What If Workers' Comp Insurance Disputes My Treatment?

Your doctor ordered a treatment. The insurer is not paying for it yet. That gap between the request and the authorization is a treatment dispute. California law sets strict time limits on how long the insurer can hold you there.

A treatment dispute is not the same as a denial. A dispute often means UR is in process and the clock is running on the carrier's decision deadline. It might also mean the insurer asked for additional clinical records and extended the window. Knowing exactly which situation you are in changes what you do next.

Below: how the UR timeline works. What the insurer is allowed to do during a dispute. When expedited review applies. What penalties a carrier faces for missing its deadline.

How long does the insurer have to respond to a treatment request?

Under Labor Code 4610, the carrier has five working days for routine prospective requests. Extensions are allowed up to 14 working days. Urgent care requests must be decided within 72 hours.

When your treating physician submits a Request for Authorization, the carrier's clock starts. For prospective routine treatment, the carrier must issue its UR decision within five working days of receipt. The carrier may extend this to 14 working days if it requests additional clinical information and the treating physician fails to respond.

For urgent prospective treatment, where delay would seriously harm the worker, the carrier has 72 hours. For retrospective review of treatment already delivered, the carrier has 30 working days. These deadlines are in the statute, not advisory guidelines. A carrier that routinely blows these windows faces both procedural consequences and potential penalty liability.

What is the difference between a UR delay and a UR denial?

A UR delay means the carrier has not responded yet. A UR denial means it responded with a rejection that triggers your 30-day IMR appeal right immediately.

When the insurer has not responded within the statutory window, the treatment may be deemed authorized. But this is not self-executing. The worker or attorney must affirmatively document the missed deadline and push the carrier. Take a school custodian whose spinal MRI request sat unanswered for three weeks past the five-day window. That missed deadline creates leverage. The carrier created it by staying silent.

When the insurer issues a UR denial within the statutory window, your 30-day IMR clock starts. That clock runs from the denial date. The denial must state the specific clinical reason and the MTUS guideline applied. A denial that is vague or does not cite MTUS criteria may be procedurally defective.

What can you do while a treatment dispute is pending?

While UR is pending, the treating physician can request expedited review, and you can continue authorized treatment. Do not stop ongoing medication or therapy without medical clearance.

If the dispute involves a new treatment while other authorized treatment continues, keep attending authorized appointments. The insurer's dispute over one RFA does not affect other already-authorized care. Take a delivery driver with authorized physical therapy for a knee injury. He also has a pending RFA for an MRI. He should keep attending PT while the MRI dispute resolves.

If the dispute involves urgent care, the treating physician can flag the request as expedited under Labor Code 4610. The expedited window is 72 hours. The physician must provide clinical documentation that delay poses a serious risk of harm. Expedited requests cannot be delayed for additional information requests the same way routine requests can.

What happens when the insurer misses the UR deadline?

A carrier that misses the UR decision deadline may face a deemed-authorization argument. The worker can also file a WCAB petition. Unreasonable delay penalties under Labor Code 5814 may also apply.

A UR decision issued outside the statutory timeframe may be invalid. The worker can petition the WCAB to enforce the timeline. An unreasonable delay in providing required medical treatment can support a 25 percent penalty under Labor Code 5814. That penalty is 25 percent of the delayed benefit amount. Carriers that routinely delay UR responses are not just slow. They may be creating liability on every delayed RFA.

Document every RFA submission date, every carrier response date, and every extension notice. This record is the foundation for any delay-based claim.

• §4610 - Utilization Review timelines, procedures, and penalty for late decisions
• §4610.5 - Independent Medical Review: 30-day appeal deadline after UR denial
• §5814 - 25% penalty for unreasonable delay in providing required benefits
• §4600 - Employer's continuing duty to provide medically necessary treatment
• State Comp. Ins. Fund v. WCAB (Sandhagen) (2008) - WCAB jurisdiction over untimely UR

How Yazdchi Law Handles Treatment Disputes

Treatment disputes are time-sensitive. Yazdchi Law tracks UR deadlines from the day the RFA is submitted and moves immediately when the carrier falls behind.

Many injured workers do not know that the insurer has a hard deadline to respond to treatment requests. When that deadline passes without a response, leverage shifts. Yazdchi Law identifies missed UR deadlines. It coordinates with treating physicians on expedited requests when appropriate. It pursues delay penalties when carriers repeatedly fail to respond on time.

Eman Yazdchi is a Certified Specialist in workers' compensation law, certified by the California Board of Legal Specialization, State Bar of California. The firm handles treatment disputes from the initial RFA through IMR appeal at every WCAB venue across California.

If your treatment is being held up by an insurer that is not responding to your doctor's requests, call (661) 273-1780.