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Overcome denied Medical Treatment in Workers Compensation

Overcome denied Medical Treatment in Workers Compensation

Overcome denied Medical Treatment in Workers Compensation by Insurance Company

Being hurt at work can be stressful, leading to physical and mental pain. Then you have to worry about getting your worker’s compensation claim approved. Often, people are relieved when they finally get their worker’s comp award order from the Virginia Worker’s Compensation Commission. In some cases, this award may provide lifetime medical benefits.

Unfortunately, this isn’t the end of the story for some injured workers. What if your employer’s insurance company refuses to pay for the care you need? 

“They can do that?” We hear this question a lot, and unfortunately the answer is yes. Most people don’t realize that insurance carriers can refuse to pay workers’ comp claims, and for many of the same reasons they cite for refusing to pay other types of claims.

First, it’s important to understand that employers can either self-fund worker’s comp claims, maintaining a fund to pay out for these, or they can purchase insurance that will pay out if a claim is approved. The latter is very common, so in many cases, even with a worker’s comp award, you will be at the mercy of your employer’s insurance carrier.

What is  the Virginia Worker’s Compensation Act?

This legislation requires an employer and their insurance carrier to cover the cost of medical care that is “reasonable, necessary, and related to your compensable work injury.” After reading that, you can probably tell those are the three reasons an insurance company will most likely claim when refusing to pay. We’ll come back to those and how they can be refuted a little later.

Now, let’s look at what is typically required to be covered under this law. In general, these types of care should be covered by an insurance carrier:

  • Emergency room and hospital visits
  • Doctor’s office visits
  • Prescription medication
  • Physical therapy
  • Occupational Therapy
  • Diagnostic testing (x-rays, CT scans, MRIs, PET scans, etc.)
  • Pain management, including steroid injections and other treatments for pain
  • Surgery
  • Specialist referrals
  • Prostheses and assistive devices to treat your work injury (prosthetic limbs if you’ve had an amputation, canes, crutches, wheelchairs, hearing aids, and other assistive devices)

How Does a Medical Treatment Denial Work?

A medical treatment denial happens something like this. A worker we’ll call Bob hurts his back in an accident at work and goes to see a doctor or other healthcare provider. The provider recommends surgery, and since this is an expensive procedure, they submit a claim with the worker’s compensation insurance adjuster to make sure it’s covered.

A few things can happen at this point. The adjuster can approve the surgery, or they can deny it, or they can simply not respond at all. If it’s either of the last two options, Bob’s surgeon isn’t going to perform his surgery unless Bob can pay out of pocket. Now Bob is in pain, unable to work, and even though he was approved for worker’s compensation, it’s not covering his claim.

Does this situation sound familiar? If you’re having a similar issue with a worker’s comp claim denial, please contact a Virginia employment attorney. They can review your case and advise you on your options for appealing the claim.

Types of Medical Claim Denials

There are four kinds of claim denials that you may experience when dealing with worker’s compensation:

  • Actual denial. The insurance company writes you and/or your healthcare provider a letter saying they won’t pay for your recommended treatment. Usually the letter will give a vague reason why, but not always.
  • Partial denial. With this option, the insurance carrier says it will pay for your treatment, but only if you go to a different provider. This can be upsetting, as you may have already built rapport with your doctor. It may also turn out that the insurance company’s provider is less experienced with the type of procedure or treatment you need.
  • Delay. In this tactic, the insurance carrier doesn’t outright approve or deny your treatment but “kicks it down the road.” Usually they will ask you to get a second opinion to determine if it’s really necessary.
  • No answer. With the “radio silence” tactic, you just never hear back from the insurance carrier and neither does your healthcare provider’s office. Sometimes clients tell us they’ve repeatedly called the carrier, or their doctor’s office staff have called, or they both have called. In many of these cases, all parties who called got the run-around—they left messages that weren’t returned, they were told a decision was pending and they would be contacted soon, etc.

Why Was My Claim Denied?

This is another question we hear a lot. There are many specific reasons why insurance adjusters deny claims, but they all boil down to one thing: Denying your claim will save the insurance company money, and despite what they may have told you, the insurance adjuster’s job is to save their company money. They’re hoping that if they deny or ignore a claim, you’ll give up trying to get them to pay for it! Maybe you’ll pay out of pocket, maybe you’ll give up and just be in pain, maybe you’ll try a less expensive (and often less effective) treatment. That’s what the insurance adjuster expects to happen with a claim denial.

But those aren’t your only options. You can appeal your claim denial!

How Do I Appeal My Claim Denial?

First, try contacting your insurance adjuster. If you can’t reach them by phone, search online for an email address, mailing address, or even a fax number. In some cases, your medical provider’s office staff may also help by filing another claim and/or calling any contacts they have with the carrier.

Sometimes, if you’re able to speak with an adjuster, you may find out that they just need more information from you or your doctor to get your claim approved. At this point, you may run into those three qualifiers—reasonable, necessary, and related to your work injury—again. For example, the adjuster may claim your treatment isn’t necessary because other treatment options (usually cheaper ones) exist. In this case, your doctor may need to submit documentation explaining why this particular treatment is necessary (you already tried other options that didn’t work, your medical history made the the other option a bad choice, etc.).

Or, the adjuster may claim your injury isn’t the cause of the condition you need treatment for. Again, submitting medical records may help here, but if not, your lawyer may be able to recommend other ways to prove the treatment is necessary.

Other times, the adjuster may offer to pay if you switch to another provider. If that happens, talk with your employment law attorney right away. Generally insurance adjusters don’t have the right to manage your care to the extent of choosing which healthcare provider you go to. Your attorney may be able to appeal this recommendation and convince them to pay with your current provider.

What if the adjuster continues to stonewall you? Again, this is the point where you may need the help of an attorney. An experienced virginia workers compensation lawyer can file a change of condition claim with the Worker’s Compensation Commission, asking them to essentially force the insurer to pay for your medical care.

If your claim has been denied, or you have questions about workers compensation or an injury you’ve received at work, please contact us for a free consultation.