.
In September 2013, King’s primary treating physician put King back on Klonopin. But another utilization reviewer, Dr. Mohammed Ashraf Ali, also determined the medication was medically unnecessary and also failed to put King on a weaning schedule or warn that there may be risks associated with abruptly stopping the medication.
In 2014, King filed suit against CompPartners, Dr. Sharma and others, alleging negligence, professional negligence, intentional and negligent infliction of emotional distress and loss of consortium. CompPartners demurred, arguing that King’s claims were preempted by the Workers’ Compensation Act.
As WorkersCompensation.com reported in May, a trial court agreed with CompPartners and sustained the demurrer. Later an appeals court also upheld the defendants’ claims saying that King’s exclusive remedy is through the workers’ compensation system.
“To the extent the Kings are faulting Sharma for not communicating a warning to Kirk, their claims are not preempted by the WCA because that warning would be beyond the ‘medical necessity’ determination made by Sharma,” the Appeals Court ruled. “To the extent the Kings are faulting Sharma for incorrectly deciding the medical necessity decision because Klonopin was medically necessary until Kirk was weaned, and thus a particular number of pills, e.g., 10, 20, should have been authorized for weaning, the Kings’ claims are preempted by the WCA because the Kings are directly challenging Sharma’s medical necessity determination.”
But the appeals court gave way for King to amend his complaint that Sharma’s failure to warn King of the adverse consequences of abruptly stopping the drug. The appeals court found that while “if something goes wrong in the claims process for (a) workplace injury” that the WCA exclusivity provisions would apply, but that “if a new injury arises or (a) prior workplace injury is aggravated, … the exclusivity provisions do not necessarily apply.”
CompPartners appealed the decision to the CA Supreme Court. After hearing oral arguments in May, the Supreme Court ruled on Thursday in favor of the lower courts, but overturned the appeals court’s decision on the role of Sharma in his capacity as utilization reviewer. In its decision the court said that utilization reviewers are acting on behalf of the employer and therefore covered by California’s Workers’ Compensation Act.
“The established principles lead to a straightforward answer here,” the court wrote. “The Kings seek to recover for injuries that arose during the treatment of King’s industrial injury and in the course of the workers’ compensation claims process. Because the Kings allege injuries that are derivative of a compensable workplace injury, their claims fall within the scope of the workers’ compensation bargain and are therefore compensable within the workers’ compensation system.”
In a concurring opinion, Justice J. Liu said that the case points to a flaw in the workers’ compensation system, however.
“But the undisputed facts in the case suggest that the workers’ compensation system, and the utilization review process in particular, may not be working as the Legislature intended,” he wrote in the concurring decision. “As today’s opinion notes, “the detailed scheme the Legislature enacted… contains several safeguards to protect employees form the sort of harm the Kings have alleged.”
Protecting employees and the workers’ compensation bargain may mean further investigation and action by the legislature, he concluded.
“The record in this case does not indicate whether (the) defendants followed the relevant statutory and regulatory requirements in discontinuing Kirk King’s prescription for Klonopin,” he continued. “But the seizures King suffered as a result of his abrupt withdrawal from the drug provide grounds for skepticism that ‘a care plan… appropriate for the medical needs of the employee’ was established before his prescription was discontinued…”
“And even if defendants fully complied with the relevant requirements, it is questionable whether those requirements are enough to prevent similar injuries from occurring in the future. The ‘compensation bargain’ that underlies the workers’ compensation system may allow for some ‘mistakes in the utilization review process…’ but the balance the bargain strikes between employers’ interests and workers’ interests presumes that utilization review — which is conducted either by the workers’ employer or by an entity ‘stand(ing) in the sho(es) of the employer’ will be performed ‘with appropriate competence and care.’ The limited record here raises doubts as to whether King’s utilization review was handled properly. The Legislature may wish to examine whether the existing safeguards provide sufficient incentives for competent and careful utilization review.”
Mark Walls, VP of Communications & Strategic Analysis at Safety National, told WorkersCompensation.com this ruling is a positive one.
“I am very pleased by the Supreme Court’s ruling in King vs. Comp Partners. This was clearly an effort to punch a hole in the exclusive remedy of workers’ compensation. Had the California Supreme Court ruled otherwise, you would have seen a flood of lawsuits not only against UR physicians, but likely also against others in the workers’ compensation system as well,” he said.
“To my knowledge, utilization review physicians ARE licensed like other physicians. These rules vary by state but for the most part they are licensed to practice medicine in the state they are rendering the opinion. Frankly I don’t see why having the UR physician in the same state is needed. The practice of medicine and human anatomy does not vary by state so I view this as an unnecessary impediment to not only UR but to things like telemedicine.”