California company challenges workers’ comp coverage

Concrete supplier argues MRI and more weren't 'reasonable and necessary'

California company challenges workers’ comp coverage

If the medical record in a worker compensation matter needs further development, the doctor already involved in the case should first supplement the record, a panel of the Workers' Compensation Appeals Board of California recently said.

In Erhardt vs. U.S. Concrete dba Central Concrete Supply Company, Inc. permissibly self-insured, administered by Sedgwick Claims Management Services, an employee claimed that he injured his left knee while working for the employer as a concrete mixer driver. He applied for worker compensation.

Read more: Workers' Compensation Appeals Board dismisses petition

Section 4600 of California’s Labor Code requires employers to provide reasonable medical treatment to cure or to relieve from the effects of an industrial injury suffered by employees.

In this case, the doctor authorized to act as the applicant’s primary treating physician issued a progress report. The report included a request for authorization for a magnetic resonance imaging (MRI) for the applicant’s right knee and an arthroscopy for his left knee.

At trial, one of the issues was whether the requested medical procedures were reasonable and necessary. The workers’ compensation administrative law judge ordered the company to authorize the MRI and the surgery. The judge found that these medical procedures were reasonably necessary to cure or to relieve from the industrial injury’s effects.

The employer requested reconsideration. It argued that there was no evidence in the trial record that the right knee MRI and the left knee surgery were reasonable and necessary medical treatment.

The panel of the Workers’ Compensation Appeals Board of California amended the judge’s order to defer the issues of whether the requested medical procedures were reasonably necessary to cure or to relieve the applicant from the effects of his injury. The panel returned the matter to the judge in relation to this issue but otherwise affirmed the judge’s order.

The panel agreed with the employer’s argument that the trial record did not include medical evidence explaining why the MRI and the surgery were reasonable and necessary treatment for the applicant’s industrial injury.

The panel, upon reviewing the trial record, found that the physician’s progress report was the only medical report covering the applicant’s need for the specified procedures. These documents did not discuss or explain why the requested treatment was reasonable and necessary.

The panel recommended that the parties request the doctor to submit a narrative report stating his opinion on why the suggested treatment was reasonable and necessary to relieve the applicant from the effects of his industrial injury.

Recent articles & video

32% of Americans admit to lying on their resume

Safeguard Global chief people officer on effectively leading a hybrid workforce

Amazon DEI program manager on increasing mental health benefits

Employer pays $1.5 million over wage miscalculations

Most Read Articles

Biden extends pause on student loan repayment

Amazon DEI program manager on increasing mental health benefits

Students claim school employees failed to report janitor who allegedly sexually abused them