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Doctor, Attorneys Find Widespread Denial Of Care For Workers
By Steve Lawrence, Associated Press Writer - December 17, 2004

SACRAMENTO (AP) _ A physician and an attorneys' group said Thursday that efforts to overhaul California's workers' compensation system have led to widespread denials of care for employees who suffer job-related injuries.

"It's rampant. It's everywhere," said Dr. James Sylvain, a Watsonville specialist in physical medicine and rehabilitation who spoke by telephone at a Capitol news conference held by the California Applicants' Attorneys Association.

"There's not a single physician who's not affected by this. Surgeons, neurosurgeons, orthopedic surgeons have patients lining up who are incurring higher and higher levels of disabilities while waiting for their surgeries."

A spokeswoman for the American Insurance Association, Nicole Mahrt, said workers' comp insurers are "following the law" and "denying care that does not meet the standards because it's excessive or unnecessary."

Legislation adopted last year requires the state Division of Workers Compensation to draft treatment guidelines for doctors to follow when handling workers' comp cases. Those guidelines were supposed to be in place by Dec. 1 but are overdue.

In the meantime, the 2003 legislation required that injured workers receive treatment following guidelines put out by the American College of Occupational and Environmental Medicine, or ACOEM.

Sylvain said that's resulted in a "cookie cutter application" that has forced many injured workers to go without treatments recommended by their physicians.

He said the use of "medically untrained insurance adjustors" directing or denying care is a troublesome precedent that's being set. Sylvain added that the increased paperwork is causing some physicians to drop workers' comp practices.

A Tracy couple, Conrad and Sammie Sinclair, blamed their son Brandon's suicide last April on his struggles with an insurer over workers' comp benefits. "He was denied the basic care you would give to an animal," Conrad Sinclair told reporters.

Mark Gerlach, a consultant for the Applicants' Attorneys Association, said a panel of experts used for a Rand Corp. study found that five sets of treatment guidelines, including those offered by the ACOEM, "barely meet standards."

Gerlach also said the state Commission on Health and Safety and Workers Compensation had had "frequent reports" of treatment being withheld because it was not covered by the ACOEM guidelines.

Andrea Hoch, director of the Division of Workers Compensation, said she had heard ``some of the same concerns'' about denial of care but didn't know how widespread it was.

She said injured workers who felt they were being unreasonably denied treatment could seek an expedited hearing before a workers' compensation judge.

"What I don't want to do is jam through the medical treatment guidelines without having the benefit of an advisory group and having draft regulations posted for public comment," Hoch said.

She also said the guidelines were late because she had to wait for completion of the Rand study and recommendations from the Commission on Health and Safety and Workers Compensation.


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