[Billy Miller]

(04-02-2018, 08:49 AM)kev_b Wrote: File for a hearing claiming Unreasonable delay, if UR and IMR deemed the medication medically necessary then the claims administrator MUST authorize, I would also file an audit complaint with the DWC.

https://www.dir.ca.gov/dwc/educonf12/5814/Penalty.pdf

A. Unreasonable delay: 5814. When payment of compensation has been
unreasonably delayed or refused, either prior to or subsequent to the issuance of
an award, the amount of the payment unreasonably delayed or refused shall be
increased up to 25 percent or up to Ten Thousand Dollars ($10,000), whichever
is less. In any proceeding under this section, the appeals board shall use its
discretion to accomplish a fair balance and substantial justice between the parties.

II. Audit penalty: Any employer or insurer that knowingly violates section 5814
with a frequency that indicates a general business practice is liable for administrative
penalties of not to exceed four hundred thousand dollars ($400,000). Penalty
payments shall be imposed by the administrative direction and deposited into the
return-to-work fund established pursuant to section 139.48. The administrative
director may impose a penalty under either this section or subdivision (e) of section
129.5.

DIR employee called and left a message saying they were filing a "DOR" even though the UR had certified the medication. Is there another form to fill out when the adjusters are not adhering to their own UR forms?


The UR approved a medication from Jan to March 2018 and my adjuster refused to fill that medication. The UR finally denied this particular medication on April 3, are there forms I can fill out because the adjuster refused to fill UR Certified Medications? I want the company to get a penalty because they play lots of games, it gets so old having them deny medications that were approved by their doctors.