CA Case Review: King v. CompPartners Inc.

08 Mar, 2017 John Gerboth

                               

CA (WorkersCompensation.com) - If allowed to stand, the recent California case of King v. CompPartners Inc. will create a seismic shift in the California workers’ compensation system. In this case, the plaintiff suffered a work-related back injury in 2011. As a result of this injury, he began to suffer from anxiety and depression for which he was prescribed the drug Klonopin. This treatment was all provided under the plaintiff’s workers’ compensation claim. In 2013, the employer requested a utilization review to determine if the prescription was still medically necessary. 

Under Section 4610 of the California Labor Code, either party to a workers’ compensation claim can request a “utilization review,” which authorizes an independent medical profession to “prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians . . . or concurrent with the provision of medical treatment services . . .” In layman’s terms, upon request, an independent doctor will review the treatment plan and make a determination as to whether or not the procedures or medication being provided are necessary as part of the claimant’s medical treatment.

Section 4610.6 spells out the procedure for this medical review. It reads in relevant portion “the medical reviewer or reviewers selected to conduct the review by the independent medical review organization shall promptly review all pertinent medical records of the employee, provider reports, and any other information submitted to the organization or requested from any of the parties to the dispute by the reviewers.” Importantly, the medical professional who performs the utilization review does not meet with the patient in person, but rather simply reviews the pertinent medical records.

In the King case, a utilization review was performed Dr. Naresh Sharma, who, after reviewing the medical records determined the prescribed Klonopin was no longer medically necessary. King’s complaint alleges that his supply of Klonopin immediately ceased, and he could not wean off the drug as is medically recommended. As a result of this immediate cessation, King suffered seizures for which he filed a complaint in civil court against CompPartners (the utilization review company) and Dr. Sharma.

Rather than file an answer to the complaint, the defendants filed a demurrer, which is essentially an objection to the pleading. In this case, the defendants objected because they believed that King’s claims could not be brought in a civil court, and instead were preempted by workers’ compensation law. King disputed the demurrer and argued that his complaint was not about the decision to cease the supply of Klonopin, but rather the failure to allow him to wean off the drug. He asserted that CompPartners and Dr. Sharma were professionally negligent. The trial court sustained the demurrer, with the comment the matter “needs to go up to the Court of Appeals.” 

In order to establish a claim for medical negligence, the first element that must be proven is that a doctor-patient relationship existed. Relying exclusively on the case of Palmer v. Superior Court, a case that did not involve a workers’ compensation claim, the court found that there was a doctor-patient relationship between King and Sharma. Thus, King could plausibly argue that Dr. Sharma owed a duty to King, which he breached by ordering the supply of Klonopin to immediately stop. The finding of the doctor-patient relationship and its resulting duty represents a significant shift in the law.

“The legislative reforms of the workers’ compensation treatment dispute resolution process over the past 15 years (SB 228, SB 899, SB 863) were explicitly designed to put medical decisions into the hands of independent doctors trained in using evidence-based medicine and performing an adjudicatory function, and lessen the involvement of lawyers and judges,” said Ellen Sims Langille, General Counsel for the California Workers’ Compensation Institute, a research group that analyses issues and trends surrounding California workers’ compensation matters, in an email to WorkersCompensation.com. “The Court of Appeal decision subverts these reforms, in direct contravention of Labor Code Section 4610.5(e) (prohibiting utilization review decisions from being challenged except via independent medical review),” she added.

“Furthermore,” Langille continued, “considering the legislative purposes behind adoption of UR in workers’ compensation, the expedited time frames within which a workers’ compensation UR reviewer must submit a detailed written response to a treating doctor’s request for authorization, the limited medical information generally submitted by the treating doctor with the RFA, and the adversarial nature and role of the UR report, it was error for the Court of Appeal to find the UR doctor is a treating physician, or that any duty is owed to the claimant, or that the report is too remote to be protected by the litigation privilege, or that the injury falls outside the exclusive remedy of the workers’ compensation system.” 

Langille further stated that “[a] workers’ compensation UR doctor is not a treating doctor in the traditional sense of a hands-on patient advocate. Indeed, the UR physician neither meets nor examines the injured worker, much less establishes a ‘relationship’ with him. Rather, the UR physician is acting in the vein of an expert witness reporting to the employer on the application of principles of evidence-based medicine,” she continued (emphasis in original). “Simply put, the UR physician is not an examining nor attending physician, but instead is part of an adversarial administratively regulated dispute resolution process, and the UR doctor is therefore immune as part of the workers’ compensation ‘exclusive remedy’ and under the litigation privilege,” she concluded. 

The California Supreme Court granted review of the lower court decision meaning that the decision is on hold pending a decision by the court. “Based upon the speed with which the Supreme Court granted review, and the nature of the questions posed by the Court in its grant of review, we are optimistic that the Court of Appeals decision will be reversed,” said Langille. The stakes are high, though, according to Langille. “Should the Supreme Court instead uphold the decision, it would needlessly undermine over a decade of legislative reforms and reintroduce significant frictional costs and administrative expense into the system, both of which are contrary to the legislative intent of the reforms.”

 


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    About The Author

    • John Gerboth

      John Gerboth worked for many years as a workers' compensation attorney in Ohio. Since relocating to Connecticut, he has taken to "blawging" about various legal topics. He's also a husband, a father and a huge fan of the New England Patriots.

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