Case BriefUtilization Review / IMRUtilization Review Physicians May Owe Duty of Care to Applicants

March 10, 20160


(2016) 243 Cal. App. 4th 685

Applicant sustained an injury to his back on February 15, 2008. In 2011 he developed anxiety and depression, allegedly as a compensable consequence of his back pain and his treating physician prescribed Klonopin. The defendant provided the Klonopin until 2013 when they first submitted the prescription for Utilization Review.

The Utilization Review was conducted by an anesthesiologist, Dr. Sharma. The doctor determined that the Klonopin was not medically necessary and non-certified it. Based on the Utilization Review determination, the defendant ceased providing the medication without a tapering period. Because of the sudden cessation of the medication, the applicant suffered four seizures, resulting in physical injury.

In September 2013, another Request for Authorization for Klonopin was submitted for Utilization Review. This review was conducted by a psychiatrist, Dr. Ali, who also non-certified the request.

Neither Dr. Sharma nor Dr. Ali warned the applicant of the dangers of abrupt stoppage of medication and neither recommended a tapering program.

Rather than appeal the Utilization Review decisions through Independent Medical Review, the applicant filed a civil suit alleging negligence on the part of the Utilization Review company (Comp Partners) and its employees, Sharma and Ali.

Comp Partners filed a demurrer asserting that the plaintiff’s exclusive remedy was through the workers’¬†compensation system. They also argued that the doctors did not owe the plaintiff a duty of care because there was no doctor/patient relationship.

Plaintiff argued that the claims were not preempted by the workers’ compensation laws because King was not working at the time of the injury (seizures due to cutting off the medications) and the injury was not caused by the employee’s job. He argued that the defendants owed a duty of care because their medical decision-making was determining the plaintiff’s medical treatment. It was this medical decision-making that was negligent.

The trial judge sustained the demurrer without leave to amend. The plaintiff appealed.

The Court of Appeal first reviewed the preemption issue. It relied on Vacanti vs. State Compensation Insurance Fund, a lien case, and explained the exclusive remedy doctrine to mean “If something goes wrong in the claim process for the workplace injury, such as collecting the money for the workplace injury, then that collateral claim must stay within the exclusive province of workers’ compensation. However, if a new injury arises or the workplace injury is aggravated, then the exclusivity provisions and do not necessarily apply”.

The justices noted that the plaintiff’s complaint alleged that the applicant was harmed by both the Utilization Review decision to non-certify the medication and the failure to warn the applicant of the need to wean. The first issue is preempted by the workers’ compensation process (Utilization Review and Independent Medical Review); the second issue is not because it goes beyond the medical necessity determination of Utilization Review.

Because of this uncertainty, the demurrer was properly sustained. However, the plaintiff should have been allowed to amend the complaint to more specifically plead a cause of action.

The court also addressed the duty of care owed by Utilization Review physicians. Based on Keane vs. Wiggins, the court found that the Utilization Review physicians provided “medical care” because their medical decision-making determines the applicant’s course of treatment. However, they also noted that the duty of care varies with the relationship of the parties; with the foreseeability of harm that may be expected to flow from their conduct; and the reliance of persons on their opinions. Therefore, while the Utilization Review physicians owed a duty of care to the plaintiff, the nature and extent of that duty would depend on the facts of each case.

The case was remanded to the trial judge with instructions to allow plaintiffs to amend the complaint to allege facts clarifying the alleged breach of the duty of care.

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