Seeking Medical Treatment after a Work Injury: What Does the Lifetime Medical Award Cover?
Workers Comp Medical Benefits Include Hospital and Medical Services, as well as Ancillary Items Related to Your Healing and Recovery
Guide to Medical Benefits for a Compensable Occupational Injury or Illness
All states, including Virginia, provide hospital and medical benefits coverage to injured workers who need health care due to a compensable injury or an occupational disease.
These workers comp medical benefits include not only hospitalizations and office visits with doctors but also physical therapy, diagnostic imaging, prescription medication, transportation, assistive devices, orthotics, prostheses, rehabilitation, home and vehicle modifications, and nursing care.
Indeed, medical benefits include palliative care meant to provide temporary pain relief after you have reached maximum medical improvement (MMI).
The employer’s responsibility to pay for medical expenses is unlimited when it comes to time, which is why these benefits are known as lifetime medical awards.
In addition, there is no limit on the amount of money the employer may have to pay to help you heal after a work accident.
But, in most cases, you must follow specific rules to get medical treatment paid for by the employer.
For example, you must select a treating doctor from the panel of physicians offered by the employer and stay within the appropriate referral chain.
Further, if a dispute arises, you may have to prove that the treatment is reasonable, necessary, and causally related to the work accident.
This article explains the medical services covered by workers comp.
These services are not only critical to healing after an industrial accident. In addition, the value of future medical expenses for your occupational injury or illness is a significant factor in calculating a fair workers compensation settlement.
Read on to learn more about using your lifetime medical award under workers comp. These hospital and medical benefits are only helpful if you can use them.
If you have other questions about workers comp law in Virginia, contact us for a free consultation.
We help employees hurt on the job recover every type of workers compensation benefit available. And we are here to assist you and your family.
What Medical Treatment Does Workers Comp Provide?
Reading the applicable statute on medical benefits is the first step to determining if workers comp covers the specific treatment you want or need.
The statute may not specifically address the medical attention needed.
In that case, you should review the case law interpreting the statutory language.
For example, the Workers Compensation Commission has defined what constitutes reasonable and necessary medical treatment in hundreds (if not thousands) of judicial opinions. And the answer to whether a given service qualifies as appropriate and necessary medical care is not always intuitive.
Finally, you may need additional medical evidence, such as a doctor’s disability letter, to prove the causal relationship between the work injury and the health care you seek.
Though you may have a lifetime medical award in your workers comp case, the employer still has the right to dispute or question the recommended treatment. If this happens, you must prove by a preponderance of the evidence that the medical care (surgery, prescription drugs, diagnostic testing) is reasonable, necessary, and related to the work accident.
What Does the Workers Compensation Statute Say About the Employer’s Duties and Responsibilities to Provide Medical Treatment?
Though workers comp laws vary by state, all American jurisdictions require employers to provide medical care to workers who suffer a compensable occupational injury.
Titled “Duty to Furnish Medical Attention, Etc., and Vocational Rehabilitation; Effect of Refusal of Employee to Accept,” this statute reads, in part:
A. Under this section:
1. As long as necessary after an accident, the employer shall furnish or cause to be furnished, free of charge to the injured employee, a physician chosen by the injured employee from a panel of at least three physicians selected by the employer and such other necessary medical attention. Where such accident results in the amputation or loss of use of an arm, hand, leg, or foot or the enucleation of an eye or the loss of any natural teeth or loss of hearing, the employer shall furnish prosthetic or orthotic appliances, as well as wheelchairs, scooters, walkers, canes, or crutches, proper fitting and maintenance thereof, and training in the use thereof, as the nature of the injury may require.
In awards entered for incapacity for work, under this title, upon determination by the treating physician and the Commission that the same is medically necessary, the Commission may:
a. Require that the employer either (i) furnish and maintain modifications to or equipment for the employee’s automobile or (ii) if there is a loss of function to either or both feet, legs, hands, or arms and if the Commission determines that modifications to or equipment for the employee’s automobile pursuant to clause (i) are not technically feasible, will not render the automobile operable by the employee, or will cost more than is available for such purpose after payment for any items provided under subdivision b, order that the balance of funds available under the aggregate cap of $55,000 be applied towards the purchase by the employee of a suitable automobile or to furnish or maintain modifications to such automobile; and
b. Require that the employer furnish and maintain bedside lifts, adjustable beds, and modification of the employee’s principal home consisting of ramps, handrails, doorway alterations, or any appliances prescribed by the treating physician, except for appliances or medical equipment required to be furnished by the employer pursuant to subdivision A 1.
The aggregate cost of all such items and modifications required to be furnished pursuant to subdivisions a and b on account of any one accident shall not exceed $55,000. This limit shall be increased on an annual basis at the same rate as provided in subsection C of § 65.2-709.
The employee shall accept the attending physician, unless otherwise ordered by the Commission, and in addition, such surgical and hospital service and supplies as may be deemed necessary by the attending physician or the Commission.
2. The employer shall repair, if repairable, or replace dentures, artificial limbs, or other prosthetic or orthotic devices damaged in an accident otherwise compensable under workers compensation, and furnish proper fitting thereof.
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B. The unjustified refusal of the employee to accept such medical service or vocational rehabilitation services when provided by the employer shall bar the employee from further compensation until such refusal ceases and no compensation shall at any time be paid for the period of suspension unless, in the opinion of the Commission, the circumstances justified the refusal. In any such case the Commission may order a change in the medical or hospital service or vocational rehabilitation services.
C. If in an emergency or on account of the employer’s failure to provide the medical care during the period herein specified, or for other good reasons, a physician other than provided by the employer is called to treat the injured employee, during such period, the reasonable cost of such service shall be paid by the employer if ordered so to do by the Commission.
D. As used in this section and in § 65.2-604, the terms “medical attention,” “medical service,” “medical care,” and “medical report” shall be deemed to include chiropractic service or treatment and, where appropriate, a chiropractic treatment report.
E. Whenever an employer furnishes an employee the names of three physicians pursuant to this section, and the employer also assumes all or part of the cost of providing health care coverage for the employee as a self-insured or under a group health insurance policy, health services plan or health care plan, upon the request of an employee, the employer shall also inform the employee whether each physician named is eligible to receive payment under the employee’s health care coverage provided by the employer.
F. If the injured employee has an injury which may be treated within the scope of practice for a chiropractor, then the employer or insurer may include chiropractors on the panel provided the injured employee.
What are Medical Services under the Workers Comp Statute and Case Law Interpreting the Statute?
Now we will examine what specific care the Commission has considered necessary medical attention in workers compensation cases.
The Commission has ordered the employer to provide payment for these services as part of an injured worker’s lifetime medical award:
Payment of Emergency Room (ER) Visits and Hospitalizations
In addition, you may require hospitalizations for worsening pain or symptoms of post-concussion syndrome, or after undergoing an operation, such as a lumbar spinal fusion or total joint replacement, for your occupational injury.
Regardless of the reason, the employer must pay for reasonable and necessary hospitalizations related to a workplace accident, including the initial ER visit or hospitalization and subsequent outpatient treatment or in-patient admissions.
Provision of and Payment for a Treating Physician
The employer’s obligation to provide medical care starts as soon as you get injured at work.
When it receives notice of a work accident or the diagnosis of an occupational illness, your employer should provide a list of doctors from which to choose.
This list, which the employer creates subject to the Act’s requirements, should include at least three medical providers.
The doctor you choose from the list becomes your authorized treating physician for the duration of the workers comp claim, subject to referrals and approved changes in treating physicians.
Your employer must pay for all medical treatment provided by that treating physician so long as the care is reasonable and necessary medical attention related to your work injuries.
Provision of and Payment for Doctors (including Specialists) within Your Treating Physician’s Referral Chain
Your employer’s responsibility for paying for physicians is not limited to your authorized treating doctor.
In addition, your employer must provide and pay for other medical practitioners your treating physician refers you to.
For example, say you are an Amazon warehouse worker who hurt your back while lifting a box at work.
Initially, you may select an urgent care physician from the panel of physicians offered by your employer. Then, the person you choose becomes your authorized treating physician.
But suppose your pain continues for more than a few days after the work accident. In that case, your treating physician may refer you elsewhere, such as a neurologist or an orthopedic surgeon.
The orthopedic surgeon will assess your injury and determine its severity. For example, the surgeon will decide if you have a muscular injury, such as a lumbar strain, or a spinal cord injury, such as a herniated disc, requiring injections or surgery.
Multiple medical referrals to specialists are also common in whiplash, head injury, and traumatic brain injury cases.
For example, your authorized treating doctor may refer you to a neurologist or psychiatrist to diagnose the post-concussion syndrome that often develops after a concussion.
There is no limit on the number of referrals your employer may have to pay for through workers comp.
Payment of Diagnostic Imaging and Tests
Many of you will need diagnostic imaging and tests to determine your diagnosis (and its cause) and the next step in treatment.
Examples of diagnostic tests ordered in workers compensation cases include:
- Biopsy
- Colonoscopy
- CT scan
- Electrocardiogram (ECG)
- Electroencephalogram (EEG)
- Electromyography (EMG/Nerve Conduction Study)
- Gastroscopy
- Eye tests
- Hearing tests
- MRI scan
- Neuropsychological assessment
- PET scan
- Ultrasound
- Wechsler Adult Intelligence Scale (WAIS) test
- X-rays
Workers comp law requires employers to pay for these diagnostic tests.
Indeed, your employer must cover diagnostic testing to determine whether your symptoms are related to the compensable work injury, even if the test excludes a causal relationship.
Payment of Surgeries and Other Procedures, such as Epidural Steroid Injections or Spinal Cord Stimulators
The employer is responsible for paying for all reasonable and necessary surgeries, implantations, and injections recommended by your treating physician to help you heal from the work injury.
Further, the employer may have to pay for cosmetic procedures to reduce disfigurement or scarring, such as after a burn injury.
Payment of Prosthetic or Orthotic Devices
If you have a lifetime medical award, the employer must provide, fit, repair, and replace prosthetic and orthotic devices needed because of or damaged by the work accident.
Examples of prosthetic and orthotic devices needed after an occupational injury include:
- Artificial limbs due to an amputation
- Braces
- Canes
- Crutches
- Customized footwear or orthopedic shoes
- Dentures
- Ergonomic chairs
- Scooters
- Prosthetic eyes (ocular prosthesis)
- Teeth implants
- Walkers
- Walking boots
- Wheelchairs
Payment of Palliative Care for Your Work Injury
Palliative care means medical treatment meant to relieve your symptoms, reduce stress, and improve your quality of life.
Palliative treatment, such as acupuncture, often provides temporary relief.
Frequent medical attention, therefore, might be required to get the full benefit of palliative treatment.
Unsurprisingly, employers often balk at paying for palliative care because it is temporary, and its costs can add up quickly.
In Virginia, however, employers must pay for palliative treatment that temporarily relieves your work injury or occupational illness symptoms.
Payment of a Functional Capacity Evaluation (FCE) to Assess What You Can Do
You must present proof of medical work restrictions (either total disability or restrictions to light duty) to receive wage loss payments under workers comp.
Many doctors, however, are uncomfortable assessing an injured worker’s residual functional capacity (RFC) or giving written work restrictions. In my experience, this discomfort results from a lack of knowledge, education, or training in determining ongoing work capacity.
The FCE will involve various tests to determine your remaining work ability and tolerance.
Workers comp considers this FCE to determine ongoing or permanent medical work restrictions as reasonable and necessary medical attention.
Payment of an FCE with an Impairment Rating Solely to Obtain Compensation for Permanent Partial Disability (PPD)
You are eligible for compensation for permanent loss of use (partial or total) of a scheduled body part due to your work accident.
But, to get these permanent partial disability benefits, you must first have the percentage loss of use quantified once your injury stabilizes.
In a recent judicial opinion (2021), the Commission held that a rating to assess the degree of permanent partial disability (PPD) due to a work injury constitutes necessary medical treatment. And therefore, your employer must pay for the rating, which often costs $500 to $2000.
Payment of Prescription Medication
Payment of Automobile Modifications and Home Improvements to Accommodate Your Disability
A work-related catastrophic injury may affect your ability to complete daily living activities and move independently around your home.
Fortunately, vehicle modifications and home renovations can make your life easier.
For example, bedside lifts, adjustable beds, ramps, handrails, doorway alterations, and specially-equipped cars and vans may help you recover independence after a work accident.
Depending on the medical evidence, your employer may have to pay for these home and vehicular modifications (and their maintenance) as part of your workers comp case.
The Workers Compensation Act, however, limits an employer’s liability for automobile and home modifications to $55,000 total over your lifetime.
Payment of Chiropractic Care
Workers comp laws recognize that chiropractic treatment or service may help you heal from a work accident and recover functional abilities.
And therefore, your employer must pay for chiropractic care that is reasonable, necessary, and related to your work injury, as long as your treating physician recommends it.
Payment of Psychiatric Treatment for Mental Health Needs after a Work Accident
In addition, many of you will get diagnosed with depression due to the effects of your work injury.
Regardless of which situation describes your current condition, you may receive psychiatric treatment for depression, anxiety, or PTSD related to the work accident at the employer’s expense.
Examples of mental health services covered under workers comp include:
- Psychologists
- Counselors
- Therapists
- Licensed clinical social workers
- Psychiatrists
- Group therapy
- Medication to control mental health symptoms
Provision of or Payment for Transportation
Your employer must either provide transportation to and from medical appointments and the pharmacy or reimburse you for such transportation expenses if the travel is related to your work injury.
The Workers Compensation Commission has held that transportation, including mileage reimbursement, is a medical benefit.
Payment of Therapy
Your doctors might prescribe many types of therapy during your workers comp claim, such as:
- Physical therapy
- Occupational therapy
- Speech therapy
- Vestibular therapy
- Work hardening
Your employer must pay for these medical treatments, providing you prove such treatment is reasonable, necessary, and related to the occupational injury or illness.
Reimbursement or Payment of Medical Marijuana
Your employer must pay for medical marijuana (cannabis) if an authorized treating physician prescribes it.
Payment of Home Health Care
Your employer must pay for home health care and nursing services prescribed by your doctor for the work injury.
Payment of Services Provided by Your Spouse or Other Family Member
In some situations, the employer may have to pay your spouse for the care they provide you due to the work injury.
For example, your husband or wife may:
- Administer your medication
- Assist with transfers from one position to another (sitting to standing, wheelchair to bed)
- Change your bandages and gauze
- Help you bathe
- Help you change your clothes
- Inject medication
- Massage your back or injured body part
- Put you in traction
- Rub ointment on damaged skin
- Transport you to appointments
Depending on the extent of the disability, the employer may have to pay your spouse, significant other, or family member an hourly rate for these services.
Payment of Miscellaneous Medical Benefits
Almost any type of treatment or medical device is covered by workers comp so long as it is considered medically necessary by your treating physicians.
For example, your employer may have to pay for:
- Air Condition: Your employer might have to provide air conditioning if you have occupational asthma or heart disease.
- Exercise Equipment
- Gym Membership
- Therapeutic Whirlpool Tub
Right to Seek a Change in Treating Physicians
The Workers Compensation Act permits you to seek a change in treating doctors in specific situations.
Generally, you must prove one of the following:
-Your progress has plateaued;
– The medical treatment rendered is inadequate and unsatisfactory;
– Your doctor has retired; or,
– Your relationship with the physician is beyond repair.
Read my article, How to Change Doctors under Workers Comp, for more information on this issue.
Co-Pays and Medical Deductibles: Will I Have Out-of-Pocket Medical Expenses in Workers Comp?
No.
A workers comp lifetime medical award allows you to get reasonable, necessary, and causally related health care for free.
You will not have any out-of-pocket medical costs for your work accident.
Unlike other health care coverage, workers comp does not have a deductible (the amount a person must pay before insurance starts to pay).
And therefore, you will not have to pay co-payments when you go to medical appointments for your work-related injury or illness.
A warning!
You must stay within the referral chain, or else the employer may not be liable for the medical treatment.
Is there a Limit on How Long My Workers Comp Medical Award Lasts?
No.
Your employer must pay for reasonable and necessary medical care related to the work injury for as long as you need it.
This lack of a durational limit is why an award of medical benefits is called a lifetime medical award in Virginia.
Is there a Cap on How Much Money the Employer Has to Pay for Medical Care Related to My Work Injury?
No, the amount of money your employer might have to spend on medical expenses for your injury has no limit.
No.
Many of you have (or had) health insurance through your employer.
If it remains in effect, you may use this health insurance to pay for medical treatment for conditions not covered by workers comp.
But unfortunately, you cannot use the workers comp medical award to pay for unrelated treatment if you never had health insurance, or if that coverage lapsed because you could not afford it (or COBRA).
You have options for treatment if you cannot pay health insurance premiums while waiting for a workers comp hearing in a disputed claim.
For example, community and health care provider programs may provide free or reduced-cost medical treatment.
Use the Lifetime Medical Award to Maximize Your Workers Comp Case’s Value
An award of lifetime medical benefits is only helpful if you use it regularly.
Even if you have reached MMI and obtained permanent restrictions, I recommend treating with your physicians at least twice per year if you continue to have symptoms.
Consistent medical treatment is the key to getting additional workers compensation benefits if your injury flares up and requires further treatment or disability from work in the future.
For example, those with back, neck, or shoulder injuries may return to work only to have the injury flare up every six months to one year.
Indeed, I have settled claims for injured workers requiring revision surgeries for cervical spine conditions (such as stenosis) decades after the work accident.
Ignoring these symptoms and avoiding treatment until you cannot take the pain will create problems with the workers comp case.
The longer you go between medical appointments, the more difficulty your doctor may have with relating the symptoms and inability to work to the compensable injury.
Further, medical records showing consistent treatment and reporting of symptoms will help you qualify for Social Security disability benefits if you must stop working.
What Do I Do if the Employer Refuses to Cover Treatment Despite My Lifetime Medical Award?
Unfortunately, your employer may ignore the lifetime medical award and deny treatment for your work injury.
Often, these denials are accompanied by a statement that the treatment sought is related to a preexisting condition or past injury, not the occupational injury, and that you have recovered from the work accident.
Read here to learn how to overcome medical treatment denials in workers comp and exercise your rights under lifetime medical awards.
A Workers Comp Lawyer to Help You Get and Use a Lifetime Medical Award
Money is not as helpful if you are in poor health. ‘
And to heal and regain your health after a work accident, you must get a lifetime medical award. And then you must enforce your right to use it.
Or you may decide you want more freedom and control over your health care than the workers comp gives you.
In that case, we can help you negotiate a cash payout for the lifetime medical award and other benefits you might be eligible for.
Contact us today to discuss your legal options.
We want to help you get the medical treatment you need to heal fully after an occupational injury or illness.
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