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A California health system does not have to reimburse a former employee for self-procured medical care that she sought after receiving “nightmare” care from an authorized physician, a California appellate court has ruled.
Roseville, Calif.-based Adventist Health was responsible for paying Evelyn Fletcher's “reasonably and necessarily incurred medical expenses” for her work injury, the California 3rd District Court of Appeals said in a Monday ruling. However, the court said Ms. Fletcher did not follow workers comp rules to secure suitable medical treatment.
Ms. Fletcher was working for Adventist Health when she injured her back in May 2000. She had unsuccessful back surgery in 2004, leaving her unable to work and in chronic severe pain, court records show.
Ms. Fletcher's original treating physician was dismissed from her case because he failed to meet workers comp reporting requirements. During the process of finding a new treating physician for Ms. Fletcher, Adventist “insisted” that she be treated temporarily by Dr. Justin Wasserman, records show.
Dr. Wasserman and Ms. Fletcher both described the visits unfavorably in claims records. Ms. Fletcher stopped visiting Dr. Wasserman, telling Adventist that his treatment was a “nightmare” and “disgusting.”
Ms. Fletcher soon sought treatment from an unauthorized physician and later requested reimbursement for her care under that doctor. California's Workers' Compensation Appeals Board ordered Adventist to pay Ms. Fletcher's care with the new doctor, and Adventist appealed.
In a unanimous decision, a three-judge panel of the appellate court annulled the comp board's ruling. It said that Ms. Fletcher prevented Adventist from reviewing her treatment by “unilaterally” changing doctors without authorization.
The workers comp board was not “unreasonable or unjust” in ordering Adventist to pay Ms. Fletcher's medical bills, the appellate court said. But it noted that the board did not have authority to order the payment since she “flaunted” California's workers comp rules.
“The dispute is not whether Fletcher has a right to a new physician, but whether she exercised that right according to workers compensation laws and regulations,” the opinion reads. “She did not, and her failure severely impinged on the employer's right to monitor her treatment to ensure that she was receiving reasonable treatment to relieve her pain.”
The court also annulled a decision by the comp board to exclude Dr. Wasserman's medical reports from Ms. Fletcher's comp claim history.
In its opinion, the court noted that Dr. Wasserman's notes — which identified a treatment plan and said Ms. Fletcher appeared to have opioid resistance — should be available for future treating physicians.
The case was remanded to the state comp board for further proceedings.