Friday, March 6, 2009

Don’t Ignore Disputes With The Work Comp Insurer Over Your Medical Care

Disputes with the workers’ compensation insurance company over medical care and treatment for a work injury frequently arise even if the insurance company admits liability. This type of medical dispute can arise in a variety of situations. It is important that you don’t ignore these disputes.

In the first type of situation, the insurance company has accepted liability for your injury, and is paying for your benefits. Then, the insurance company attempts to deny any additional treatment, refuses to pay for certain kinds of treatment, or refuses to authorize certain procedures.

In the second type of situation, you negotiated a settlement of your case on what’s known as a “full, final and complete” basis, leaving open reasonable and necessary medical care and treatment. Then, the insurance company refuses to pay for additional treatments, denies certain kinds of treatment, or refuses to authorize certain kinds of procedures.

In the third type of situation, the insurance company has denied primary liability on your case. They are not paying wage loss benefits, and they are not paying for your medical expenses. In this type of situation, you need the assistance of an attorney to establish your entitlement to benefits, including wage loss and medical benefits.

In the first two types of situations, the insurance company has agreed to pay for ongoing medical treatment, subject to certain requirements. They may attempt to deny payment for treatment on the grounds that it is unreasonable and/or unnecessary, that the treatment is not related to your original work injury, or that it exceeds the workers’ compensation treatment parameters.

It is critical that you do not ignore these disputes! Often, when a dispute arises, rather than dealing with it, an injured worker simply submits the bills through major medical insurance, or pays out of pocket for the treatment. Workers also sometimes don’t realize that their medical benefits, in many cases, remain open even after they’ve settled their case.

There are several reasons why you need to deal with these medical disputes with the workers’ compensation insurer. If you submit bills for treatment related to your work injury through your major medical insurance, your personal insurance may deny these bills because the workers’ comp insurance should be paying for it. If you lose your personal medical insurance in the future, and you need medical treatment for your work injury, it is much more difficult to get the workers’ compensation insurer to pay for the bills if you’ve been submitting those bills through your personal insurance. Finally, if you are entitled to workers’ compensation medical benefits, you should take advantage of that benefit.

If there’s a dispute over your medical treatment, it is a good idea to deal with these issues sooner, rather than later. By way of example, our firm recently represented a gentleman who sustained an admitted low back injury which required fusion surgery in 1989. He later settled his claim for monetary benefits. After his surgery, he was symptom free, for the most part. After a few years, however, his symptoms started coming back, and he started seeing a chiropractor to help with his pain. Rather than submitting the bills through the workers’ compensation insurance company, he simply submitted them through his personal medical insurance. Over the next 15 years, he treated at a variety of facilities for his back condition. He is now looking at a fusion surgery at the vertebral level above the original fusion, as a result of a progressively worsening bulging disc. He was recently laid off, and no longer has major medical insurance, and he cannot afford to pay for lumbar fusion surgery out of his own pocket. By the time he retained our office to help him, his major medical insurance had paid over $10,000.00 in expenses for his work injury, he had nearly $10,000.00 in outstanding expenses, and he had treated with at least ten different facilities. Because he waited so long to deal with the medical dispute, this gentleman’s case became substantially more complex and contentious than it ever needed to be.

Waiting a long time to deal with medical disputes can substantially complicate your case. For example, the workers’ compensation insurance company may not even be aware that you have been having ongoing problems. The longer the amount of time between your date of injury, and the time you try to get the workers’ compensation insurance company to pay your bills, the more likely it is that they will argue that your original injury is not the cause of your current need for treatment. Tracking down information to support your claim also becomes substantially more difficult. Most medical providers do not keep records indefinitely, and medical records are necessary to substantiate your claim for benefits. It also becomes difficult to track down medical information if the name or location of the facility has changed, if the doctor you treated with has left, or if you simply can’t remember the names of the places where you treated.

The longer you wait to deal with medical disputes, the more complex your case becomes. While we frequently handle medical disputes where an individual has several years worth of medical expenses that should have been paid for by the workers’ compensation insurance company, we strongly encourage you to contact us as soon as a medical dispute arises. The sooner you contact us, the sooner we can resolve the dispute.

To schedule a free consultation with one of the workers' compensation lawyers at Meuser & Associates, call us at 877-746-5680 or click here to send us an email.

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