The Key Role Your Doctor Visit Plays in Workers’ Comp Claims
When employees are hurt at work, their first concern should be obtaining medical aid from a pre-approved doctor or a hospital. Once an individual is out of immediate danger, he or she will also most likely receive a recovery plan from the treating physician, which could include undergoing surgery, taking prescription medications, attending physical therapy, or a new experimental procedure. These treatments can quickly become expensive, especially for employees who suffer severe or catastrophic injuries. Fortunately, workers’ compensation insurance covers these costs, as well as lost wages until injured employees are able to get back on their feet.
While many employers and their insurers are eager to pay for employee treatment, some insurers are known for dragging their feet or balking at paying for certain procedures. At this point, the doctor’s diagnosis and proposed treatment plan play a critical role in whether an employee’s medical bills are completely covered. For help demonstrating a link between your medical treatment and the injury you suffered at work, please contact a Philadelphia workers’ compensation lawyer who can explain your legal obligations and rights.
Although Pennsylvania’s workers’ compensation system is not fault based, injured employees are still required to fulfill certain responsibilities before they can receive benefits. For example, once they have received medical treatment, injured employees must notify their employer or supervisor of the accident within four months of the date that it occurred. With a few exceptions, those who fail to comply with this deadline will miss out on the opportunity to collect benefits, so promptly filing workers’ compensation claims is extremely important. Injured workers will also need to submit all necessary paperwork and respond to any questions or requests for additional information from their employer or its insurer. Keeping records of each doctor visit is critical at this juncture and could make all the difference in whether an injured employee is able to establish a link between the accident and the injury.
When Will an Employer Pay for Treatment?
Almost all Pennsylvania employers are required to provide their employees with workers’ compensation benefits in the event of an injury. The only exceptions to this rule are for those employees who are specifically exempted from coverage, such as railroad workers, federal employees, and domestic workers, and those whose injuries were:
- Sustained while the employee was violating a law;
- Sustained while the employee was intoxicated or under the influence of illegal drugs;
- The result of a third party’s negligence (excluding coworkers);
- Sustained while commuting to or from work (with the exception of salesmen); or
- The result of a personal conflict that was unrelated to the workplace.
Aside from these exceptions, those who are injured in the workplace will be eligible to collect workers’ compensation as long as they can establish that the injury occurred in the course of employment. Without this direct causal relationship between the injury and the medical treatment, an insurance company will not agree to pay for an injured employee’s medical bills. Medical evidence is the best way to establish this link, making it especially important for injured workers to seek medical attention as soon as possible after the accident and to keep extensive records related to the diagnosis and treatment.
Medical evidence can be used to address certain issues often raised by employers, including:
- Whether the injured worker has an official diagnosis;
- How quickly the individual will be able to return to work;
- The nature of the employee’s symptoms;
- The cost of treating the employee’s symptoms; and
- How long it will take for the employee’s symptoms to subside.
All healthcare providers will make notes during examinations and procedures regarding observations and medical opinions. These notes and accompanying data and information will be used by the insurer to determine whether an employee’s injury is covered. Generally, covered expenses include emergency room care, hospital stays, doctors’ visits, diagnostic tests, and rehabilitation. As long as an injured worker can provide evidence that the medical treatment recommended by a doctor is proper and necessary to treat a workplace injury, medical expenses will be covered by the insurer, at least temporarily.
Because there is so much at stake after a workplace accident, injured workers are strongly encouraged to tell their doctors about their workers’ compensation claim during their first visit. This will help ensure that the doctor automatically bills the appropriate insurance agency for treatment and takes copious notes. Otherwise, an injured worker could be stuck with footing the bill and seeking reimbursement, which can be difficult. It is also important to note that some physicians do not accept workers’ comp cases. In these situations, injured parties may need to be prepared to pay for certain treatments out-of-pocket. To ensure that your doctor is willing to take on your case, you should consider asking whether he or she takes workers’ compensation cases before making an appointment.
Independent Medical Examinations
In some cases, insurers also request that an employee undergo an independent medical examination (IME) with a physician of its choice. This doctor will be tasked with evaluating the employee’s medical records and the notes of the treating physician, as well as conducting a physical examination, after which he or she will issue a report that addresses:
- Whether the employee’s injury is consistent with the type of accident in question;
- Whether the treatment recommended by the employee’s doctor is appropriate;
- Whether the employee faces physical or mental limitations as a result of the injury;
- Whether the injured worker has reached maximum medical improvement (MMI), which means that he or she has made as much progress as is possible; and
- The degree of the impairment suffered by the employee.
Although these examinations can feel like an attempt on the part of an employer or insurer to avoid paying for benefits, employees are required under state law to comply with an IME request. In fact, employees who fail to attend an IME without a reasonable excuse will stop receiving benefits. Fortunately, employers must cover the cost of traveling to the appointment before the exam takes place and can even be required to pay an employee’s lost wages as well.
Employers are permitted to request IMEs every six months. If during one of these examinations, a physician claims that an injured party has reached MMI and is less than 50% impaired, the employee may only receive partial coverage for a maximum of 500 weeks. When an employee disputes an impairment rating or an insurer refuses to pay for a certain type of treatment, the injured worker has the right to appeal the decision. At this point, the treating physician’s expert testimony could play a key role in helping injured workers receive coverage for a certain procedure or have their level of impairment adjusted. Physicians who are properly licensed, specialists, and have extensive experience are often considered more credible by courts, so injured workers should choose their treating physicians with care.
Contact Us Today
Please contact Krasno Krasno & Onwudinjo at 800-952-9940 to speak with an experienced Philadelphia workers’ comp attorney who is well-versed in state law and can help ensure that your rights are protected. Remember, we do not charge any fees unless your case is successful.