Overcome Insurance Company Medical Treatment Denials in Workers Compensation
Many injured workers call me when the insurance company has denied medical treatment for their work injury. Even though the insurance company accepted the workers’ compensation claim and the Workers’ Compensation Commission entered an Award Order providing lifetime medical benefits, the insurance carrier refuses to pay for treatment recommended by the authorized treating physician.
This article explains the role of medical benefits in workers’ comp claims, the types of medial treatment denials, why insurance companies deny medical care recommended by the treating doctor, and what you can do about it. If you have any questions about workers’ compensation in Virginia, or are looking for a top-rated workers’ comp lawyer to help you with the work injury claims process, contact Corey Pollard for a free strategy session. We help disabled workers across the state.
The Insurance Company Must Pay for Reasonable and Necessary Medical Treatment Related to Your Work Injuries
The Virginia Workers’ Compensation Act requires the employer and its insurance carrier to pay for medical treatment that is reasonable, necessary, and related to your compensable work injury.
For example, the insurance company is responsible for the payment of:
- Hospital visits
- Emergency room visits
- Doctor’s visits
- Prescription medication
- Physical therapy
- Occupational Therapy
- Diagnostic testing (x-rays, CT scans, MRIs, etc.)
- Pain management, including steroid injections
- Referrals to specialists
- Prostheses and assistive devices to treat your work injury
Basically the insurance company has to pay for any medical care and medical testing you need for your workplace injury.
What is a Medical Treatment Denial?
Here is how a medical treatment denial happens in workers’ comp.
First, your medical provider recommends that you undergo specific treatment for your work injury.
Most doctors and health care providers want to know how they will get paid for treatment before providing it. So the doctor’s office will call the workers’ compensation insurance adjuster and ask if the treatment is authorized.
The insurance adjuster may tell the doctor’s office that the treatment is denied. Or it may simply not respond. This has the same effect as a denial.
If the insurance company does not approve the medical treatment, then your doctor will probably cancel it until you get approval. This means that you’ll continue to have pain and limitations, and that your recovery will be slower while you wait for approval of the medical treatment.
Types of Medical Treatment Denials in Workers’ Comp
There are four types of medical treatment denials in Virginia workers compensation:
- Actual Denial: The insurance company sends you a letter stating that it will not pay for the recommended surgery, injection, or diagnostic procedure.
- Partial Denial: The insurance company states that it will cover the recommended treatment, but only if you go to a different medical provider that it hand picks.
- Delay: The insurance company neither approves nor denies the recommended medical treatment. Instead, it ask you to see another doctor for second opinion before it makes a decision.
- No Answer: The doctor has asked the insurance company for authorization but has not received a response despite trying multiple times.
No matter the type of medical treatment denial, the insurance company is putting your physical recovery in jeopardy by delaying much needed medical care for your work injury.
Why Do Insurance Companies Deny Medical Treatment in Workers’ Comp Cases Where the Injury is Compensable?
In our experience insurance companies are motivated by profit.
There are several reasons that insurance companies deny medical treatment. These include:
- Delaying medical care so that you get frustrated and give up on your claim.
- Stalling and delaying treatment with the hope that you may re-injure yourself in an intervening accident or injury, at which time the insurance company may no longer be held liable.
- Because they can. Insurance companies want to avoid paying money unless you – the injured worker – make them.
What Can You Do if the Insurance Company Denies Payment of Medical Treatment?
If the insurance company is denying medical treatment recommended by your authorized treating physician then you have several options. The Commission typically gives greater weight to the opinion of an authorized treating physician than to any other medical provider.
If the insurance company denies medical treatment, you should contact the insurance adjuster by phone. If you’re unable to reach him or her by phone, then send a fax or email.
Sometimes medical treatment denials can be resolved with a quick phone call. Your adjuster may need additional information from the doctor’s office or may have simply not received the message from the doctor’s office. Either you or your attorney can help them get this information so that the treatment is approved.
If the insurance adjuster says that he or she will approve the treatment if you get it done elsewhere, talk to your attorney right away. The insurance company cannot manage your medical care to that extent. Your authorized treating physician chooses which doctor you see in most case. If, however, the adjuster is asking you to see a doctor with whom your attorney has had good experiences and your treating physician is fine with, then it may be worth switching doctors. Do not make this decision lightly though.
If the insurance adjuster refuses to respond to your phone calls or emails, or continues to deny medical treatment, then your attorney can file a change in condition claim seeking authorization and payment of the medical care with the commission.
The insurer will have an opportunity to respond. If it does not respond or continues to deny the medical care, then the Commission will schedule your claim for medical treatment for a workers’ comp hearing in front of a deputy commissioner. At the hearing you will present evidence in support of your claim. And the judge will make a decision. He or she may order the insurance company to pay for medical treatment. This care will help you get better.
Workers’ Comp Attorney for Medical Treatment Denials
The delay, dispute, and denial of medical treatment is frustrating. Most injured workers want to get the treatment they need to stop their pain, improve their ability to work, and return to the labor market.
Defeating medical treatment denials is difficult. Medical care is expensive – often the most expensive part of the workers’ comp claim – and insurers will do everything they can to avoid paying for treatment.
As your attorney, Corey Pollard will do everything he can to resolve the medical treatment denial without litigation. But if it’s necessary, we’ll help you win your case at trial and even negotiate a valuable workers’ compensation settlement if appropriate. Contact us today for a free consultation. We’re ready to help.