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If you’ve been injured at work, you’re entitled to medical treatment under California’s workers’ compensation system.
At DiMarco | Araujo | Montevideo, our workers’ comp lawyers have helped thousands of injured workers get the care and benefits they deserve. Below is a general overview of how medical care works.
For advice tailored to your situation, contact us for a free consultation at (714) 783-2205.
Treatment must follow guidelines set by the Division of Workers’ Compensation (DWC), based on peer-reviewed, evidence-based standards. Until DWC finalizes its own rules, the system relies on the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines. Other guidelines may apply if your injury isn’t addressed in ACOEM.
Yes. The treatment guidelines remain relevant even if your case settled before they were implemented. If your medical care is denied, you can request an expedited hearing before a workers’ compensation judge.
Yes. There is a cap of:
The law requires the claims administrator to authorize medical treatment within one business day of receiving your completed claim form, even while your claim is under review. This early care is limited to $10,000. If treatment isn’t approved promptly, speak with your employer right away.
As long as it’s medically necessary. Continued treatment must be supported by your doctor and justified under workers’ comp guidelines. These requests go through Utilization Review (UR) — a mandatory process where a third party determines whether proposed care is appropriate.
UR is used to confirm whether your doctor’s recommended treatment is medically necessary under workers’ comp law. If you believe UR isn’t being followed properly, you may file a complaint with the DWC or request a hearing before a judge.
Generally, no. If the claims administrator denies coverage, the doctor or provider must resolve it directly with them. However, disputes over payment may arise, especially after exams by a Qualified Medical Evaluator (QME) or Independent Medical Examiner (IME).
If the insurer refuses to pay for an authorized QME or IME exam—or the resulting treatment—you may need legal help to recover the cost or enforce compliance.
An MPN is a network of doctors approved by your employer’s insurance company to treat work injuries. If you didn’t pre-designate your personal physician before your injury, you must choose a doctor within the MPN.
Yes. You may request a list of MPN doctors and change providers within the network at any time.
You may pre-designate your regular doctor if:
You have options:
Your treating doctor must explain:
You, your doctor, your employer, and your work injury attorney should review this plan. If you disagree with the doctor’s recommendations, notify the claims administrator immediately in writing.
If a dispute arises, the administrator may request a second opinion through a QME or an Agreed Medical Evaluator (AME) if you’re represented by an attorney. This doctor will examine you and issue a report that may resolve the dispute. If not, you may bring your case before the Workers’ Compensation Appeals Board (WCAB).
Why Are QME and AME Reports Important?
These evaluations can help resolve disagreements about:
QME and IME reports often play a critical role in determining your benefits. If a payment dispute arises from these evaluations, legal intervention may be necessary to protect your rights and ensure fair compensation.