CA Court to Decide Constitutionality of Independent Medical Reviews

California (WorkersCompensation.com) - As part of its effort to streamline the workers’ compensation procedure, California made several changes to its laws in 2013. One of the major changes was the introduction of the Independent Medical Review (IMR) procedure.

The way the law works is if an injured worker disagrees with a treatment decision, he or she can request a utilization review (UR), in which an independent medical doctor reviews the records and makes a determination as to the necessity of the treatment. (A more thorough analysis of the UR process and how it works can be found here). If the claimant disagrees with the UR assessment, the claimant’s attorney can then file an appeal requesting the IMR. If an IMR is requested, another doctor will review the records and make a decision that is then implemented by the workers’ compensation judge. Neither the UR physician nor the IMR physician see the claimant in person.

The purpose of the law is for efficiency as stated by the Assembly Committee on Insurance in its August 2012 meeting. The statement reads:

[The current] system of “dueling doctors” with lawyers/judges making medical decisions has resulted in an extremely slow, inefficient process that many argue does not provide quality results. Long delays in obtaining treatment result in poorer outcomes, reduced return to work potential, and excessive costs in the system, none of which are good for injured workers. SB 863 would instead adopt an independent medical review system patterned after the long-standing and widely applauded IMR process used to resolve medical disputes in the health insurance system. Thus, a conflict-free medical expert would be evaluating medical issues and making sound medical decisions, based on a hierarchy of evidence-based medicine standards drawn from the health insurance IMR process, with workers’ compensation-specific modifications. The bill contains findings that this system would result in faster and better medical dispute resolution than existing law.” [Assembly Committee on Insurance, August 31, 2012 Hearing]

The constitutionality of the IMR procedure has been challenged in a few different court cases. The primary argument advanced by the challengers was one of due process. Both the Federal Constitution and the California State Constitution guarantee a right to procedural due process. In simple terms, this means that the government cannot deprive a person of life, liberty or property without notice and an opportunity to be heard by a neutral decision maker. The workers argued that because the IMR physicians denied the claimants the right to a particular medical procedure without an in-person examination, their right to due process was violated.

In October of 2015, California’s First District Court of Appeals rejected that argument in the case of Stevens v. WCAB. The court held that each level of appeal allowed the claimant to submit new information and have a voice in the determination, even if it was not in person. Also the court found that section 4 of the state constitution vested the legislature with the authority to create a workers’ compensation system, and that this authority was “unlimited by any provision of this Constitution.”

On Monday, March 20, California’s Third District Court of Appeals is set to hear oral arguments in the case of Ramirez v WCAB, another case that challenges the constitutionality of the IMR procedure. “In light of other developing case law, it seems quite unlikely that IMR would be declared unconstitutional at this point,” 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. However, she added “in the unlikely event that the Ramirez court finds any portion of Labor Code Section 4610.6 unconstitutional, the statute should not be entirely stricken as 4610.6(n) contains an express severability clause,” meaning that the parts of the law deemed unconstitutional can be removed without affecting the other parts.

If the Ramirez court does uphold the constitutionality of the IMR procedure, Langille predicts the matter will likely end there. “Given that the California Supreme Court declined to review either Stevens or Margaris [another IMR case], it seems unlikely that they would take interest in this case instead,” she said.

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