When it comes to having your medical expenses paid for by your employer’s insurance company after a work injury, a certain threshold has to be met. Insurance companies typically require that any medical care provided to a patient be “reasonable, necessary or related to the work injury,” otherwise they may deny the claim.
So what happens if you are informed by the insurance company that your surgery or other medical care won’t be covered? Do you have legal options, or do you just have to take their word? Below, we explain what you should do if insurance won’t cover some of your medical expenses in today’s blog.
Medical Care Denied
Just because you are seeking medical care as a result of a work injury doesn’t mean that every treatment course is going to be covered. Because of this, it is important to seek out pre-authorization if you are concerned if an expense is going to be covered. Most times, the medical facility and insurance company will coordinate and let you know ahead of time, but it’s always a good idea to go out of your way to ensure bigger expenses or changes in your course of treatment are covered before diving in head first.
One of the more commonly denied treatments after a work injury is surgery. Surgery may very well be able to help you after a work injury, but that doesn’t necessarily mean it should be your first course of treatment, and oftentimes this is why an insurance company will deny surgery. It’s not that they are denying surgery altogether, it’s just that they are denying it right now.
For example, a lot of injuries to the back or a joint have good healing rates with conservative care. You may make a full recovery 80 percent of the time with physical therapy and rest, while surgery has a 90 percent success rate. Even though surgery has a higher rate of success, there’s a much bigger downside if the treatment doesn’t go as planned. When conservative treatments fail, the patient’s main issue is usually lingering discomfort. When a surgery doesn’t go as planned, a patient could face infections, nerve damage or worse pain, which all greatly increase medical expenses. For this reason, most insurance companies will require that, if applicable, you pursue conservative treatment prior to an operative option.
Reasonable, Necessary and Related To Work Injury
In order for an insurance company to deny your medical procedure or expense, they need to have questions about whether the care is reasonable, necessary or related to the work injury. If they deny coverage, they will request that you attend an independent medical exam. This IME is performed by a third-party doctor who will provide a medical assessment to the insurance company. If the IME doctor believes that the injury is reasonable, necessary or related to the work injury, the insurance company will likely approve the care.
Working with a professional firm like Hey Workers is very important if you’re running into issues about medical coverage. Your lawyer can point you in the direction of a good physician who understands how reports need to be written in order to get insurance approval. This is not to say that the doctor will bend the truth about your injuries, just that they will include enough details and relevant information so that the insurance company can clearly tell that proposed treatments are indeed reasonable, necessary and related to the work injury.
If the insurance company denies parts of your medical care, your lawyer will be able to file a dispute with the workers’ compensation system. This will result in a hearing in front of a workers’ compensation judge. Both sides will explain their reasoning, and your lawyer will work closely with your doctor and any other experts who can help prove your case to help win a judgment in your favor.
We’ve gone through this process with many clients and won, and we can do the same for you. If you’re running into trouble getting medical care approved after a work injury, reach out to the experienced lawyers at Hey Workers today.
