Medical Care When Your Workers’ Comp Claim Is Denied
If you or someone you care about has suffered a work-related illness or injury, you doubtless have many questions and worries. How will I afford the costly medical care I need? Will I make a full recovery? Under California law, almost all employees are entitled to receive workers’ compensation (WC) benefits to help mitigate the financial burden of losing time at work, a physical disability, or other losses. However, it is not uncommon for an employer or insurance company to reject a legitimate claim, causing an injured worker to forego expensive, but essential, medical treatment.
If your workers’ compensation claim has been denied and you are in need of medical care, take action as soon as possible to protect your right to receive the treatment you need and deserve after a work-related incident. Contact the Los Angeles workers’ compensation lawyers at the Kenton Koszdin Law Office. We offer free and comprehensive consultations, which may be conducted at our office or at your home if you are unable to travel. Please call us to learn more at (800) 438-7734 or complete an online contact form.
How Can I Get Medical Care If My WC Claim is Denied?
It is crucial to take action immediately to ensure that your claim is taken seriously. With the help of a skilled Los Angeles workers’ compensation attorney, you can contest the denial of your claim by filing an adjudication of claim at the California State Division of Workers’ Compensation where your claim will go before a workers’ compensation judge. An experienced workers’ compensation lawyer will not only help expedite this process, but will also fight on your behalf to ensure success.
For injuries or illnesses that require immediate attention, it is illegal for a doctor or medical provider to bill an employee if they know the damage may be work-related. The medical provider may request that you sign a lien form stating that he or she will wait for payment for any services until after the case is settled.
What Happens If Your Claim Is Denied in Los Angeles?
If your claim is denied, or you were not timely provided with medical treatment after your injury, you are entitled to treat outside the MPN. In certain circumstances, you may be able to treat outside the MPN if your case is admitted.
In all cases, the injured worker is limited to 24 physical therapy, 24 chiropractic, and 24 occupational therapy visits per claim. The days being off work and getting 3 PT visits per week for one and a half years are over. However, if the injury requires surgery, than the insurance company may, but is not required to, authorize additional therapy.
Medical treatment is limited by the American College of Occupational and Environmental Medicine Practice Guidelines (ACOEM). ACOEM assumes that all human beings will respond in the same way to medical treatment. In practice, the ACOEM Guidelines are wrongfully applied by the insurance company to deny care. This causes major delays and denials of care.
If your claim is denied, you will not receive reimbursement until the case is determined to be compensable.
If 55 days have not passed since the reimbursement request, the payment is not late. The insurance company has 45 days to make these payments.
Due to the elimination of meaningful penalties and the inability to obtain attorney fees for a trial on mileage and expense reimbursements, if the insurance company does not pay timely, the issue of medical mileage and medical expense reimbursement will have to wait until the entire case is ready for trial.
Will Workers’ Comp Cover My Medical Treatment?
Doctor’s appointments, hospital stays, and emergency medical care can all add up to an incredibly expensive bill in a single day. While you may be able to pay for your treatment through a variety of different policies and programs, such as your spouse’s insurance, Medicare, and MediCal, you may be limited to relying on your workers’ compensation insurance for adequate coverage.
Under California’s workers’ compensation laws, WC is obligated to cover any injury or illness due to a work-related incident, such as an accident that occurs when an employee is at work and performing his or her duties, injuries or illnesses that develop due to repetitive actions or exposure to dangerous substances, or even stress-induced injuries. There are some exceptions to the type of injuries that are covered, but generally, if an employee can demonstrate that the damage occurred at work or because of work, he or she is entitled to WC benefits.
Medical Treatment for Los Angeles Injured Workers
One of the most important changes in Workers’ Compensation is that the injured worker is no longer allowed to treat with any doctor of their choice. In most cases, the injured worker is required to treat with a doctor who is a member of the employer or insurance company’s medical provider network (MPN). An injured worker can treat with any doctor who is a member of the MPN. This office has an extensive list of participating MPN doctors. I will do my best to direct you to the MPN doctor who will give you the best possible care within the limitations of the MPN. To discuss, please call (800) 438-7734.
Following Doctor Requests
When a doctor makes a request for medical treatment, diagnostic test, medical appliance, or other medical procedure, the insurance company may direct these requests to a utilization reviewer. This reviewer will not examine or talk to the injured worker. In many cases, this reviewer will not even talk to the treating doctor. Many times, the reviewer will be an out of state doctor, chiropractor, or osteopath employed by the insurance company. The reviewer will look at notes and reports, and make the treatment decision based on ACOEM. Absent a life threatening situation, the insurance company has 14 days from the receipt of the information to make a utilization review decision.
Workers’ Compensation & Medical Expenses
If you must pay out of pocket for medical treatment, medication, or other medical expenses, it is good idea to keep a record with the date of those expenses were incurred, and name of the doctor who recommended or required said expenditure. Attach copies of canceled checks, receipts and bills to this record. Be sure to mail a copy to this office. ALWAYS keep a copy of anything you send or give to this office.
Filing a Claim for Reimbursement
If you make a claim for reimbursement without attaching evidence that you paid the expenses, there can be no reimbursement.
Included with this letter is a form for you to write down your medical expenses. Please submit the reimbursement requests using this forma and by attaching copies of evidence showing that you paid these expenses.
Call a California Workers’ Compensation Lawyer
If both your workers’ compensation insurance company and your own insurance provider are denying your rightful payments, call the Kenton Koszdin Law Office at (800) 438-7734 to get the help you need and deserve. Our experienced Los Angeles workers’ comp legal team can represent your claim to help you receive treatment and financial coverage in a timely fashion.