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What If Workers' Comp Insurance Disputes My Treatment?
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By Eman Yazdchi, Esq. · Certified Specialist in Workers' Compensation Law, State Bar of California Board of Legal Specialization · Cal Bar #285231
Your doctor ordered a treatment. The insurer is not paying for it yet. That gap between the request and the authorization is a treatment dispute. California law sets strict time limits on how long the insurer can hold you there.
A treatment dispute is not the same as a denial. A dispute often means UR is in process and the clock is running on the carrier's decision deadline. It might also mean the insurer asked for additional clinical records and extended the window. Knowing exactly which situation you are in changes what you do next.
Below: how the UR timeline works. What the insurer is allowed to do during a dispute. When expedited review applies. What penalties a carrier faces for missing its deadline.
How long does the insurer have to respond to a treatment request?
Under Labor Code 4610, the carrier has five working days for routine prospective requests. Extensions are allowed up to 14 working days. Urgent care requests must be decided within 72 hours.
When your treating physician submits a Request for Authorization, the carrier's clock starts. For prospective routine treatment, the carrier must issue its UR decision within five working days of receipt. The carrier may extend this to 14 working days if it requests additional clinical information and the treating physician fails to respond.
For urgent prospective treatment, where delay would seriously harm the worker, the carrier has 72 hours. For retrospective review of treatment already delivered, the carrier has 30 working days. These deadlines are in the statute, not advisory guidelines. A carrier that routinely blows these windows faces both procedural consequences and potential penalty liability.
What is the difference between a UR delay and a UR denial?
A UR delay means the carrier has not responded yet. A UR denial means it responded with a rejection that triggers your 30-day IMR appeal right immediately.
When the insurer has not responded within the statutory window, the treatment may be deemed authorized. But this is not self-executing. The worker or attorney must affirmatively document the missed deadline and push the carrier. Take a school custodian whose spinal MRI request sat unanswered for three weeks past the five-day window. That missed deadline creates leverage. The carrier created it by staying silent.
When the insurer issues a UR denial within the statutory window, your 30-day IMR clock starts. That clock runs from the denial date. The denial must state the specific clinical reason and the MTUS guideline applied. A denial that is vague or does not cite MTUS criteria may be procedurally defective.
What can you do while a treatment dispute is pending?
While UR is pending, the treating physician can request expedited review, and you can continue authorized treatment. Do not stop ongoing medication or therapy without medical clearance.
If the dispute involves a new treatment while other authorized treatment continues, keep attending authorized appointments. The insurer's dispute over one RFA does not affect other already-authorized care. Take a delivery driver with authorized physical therapy for a knee injury. He also has a pending RFA for an MRI. He should keep attending PT while the MRI dispute resolves.
If the dispute involves urgent care, the treating physician can flag the request as expedited under Labor Code 4610. The expedited window is 72 hours. The physician must provide clinical documentation that delay poses a serious risk of harm. Expedited requests cannot be delayed for additional information requests the same way routine requests can.
What happens when the insurer misses the UR deadline?
A carrier that misses the UR decision deadline may face a deemed-authorization argument. The worker can also file a WCAB petition. Unreasonable delay penalties under Labor Code 5814 may also apply.
A UR decision issued outside the statutory timeframe may be invalid. The worker can petition the WCAB to enforce the timeline. An unreasonable delay in providing required medical treatment can support a 25 percent penalty under Labor Code 5814. That penalty is 25 percent of the delayed benefit amount. Carriers that routinely delay UR responses are not just slow. They may be creating liability on every delayed RFA.
Document every RFA submission date, every carrier response date, and every extension notice. This record is the foundation for any delay-based claim.
Injured at work? Call (661) 273-1780
Tap to call →How Yazdchi Law Handles Treatment Disputes
Treatment disputes are time-sensitive. Yazdchi Law tracks UR deadlines from the day the RFA is submitted and moves immediately when the carrier falls behind.
Many injured workers do not know that the insurer has a hard deadline to respond to treatment requests. When that deadline passes without a response, leverage shifts. Yazdchi Law identifies missed UR deadlines. It coordinates with treating physicians on expedited requests when appropriate. It pursues delay penalties when carriers repeatedly fail to respond on time.
Eman Yazdchi is a Certified Specialist in workers' compensation law, certified by the California Board of Legal Specialization, State Bar of California. The firm handles treatment disputes from the initial RFA through IMR appeal at every WCAB venue across California.
If your treatment is being held up by an insurer that is not responding to your doctor's requests, call (661) 273-1780.
Frequently Asked Questions
How long does UR have to approve or deny a treatment request?
For routine prospective requests, five working days from receipt, extendable to 14 working days if the carrier requests additional information and the treating physician does not respond timely. For urgent prospective requests, 72 hours. For retrospective review, 30 working days. These are statutory deadlines under Labor Code 4610. A UR decision issued after the applicable deadline may be procedurally invalid, which can create leverage for the worker and support a deemed-authorization argument. The clock runs from the date the RFA is received, not the date it was sent. Keep a confirmation of delivery. If the carrier claims it never got the RFA, that receipt matters.
Can the insurer ask for more time to decide on a treatment request?
Yes, but only for routine prospective requests. The carrier can extend the five-working-day window up to 14 working days by requesting additional clinical information from the treating physician. The extension request must be made before the initial five-day window closes. If the treating physician provides the requested information, the 14-day period runs from the date the insurer receives it. The carrier cannot extend the 72-hour expedited window. Repeated extension requests on every RFA are a pattern worth documenting for a potential delay penalty claim. The distinction between a delay and a denial is important for the 30-day IMR deadline. The 30-day clock runs from the UR denial date, not from the first day the carrier delayed responding to the RFA.
What is expedited UR and when does it apply?
Expedited UR is a faster review available when the standard UR timeline would cause a serious risk of harm to the worker. Under Labor Code 4610, the treating physician flags the RFA as urgent, provides clinical documentation of the urgency, and the carrier must respond within 72 hours. Expedited UR is appropriate for surgery recommended after an acute injury, continuation of critical medication, or urgent diagnostic imaging needed to guide imminent treatment decisions. It is not available for routine elective procedures that can wait without harm. Carriers sometimes push back on expedited requests without proper justification. If the carrier refuses to process the expedited request within 72 hours on a genuinely urgent matter, the worker can petition the WCAB for emergency relief.
Can I get emergency treatment while a UR dispute is pending?
Yes. Emergency treatment does not require prior UR authorization. Under Labor Code 4600, the employer must provide emergency medical treatment for a work injury regardless of prior approval. If the work injury produces an emergency situation during an ongoing UR dispute, go to the emergency room. The emergency care costs become part of the claim. The pending UR dispute on other treatment does not affect the emergency obligation. Document the emergency circumstances thoroughly for the claim file. Track all ER treatment costs carefully. Emergency care bills for a work injury that were paid out of pocket or through health insurance become a lien the worker can recover against the workers' comp claim once it is accepted.
What happens when the carrier does not respond to a treatment request at all?
Silence past the statutory deadline may constitute constructive authorization in some circumstances, but this is not self-executing. The worker or attorney must document the missed deadline, present it to the carrier, and if necessary petition the WCAB. The WCAB can enforce UR timelines under the Sandhagen decision framework. Delay past the UR deadline can also support a Labor Code 5814 penalty for unreasonable delay. Track every submission date and every response date for every RFA throughout the claim. Documenting the deadline miss requires a receipt showing when the carrier received the RFA and evidence that no decision was issued within the applicable window. Counsel can help build this record quickly before the carrier tries to issue a late decision.
Can I change doctors if my treatment keeps getting disputed?
Possibly. Within the Medical Provider Network, you have a right to a one-time change of treating physician under Labor Code 4600(c). If the treating physician consistently submits RFAs that the carrier disputes and denies, a physician who is more MTUS-oriented in their RFA approach may get better results. Outside the MPN, you can request a panel Qualified Medical Evaluator if the treatment dispute intersects with a broader medical-legal dispute about the nature or extent of the injury. An attorney can evaluate which pathway fits your situation. The one-time change of treating physician is available once during the claim. Using it means giving up the one-time right. Choose carefully and only after a pattern of RFA denials that suggest the current physician's documentation style is the problem.
Last reviewed by Eman Yazdchi, Esq., July 2026.
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