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Medical vs. Medical-Legal

Medical vs. Medical-Legal


Medical care is treatment based on Labor Code Section 4600. The rules that must be followed in connection with medical care are based on Labor Code 4610 and others that follow. In the context of the new law treatment that is denied is then referred to Independent Medical Review. The details of IMR will be discussed in later letters. The point is that for those of us that follow workers' compensation closely there is a concern that the new rules will make it harder yet for injured workers to get appropriate treatment. However, this should not be the case in connection with getting appropriate diagnostics and evaluations.


Medical-legal evaluations can be performed by panel QME doctors, AME doctors and by primary treating doctors. It may be obvious that a request for an MRI, a surgical consult or other testing when made by a QME comes under the medical-legal umbrella. In this writers' opinion, such requests are clearly not subject to UR or IMR. Although it may be less obvious, when there is a request by a party for a doctor to write a comprehensive medical evaluation on a disputed fact - this also comes under the medical-legal umbrella. The law in this regard has been in place for many years now and was not changed by the recent legislation.

Improper Denials

We have seen that medical-legal requests are treated by the defense as medical requests and put them through UR. In addition they require that consultations be with MPN doctors. Keep in mind that the Medical Provider Networks are under the treatment umbrella. There is no requirement that Medical-Legal consultations take place within the MPN or that they go through UR or IMR for that matter.

Why is this important? The insurance companies want to control treatment and evaluations in the workers' compensation system. Control of the process equals control of the outcome. We must fight to maintain control of the process as well to protect the rights of injured workers and to attempt to achieve reasonable results in a flawed system. Much of our control and been taken away by legislation. However, much control remains. It is important that we do not give away control by failure to understand the rules or by failure to act.

I do anticipate that control of the medical-legal process will continue to be the subject of litigation in the years to come.


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