What To Do When Workers’ Comp Refuses To Pay for Your Necessary Medical Care

If you become injured on the job and your work injury requires medical care, your employer’s workers’ compensation insurer will always be responsible for paying the whole of any necessary medical treatment which is reasonable. However, you are not responsible for co-payments in these cases. Your medical providers are also prohibited by law from billing you the balance. Balance billing is entirely illegal, yet so many people aren’t aware that it occurs. It’s a practice where a medical provider may attempt to try and bill a patient for the difference between what the insurance company has paid them and the amount they would usually bill a patient who will not have any insurance in place. Despite how there are workers’ compensation laws that mandate your employer’s workers’ comp insurer to pay for 100% of your work-related medical bills, this does not mean that will always happen or that they will always follow the law.

WHAT DOES WORKERS COMP COVER?

Workman’s comp, also known as workers’ compensation insurance, provides benefits for those employees who get sick or injured on the job. Along with that, workers comp protects the employers from being sued.
Some of the compensation benefits for workers comp include:

Medical expenses
Lost wages
Ongoing care costs
Funeral expenses

HOW DOES WORKERS COMP PAY YOU?

When you have been injured on the job, you want to know how much you can expect for workers comp. In most cases, the workers’ compensation benefits provide employees with a percentage of their average wage. However, the amount of those payments will depend on your specific state’s workers’ compensation insurance program.

That weekly amount that an employee can receive is also based on the specific illness or injury. For those employees who are partially disabled, they will receive the same benefits as someone with a temporary injury. Every state has a maximum weekly rate for workers compensation.

WHAT TO DO WITH THE MEDICAL PROVIDER

For those injured in work and pay for health insurance, give all of your health insurance information to your medical provider as soon as you can. Instruct them to bill the health insurance in the rare event that the workers’ compensation insurer decides not to authorize necessary treatment. Your doctor or medical professional will know what will be needed. Health insurers, in general terms, are not required to pay for any kinds of work-related injuries if workers’ compensation has issued a denial, the health insurer shall be required to pay for the treatment. By trying to remember this, and doing it at the earliest opportunity, you can ensure the treatment is paid for on time.

EMPLOYER REFUSES TO FILE WORKERS COMP CLAIM

If you have been injured on the job, there are times when the employers may refuse to acknowledge the accident or report it to your state. With that, you must provide a written and verbal report of injury to your employer. In most states, there is a timeline of when these injuries must be reported to ensure workers comp benefits for their injuries.

In addition to that, you must continue to receive medical treatment for your injuries. As an employee, you can check where your company has made a claim with the state. If there is reason for a denial of your benefits, you are entitled to file an appeal. All these steps can be complicated, and you will want to seek legal advice from an experienced attorney.

CAN YOU GET SURGERY THROUGH WORKERS COMP?

After you have been examined by a doctor, a surgical procedure could be recommended. However, a doctor’s recommendation is not enough to proceed with the surgery. The workers’ comp insurance must approve the surgery. In some cases, a second opinion is required before they sign off on your surgery. You might have to see a specialist or another doctor to make sure it is absolutely necessary for you.

HOW LONG DOES WORKERS COMP HAVE TO APPROVE A SURGERY?

When you have been injured on the job, you want to get back to a pain-free life. However, there are many factors that can determine the length of time for your surgery approval. Your employee has 120 days to report the injury, and the insurance company will have 21 days to deny or approve your claim.

HOW OFTEN DO WORKERS COMP CHECKS COME?

After you see a medical professional, you will start to see those expenses piling up. In most cases, the insurance company will pay your workers’ compensation at the same rate as your normal wages. For example, if you are paid weekly, you can expect a check every week. The same goes for a worker who is paid on a bi-weekly basis. They should see those checks on the same pay schedule.

CONTACT AN ATTORNEY AS SOON AS YOU CAN

Although it might not seem important to do so, you should contact an attorney as soon as possible because they’ll be able to advise you best on how to file a claim for medical benefits. People at Invictus Law can get you started. First, you need to dispel any notion of attorney fees. If any medical benefits whatsoever have been denied by the workers’ compensation insurer (and you retain the services of an attorney to bring a claim for you, on your behalf), an attorney will be able to get the workers’ compensation insurer to pay for your medical treatment. It does not cost you anything. The workers’ compensation insurer will have to pay your attorney’s fees, fully and inclusively. So if you’re sure you have the right insurance when the comp refuses to pay, you’ve got nothing to lose by using—or at least speaking to—an attorney.

Looking for an attorney right now in Orange County? Contact us at Invictus Law here!

Your bills can quickly add up in the case that you are forced to use health insurance when workers compensation declines, especially if you suffer a terrible injury that requires more medical care. This is usually seen in cases where physical therapy might be needed to help with getting the injured party back to working capacity. Imagine the costs of these if you were to have weekly sessions. For those who have been denied medical treatment by the workers’ compensation insurer and for whatever reason do not have a form of health insurance, the immediacy is even more crucial. You must contact an attorney right away because it can take up to 5 months to get your claim in front of a judge. Unfortunately, even in clear cases, only a judge at the Department of Industrial Accidents can order an employer and a workers’ compensation insurer to pay any medical benefits previously denied, for whatever reason, to the person injured at work.

SERIOUS INJURY

In some, unfortunate, situations a worker might get injured to the extent where they can’t go back to work for an extended period of time—if ever. In this case, you won’t be earning pre-accident wages. You might be entitled to a considerable amount of future weekly workers’ wages in the form of benefits, or in some instances, a lump sum settlement. These benefits are hugely important because they’ll be your lifeline if you have no other money coming in. Meaning you and your family will be able to survive during your period of disability. Yet, if your health insurance pays your medical treatment and you decide not to pursue payment of medical treatment through your workers’ compensation, any entitlement to future wage loss benefits could in some cases be complicated by the workers’ compensation insurer’s assumption (and if it progresses, maybe the judge’s) that if it was paid for by health insurance and you did not file a claim to compel the workers’ compensation insurer to pay for the treatment, that it was not work-related. Unfortunately, if this decision is reached, it means you are not entitled to any workers’ compensation benefits.

It’s not a pleasant situation to be in, but unfortunately, it’s one which crops up more than anyone would like. You need to be aware, know your rights and do your research. Speak to your colleagues and boss but always seek an attorney’s opinion because they’ll always have the definitive answers you need. Remember, the key thing to keep in your mind if worker’s compensation refuses to pay is that your worker’s compensation insurer is responsible for paying 100% of medical treatment. Things may be tough, and hard if they decide they don’t want to pay. Just remember you have the complete right to approach an attorney to get things sorted out. The sooner you do it, the better.

Want to learn more about how workers’ compensation works? Check out our breakdown of your rights here.

By Invictus Law | Posted on March 15, 2022

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