Does Health Insurance Cover Work-Related Injuries?
Find Out When You Can Use Health Insurance to Pay for Work Injuries and Illnesses
Workers’ compensation laws force employers to pay for medical care for work injuries.
But only if you suffer a compensable injury by accident. And only if the prescribed treatment is reasonable, necessary, and related to the workplace injury.
These exceptions permit employers, insurers, and claims administrators to delay and deny medical treatment.
You can – and should – fight these medical denials.
But how do you get the diagnostic tests, medication, physical therapy, or surgery you need while waiting for approval or litigating your claim?
Using health insurance for work-related injuries may be the answer.
You may be able to use private medical insurance to get prompt care and start healing while you wait for an answer, mediation, or trial.
This article explains the federal law governing private health insurance (the Affordable Care Act). It will then discuss when you can use health insurance for work injuries and the risks. Finally, it gives tips on settling a workers’ comp claim so health insurance continues to pay.
Keep reading to learn more about the pros and cons of using health insurance for work-related injuries.
Then call our law firm to see how we can help: (804) 251-1620 or (757) 810-5614.
We have obtained workers’ comp settlements for thousands of injured employees. And we want to start working for you.
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Sometimes injured workers and their employers try to find ways to pay for medical treatment other than workers’ compensation. There are several reasons for this. For example:
- The injured worker may think that the injury is minor and that they will be able to return to work without much, if any, lost time from work. They would rather treat through health insurance than having to deal with the paperwork and hassle of the workers’ compensation claims process. As such, the injured employee does not file a workers’ compensation claim with the Workers’ Compensation Commission.
- The employer is concerned that its workers’ compensation premiums will go up, so it promises the injured worker that it will pay for the medical treatment with cash or out of its own pocket. The employer does not tell its insurance company about the workplace accident, but its promise doesn’t last long, however, because the medical treatment is more expensive than the employer expected.
- The injured employee thinks that he or she will get fired because of the workplace accident, so instead of reporting the accident or filing a claim, the employee decides to pay for medical expenses out of their own pocket. Often they tell the medical provider that the injury happened at home.
Does the Affordable Care Act Address Workers’ Compensation Claims or Settlements?
No.
The ACA fails to discuss how it interacts with workers’ compensation claims, benefits, or lump sum settlements.
Workers’ Compensation vs. Private Health Insurance
Workers’ compensation provides payment for medical bills for reasonable and necessary medical treatment related to your workplace injuries or occupational disease.
Because workers’ compensation exists, many private health insurance companies will refuse payment for any treatment they believe is related to a work accident. In fact, private health insurance companies often include exclusionary language in their policies.
Many health insurance contracts include language such as: We don’t pay for care and treatment needed for sickness or injury for which benefits are provided under state or federal workers’ compensation, employers’ liability or occupational disease law. Some health insurance policies even exclude coverage when the injury or illness can be covered by workers’ compensation, regardless of whether the injured employee receives workers’ compensation benefits.
What Happens if I Treat Through Private Health Insurance for Work-Related Injuries?
When an injured employee decides to treat through regular health insurance for work-related injuries, there is a risk that the private health insurance company will conduct an investigation if it receives notice, either from the injured employee, the employer, the workers’ compensation insurance carrier, or the medical provider or his or her medical records, that the injury happened on the job.
The investigation may happen right away, as soon as your medical providers (doctors, surgeons, hospital, physical therapist, chiropractor, etc.), or it may not happen until many months later. It depends on the health insurance company. But regardless of how long it may take, you should count on the health insurance company investigating whether it is actually responsible for treatment for your work-related injuries. You must take into account the private health insurance company’s lien when negotiating a workers’ compensation settlement.
What if the Doctor Finds Out I Was Hurt at Work?
Some doctors will refuse to treat you through your regular health insurance if they know that your injury happened at work. This is because they know that the health insurance company will likely deny all bills submitted by the doctor, and then they won’t get paid.
Remember, you should always be truthful with your doctor. It’s the only way to win your workers’ compensation claim. And when you’re truthful with your doctor about a workplace injury, you should presume that the private health insurance company will find out eventually that this is a possible workers’ comp case.
When the private health insurance company finds out that your injuries happened at work, it may terminate any existing payments, refuse to authorize additional payments, and rescind any payments made already. If the private health insurer does not rescind payments, then it may seek reimbursement from you directly. This is why it’s important to discuss all medical issues with your workers’ comp attorney.
Additional Things to Consider When Deciding Whether to Use Health Insurance for a Workers’ Compensation Injury
We recommend pursuing medical treatment through workers’ compensation in every situation. Using private health insurance has many risks. Here are additional reasons why you should use workers’ compensation and not private health insurance:
1. Most of us have private health insurance coverage through our employers, which we can lose at any time. You may lose your private health insurance if you are terminated from your job, which often happens to injured employees who are unable to return to work or who have permanent partial disability that prevents them from returning to their pre-injury employment. At that point you have three options: (a) become uninsured; (b) purchase private health insurance through the Affordable Care Act (ACA) exchange; or (c) pay for private health insurance through COBRA.
None of these choices are good. You will have to pay a lot of money to stay insured – money that you don’t have when you are unemployed and unable to return to your pre-injury work. Or if you treat without insurance, you may go bankrupt because of high medical costs related to your work injuries.
Under workers compensation you receive lifetime medical benefits. These benefits are not dependent on you staying employed. The workers’ compensation insurer is responsible for the payment of medical expenses for your workplace injuries, regardless of whether you are terminated by the employer or otherwise unemployed.
2. You do not pay co-pays with workers’ compensation. Most private health insurance companies require that you pay a co-pay at every medical appointment. These co-pays can run from $10 to $100 per appointment. With workers’ compensation you do not pay a co-pay.
3. There is no deductible or maximum out of pocket amount with workers’ compensation. Most private health insurance plans have deductibles. If your claim is covered under the Virginia Workers’ Compensation Act, you do not have to pay a deductible to get treatment.
4. Workers’ compensation insurance has no limits on payments. No matter how much your medical treatment costs, workers’ compensation must pay for it.
5. Workers’ compensation reimburses you for mileage to and from medical appointments and the pharmacy. Private health insurance will not. This is a big factor, especially for those of you who live in rural areas and may have to travel long distances to see specialists or to go to the pharmacy.
6. Your private health insurance company will probably not provide transportation to and from medical appointments. Workers’ compensation requires the employer and its workers’ comp insurer to pay for transportation costs related to your medical treatment.
7. Private health insurance plans do not provide wage loss benefits or payment for permanent partial disability. Workers’ compensation not only provides payment for medical expenses, it also provides wage replacement benefits such as temporary total disability and temporary partial disability payments.
Can I Use Private Health Insurance if the Workers’ Compensation Insurance Company Denies Coverage and My Case is Pending?
So you have followed our advice and filed a claim for benefits with the Workers’ Compensation Commission following your on-the-job injury. But your employer and its workers’ compensation insurance carrier refuse to provide a panel of physicians or to pay for medical treatment. Should you use health insurance to treat for your work injuries until the Commission makes a decision at your workers’ compensation hearing?
Yes. You should use your health insurance if workers’ compensation refuses to cover or pay for the treatment you need. But tell the health insurance carrier that the workers’ comp insurance company is denying your medical treatment. And do not settle your case without considering how much your private health insurance company paid on your behalf. They may assert a lien on settlement proceeds. Or they may retract payment if you do not consider their interests. When payment is retracted, the medical provider may sue you for payment for your medical care. This is not a good situation to be in.
An experienced workers compensation lawyer can tailor the settlement agreement to try to protect you from an aggressive private health insurance company that has paid for treatment for your workplace injuries. Your attorney can also negotiate with the private health insurer before you enter into a settlement.
Need Help Getting Medical Treatment through Workers’ Compensation?
To receive medical care through a workers’ compensation insurance carrier for your job injuries, you must satisfy certain rules and requirements. These include reporting the accident as soon as possible, obtaining medical treatment promptly, and filing a claim within the applicable statute of limitations.
If you have questions about workers’ compensation, call, text, or email Corey Pollard today. We’ve helped hundreds of injured workers in Virginia resolve their claims successfully. And we want to help you get the medical treatment you need through workers’ compensation so that you don’t run the risk of the private health insurance company coming after you for payments made.
The insurance company has teams of legal and medical experts working to deny you benefits. Get someone in your corner to fight back. We’re ready to start.
Corey Pollard is a top-rated personal injury attorney focused on recovering monetary damages for injured workers and accident victims. He has secured over $30 million for clients and published over 1,000 articles on workers' compensation, Social Security disability, and negligence law.
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