In King v. CompPartners, Inc. (2018) S232197, the California Supreme Court held that workers’ compensation law provides the exclusive remedy for an employee who alleges injuries caused by a utilization reviewer’s denial of medical treatment. The employee and his wife filed a civil tort claim against a utilization reviewer and others, alleging that they caused him additional injuries by denying medications prescribed by his treating physician without authorizing a weaning regimen or warning him of the possible side effects of abruptly ceasing the medication.
The Supreme Court explained that the Workers’ Compensation Act (WCA) exclusivity provisions pre-empt not only causes of action premised on a compensable workplace injury, but also causes of action premised on injuries collateral to or derivative of such an injury. It concluded that the harm plaintiffs alleged was collateral to and derivative of the industrial injury, and arose within the scope of the employee’s employment for purposes of the workers’ compensation exclusive remedy. The Supreme Court noted that although the WCA preserves the right of employees to sue third parties, workers’ compensation exclusivity pre-empts tort claims against certain persons and entities hired by employers, and this included utilization reviewers hired to carry out the employer’s statutory claims-processing functions. It explained that in performing their statutory functions, utilization reviewers stand in the shoes of employers — they perform UR on behalf of employers, to discharge the employers’ own responsibilities to their employees. The Supreme Court added that utilization reviewers are tasked with making judgments on a limited set of documents pursuant to defined criteria and subject to further review only through statutorily specified procedures. It believed that permitting plaintiffs to bring tort suits against utilization reviewers, in the same manner as they might bring tort suits against treating physicians, would subject utilization reviewers to a second — and perhaps competing — set of obligations rooted in tort rather than statute.