The California Division of Workers’ Compensation recently completed its review of how the County of San Bernardino and the workers’ compensation system responded in the wake of the December 2, 2015, terrorist attack at the Inland Regional Center.
The county requested the review in consideration of some public concerns expressed over compensation denials and treatment approval delays.
Workers’ compensation is a system used by states across the nation to determine liability, provide compensation, and adjudicate disputes for claims and cases involving job-related deaths, injuries and illnesses.
The 2015 terror incident generated 100 workers’ compensation claims, 96 by County employees or their survivors and four involving other employers. As of mid-January, the county had paid over four million dollars for benefits and medical care and had a reserve amount of nearly $22 million for continuing and future costs.
According to county officials, denials or modifications of requests that did not fit within the Medical Treatment Utilization Schedule (MTUS) guidelines were clearly an exception to the overall pattern of treatment requests being routinely accepted or approved through the utilization review process. Because most of the victims were County employees attending a work-related function, workers’ compensation was the primary means through which medical care and other benefits were provided to those victims.
In a letter dated February 23, George Parisotto, Acting Administrative Director, Division of Workers’ Compensation, stated the agency had reviewed summaries of claims and treatment decisions forwarded by the county, as well as information available from independent sources, including Independent Medical Review decisions and Workers’ Compensation Appeals Board case files. “Our review shows that of the total 2,146 treatment decisions, 90 percent were approved and 3 percent received modified approval,” Parisotto said.
According to Parisotto, as the claims matured over time, San Bernardino County increased its scrutiny of treatment requests—this led to some modifications and denials. A portion of those requests were appealed in the Independent Medical Review (IMR) system.
While the IMR decisions generally upheld the county’s actions, often because doctors had failed to document or fully explain their requests, employees who were still suffering and expected their doctors’ recommendations to be followed were frustrated by the denials.
More recently, the county hired a nurse case manager to serve as an ombudsperson to help facilitate the presentation of treatment requests in a way that will satisfy the workers’ compensation system’s treatment guidelines.
Parisotto agreed with this approach. “We think this would be an appropriate first step when dealing with an incident of this nature and that having someone with an incident of this nature and that having someone available throughout to facilitate the approval of claims and treatment requests between providers and claims administrators would likely reduce frustration experienced by some of the victims.”
The County denied the workers’ compensation claims of 25 other employees alleging psychological injury arising out of the incident. According to the county, a common thread among these denials was that the employees were not present at the training center when the incident occurred. Three of the denials were appealed through the filling of Applications for Adjudication with the DWC/ WCAB. One was settled by Compromise and Release for $7,000; one was voluntarily dismissed without prejudice; and the other one remains open. The low rate of appeal and results of those appeals thus far suggests that the denials were largely accepted as appropriate decisions by the claimants and their advocates.
In addition to workers’ compensation claims, the County paid the allowable funeral costs of up to $10,000 through the workers’ compensation system, and additional funds to cover higher costs were available through the California Victims Compensation Board.
To date, nine death benefits claims were approved and benefit payments to the eligible dependents began within two to four months after the incident. Two additional claims are open but remain unresolved pending proof of dependency by those claiming entitlement to benefits. For the other two deceased, burial expenses were paid, but no dependents have been identified or come forward to claim monetary benefits.