Workers’ Compensation Part 1: What You Need to Know about Medical Benefits

Workers’ compensation, or workers’ comp, is a form of insurance that all employers with four or more employees or that work in construction must have. Workers’ compensation provides wage replacement and medical benefits to employees who are injured at work or because of work. If you are injured at work—or sustain certain repetitive injuries because of your work—you are likely entitled to workers’ compensation.

Workers’ comp is an extensive subject with many rules, guidelines, and best practices. Because there is so much involved, we have decided to do a two-part series about the two main aspects of workers’ comp: medical benefits and lost wages or indemnity benefits. This is the first part of the series, covering medical benefits.

As the name suggests, medical benefits cover doctor’s care, prescriptions, surgeries, and other medical procedures. Before you start seeing a doctor, make sure to follow the right steps or your care might not be covered. In fact, in order to ensure that you are covered under workers’ comp, make sure to follow these five guidelines.

Go to an Authorized Doctor

Once you have requested medical care—which you must do within thirty days or your claim may be denied because of untimely reporting—your employer must authorize a doctor or medical care provider for you. It is imperative that you go to a doctor who is within your employer’s network or your care will not be covered.

Under the law, employers are not required to pay for medical care—except in cases of emergency care—that was not authorized by them ahead of time. Going to a doctor that was not approved by your employer will mean that you do not receive coverage, and testimony from an unauthorized doctor will not hold up in court.

Avoid “Doctor Shopping”

In some cases, an insurance agent or employer who is unhappy with your doctor’s opinion will try to coerce you into seeking other opinions, or “doctor shopping.” This is not allowed in most cases and you are within your rights to refuse.

In fact, you should not see another doctor or medical caregiver without clearing it with an attorney first. The exception to this would be if your doctor refers you to another doctor—for example if a general practitioner refers you to a surgeon or specialist.

There may be cases in which you may go to another doctor or physician but only do this after discussing it with your attorney. Doing so may cause you to lose your coverage and waive your claim, so make sure to speak to an attorney about it before you do so.

Receive “Reasonably Medically Necessary Care”

Once you have found a doctor, workers’ comp entitles you to coverage for “reasonably medically necessary” care. This means that any medical treatment, service, or supplies that will treat or cure your injury are covered. If you were sick, injured, or had a condition before your workplace accident, you will need to prove that the accident was the major contributing cause (MCC) of the condition and NOT your pre-existing condition.

Workers’ comp will also pay to test for what is known as a “differential diagnosis.” This testing is designed to ensure that the symptoms you are having are not related to your injury, but rather the symptoms are a result of a different condition that may not be work-related.

Understand Maximum Medical Improvement (MMI)

When you are entitled to workers’ comp, your employer will pay for all emergency treatment and authorized medical care necessary to treat your compensable injuries. This includes the following:

• Doctors
• Medical facilities
• Surgery
• Testing
• Therapy facilities
• Prescriptions
• Orthopedic braces and devices
• Anything that is medically necessary

It is important to understand that workers’ comp only covers you so far. Maximum Medical Improvement, or MMI, is a medical term that refers to the time in your treatment that further care will aid in your recovery. With some injuries, there comes a point in treatment where the doctors can no longer make improvements to your condition, at which point your employer is no longer required to pay for your care.

Once you reach MMI, you may still visit the doctor or medical professional, but you will have a copay of $10 per visit in order to receive your care.

Forward Medical Bills

If at any point in your treatment you start to receive medical bills, forward them to your attorney immediately. Do not ignore the bills or assume that they are getting paid by your employer’s insurance.

As you can see, workers’ compensation is complex. It is important to follow the rules set forth by the law and your employer in order to receive your benefits.

If you need legal advice on your workers’ compensation claim, contact C.W. Smith, Public Attorney.