Out of State Medical Care in a California Workers Compensation Case

Workers injured on the job in California are entitled to medical treatment out of state and in other countries if the injured worker:

  • moves outside of California but still needs treatment
  • needs emergency care outside of California
  • lives near the border with another state
  • needs treatment that is not available in California

All medical treatment, whether in California or out-of-state, has to be reasonable and must address an occupational injury. It must provide some benefit to the injured worker's condition.

For medical care outside of California, there must be a reasonable basis for the injured worker to have to travel out of state for the treatment. A valid basis could be that the treatment is not available in California.

An injured worker can request out-of-state care from the insurance company or obtain the care first and later ask the insurance company to pay for it. When the injured worker gets the care first it is called “self-procured”.

If the out-of-state treatment is reasonable and the insurance company has to pay for the injured worker's travel expenses.

In this article, our California personal injury lawyers will help explain how an injured worker can obtain medical treatment for a work injury in any location.

1. What kind of out-of-state care are California injured workers entitled to?

California employers are required to provide medical care to injured workers to treat and recover from an injury.1 This is one of the many benefits available to California injured workers.

Other benefits for injured workers include permanent disability, temporary disability, death benefits, and job displacement benefits. 

1.1. Type of care

Medical treatment includes:

  • physician visits
  • surgery
  • physical therapy
  • acupuncture
  • chiropractic care
  • hospital visits and overnight stays
  • medications
  • diagnostic tests
  • supplies2
  • therapy
  • weight loss treatment

1.2. Reasonable care

The out of state treatment must be reasonable.3 This means the treatment provides some benefit to the injured worker and either treats or cures the medical condition or reduces pain.4

In California insurance companies for employers set up “Medical Provider Networks”(MPN). These are groups of doctors in different specialties throughout the state that agree to treat injured workers.5

When an injured worker needs to treat in another state or country there may not be an MPN. However, the injured worker is still entitled to medical treatment and the insurance company should assist the injured working in finding a doctor.6

2. Reasons to obtain medical treatment out of state

There are several situations in which an injured California worker who files a workers comp claim may need to treat outside of California:

  1. They are injured outside of the state and need treatment there.
  2. They live close to another state's border that has closer doctors.
  3. They move to another state after their injury.
  4. They go back to their home country.
  5. They leave the state and require unexpected treatment for their injury.
  6. The injury requires new treatment not available in California.

Example: Alan suffers an injury that results in his left arm being amputated. He continues to have pain in the arm and the treatment he receives in California is not effective. A doctor in New York has developed a new treatment to help with the pain.

Alan can get the treatment in New York since he tried and failed to find adequate treatment in California to help his pain.7

2.1. Reasonable geographic area

Whether an injured worker can get out of state care sometimes depends on whether the distance traveled is reasonable based on the injured worker's situation.

A reasonable geographic area depends on several factors.8

  1. the employee's place of residence, place of employment and place where the injury occurred; and
  2. the availability of physicians in the fields of practice, and facilities offering treatment reasonably required to cure or relieve the employee from the effects of the injury;
  3. the employee's medical history;
  4. the employee's primary language.

If an injured worker can meet this test, then the medical care is reasonable.9

Example: Jose is a Calfiornia firefighter who files a workers comp claim after he suffers a cumulative trauma injury through his work. He is not satisfied with the treatment he is receiving, so he goes to Mexico and receives treatment from a doctor there.

The back treatment is helpful and reasonable. The insurance company is responsible for payment of the treatment.10

Example: Tom, a security guard, injures his back at work. Several of Tom's doctors tell him that he should lose weight to help him recover from his work injury. They do not suggest any specific weight loss program, nor did the insurance company give Tom any options.

Tom had tried many weight loss programs in the past that were not effective. Tom's friend recommends a program at Duke University. His doctor fully supports this.

Tom enrolls in the program and lost 175 pounds.

He claims that going to Duke program is reasonable because there isn't any place similar in California. Tom has documentation of all of his expenses. The insurance company does not try to argue that the treatment is unreasonable.

The insurance company is required to pay for the treatment because they never took any action themselves to offer alternatives.11

3. How to request medical care outside of California

An injured worker should first ask the insurance company to authorize treatment out of state and give the reason. If the out-of-state treatment is approved, the injured worker will know that the treatment will be paid for by the insurance company.

When an injured worker does not get approval for treatment for a work injury, this is called “self-procured” treatment.

An injured worker can obtain self-procured treatment when the insurance company does not do its job in stating how to get medical treatment or is not providing treatment.12

The common issue with self-procured treatment is that the treatment provider may not want to provide the treatment without an understanding of how it's going to be paid for.

Example: Jane is a UPS and injures her right knee when she slipped and fell on her right side while delivering a package. The insurance company never told Jane what doctor she could see or how to find one herself.

Jane picks a doctor and treats for her right knee. The insurance company is required to pay for Jane's treatment. Medical treatment is one of the benefits for injured workers.

4. Out-of-state travel

Travel is also an included expense for out of state treatment. Mileage reimbursement in connection with a workers comp case is a commonly paid benefit.

Example: Joe injures his shoulder. The insurance company fails to notify Joe of where he could treat for his injury.

He is referred to a shoulder specialist in Seattle. After the visit, he submits the treatment and his cost of travel for payment by the insurance company.

The insurance company has to pay for the travel because they did not take action themselves to provide Joe with treatment and the shoulder treatment in Seattle was reasonable.13

Proving out-of-state care is reasonable

Obtaining medical treatment outside of California requires proving that the medical care is necessary and could not be provided at a closer location.

If an injured worker can prove those elements, the travel for the medical treatment will also be paid by the insurance company.

It is important for the injured worker to carefully consider where to obtain treatment so he or she can get the right treatment at no cost.

LEGAL REFERENCES:

  1. Cal. Lab. Code § 4600(a) Medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury shall be provided by the employer.

  2. Id.

  3. State Compensation Ins. Fund v. Workers' Comp. Appeals Bd., (1977) 69 Cal. App. 3d 884, 893

  4. Cal. Lab. Code § 4600

  5. Cal. Lab. Code § 4610

  6. Even though a doctor is described as someone who has a license to practice medicine in California, the California Workers' Compensation Court is not limited to only the state of California. See Cal. Lab. Code § 3209.3 “Physician” includes physicians and surgeons holding an M.D. or D.O. degree, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners licensed by California state law and within the scope of their practice as defined by California state law.

  7. Aliano v. Glickstein (1966) 31 Cal. Comp. Cases 440

  8. Cal. Code Regs., tit. 8, § 9780(g) "Reasonable geographic area" within the context of Labor Code section 4600 shall be determined by giving consideration to:

    (1) The employee's place of residence, place of employment and place where the injury occurred; and

    (2) The availability of physicians in the fields of practice, and facilities offering treatment reasonably required to cure or relieve the employee from the effects of the injury;

    (3) The employee's medical history;

    (4) The employee's primary language.

  9. Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd. (1983) 34 Cal. 3d 159, 168

  10. State Compensation Ins. Fund v. Workers' Comp. Appeals Bd., 69 Cal. App. 3d 884

  11. Braewood Convalescent Hospital v. Workers' Comp. Appeals Bd., 34 Cal. 3d 159

  12. Knight v. United Parcel Service (2006) 71 Cal. Comp. Cases 1423

  13. Chino Unified School District v. WCAB (1998) 63 Cal. Comp. Cases 613

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