Unreasonable or Unnecessary Treatment for Workers’ Compensation
Work is becoming more and more dangerous. As a result, workplace safety is a considerable concern in the United States. In 2015, nearly 3 million American workers were injured on the job. Many of these injuries are severe, requiring hospitalization, surgery, and other medical procedures. Some may even result in permanent disability.
The good news is that each state has its own workers’ compensation program. This program is in place to help injured employees and pay for their medical treatment, regardless of fault. The employers pay for the coverage, and employees are covered starting from their date of hire.
There are some limitations and exceptions to this program, though. If the employee caused the injury on purpose or was under the influence of drugs or alcohol at the time the incident occurred, he or she could be denied workers’ compensation benefits. Also, if the person was breaking a rule or doing something illegal at the time of the injury, benefits could also be denied.
There are also limitations regarding medical treatment. Injured employees should receive medical treatment as soon as possible following the accident. Delaying treatment to the point where the pain gets worse is not the right way to help your case. In fact, it may cause your workers’ compensation claim to be denied.
However, you should be aware that sometimes not all medical treatment is covered under workers’ compensation. You will only be compensated for treatment that is medically reasonable or necessary. Should you desire to seek out alternative forms of treatment or treatment that are not considered necessary, then you will need to pay for it out of pocket.
Workers’ compensation laws can be confusing. Read on to learn more about Pennsylvania laws regarding your benefits. Plus, see what types of treatments are considered unreasonable or unnecessary and should be avoided.
How Does Workers’ Compensation Work in Pennsylvania?
Those injured or killed in workplace accidents may be able to receive benefits through the Pennsylvania Workers’ Compensation Act. If you are injured, the benefit will pay for your medical treatment. If you are killed, your surviving family members (spouse and children) will receive death benefits.
Nearly all people who work in Pennsylvania are covered under the Pennsylvania Workers’ Compensation Act. Even seasonal workers, part-time workers, and those who work for nonprofit organizations are covered. Even those who are the sole employee of a company will receive coverage in the event of a workplace injury.
There are some exceptions, though. Federal employees, longshoremen, railroad workers, and shipyard workers are covered under similar programs. Agricultural laborers and volunteer workers are exempt from coverage.
You will receive medical benefits starting from the time of the injury. You can obtain benefits for lost wages if you have been disabled for seven calendar days or longer.
What is Considered Reasonable or Necessary Treatment?
So you need medical treatment, but what services are actually covered? The exact definition of reasonable and necessary treatment can vary from one insurance company to another. Generally, insurance companies try to avoid paying claims at all costs, so they will scrutinize your medical records and look for ways to avoid making payment.
As a rule, doctor appointments and medications are generally considered reasonable. Diagnosis tests—such as X-rays and ultrasounds—are also typically approved as long as the injury warrants them, and these tests are required to diagnose the injury.
If your injury is severe enough to warrant hospitalization and surgery, then those services will be paid for, as well. If you require assistance with walking, then medical devices such as crutches and wheelchairs will be paid by the workers’ compensation program. Physical therapy is also considered reasonable for a limited amount of time.
What is Considered Unreasonable or Unnecessary Treatment?
Any medical services not listed above would most likely be considered unnecessary or unreasonable treatment that would not be covered by the insurance company.
A good sign that the insurance company will consider a treatment unnecessary is if your doctor outright tells you that the medication or procedure is unnecessary. Most will be honest and tell you upfront because they do not want to face the risk of being charged with medical malpractice.
Chiropractic care, acupuncture, and other alternative remedies or medications are also considered unreasonable. You can still try these treatments on your own, but you will be on your own regarding paying for them.
New, experimental, and expensive drugs will likely be considered unreasonable, as well. Pennsylvania’s workers’ compensation program focuses on using evidence-based medicine. This means that the insurance company will look at clinical trials and other evidence to determine if the treatment really is necessary and has a chance of helping the injured victim. While trying the drug might yield some positive results, it is not considered a recommended course of treatment and is therefore not covered.
Inconsistent or unusually extensive treatment is also considered unnecessary. For example, the treatment for a broken arm should not still be continuing a year later. By that time, the bone should have completely healed, and the person should be back at work.
While a medical check-up or even an X-ray at that time might be acceptable to ensure no further injuries have occurred, a person who is still undergoing treatment at that time raises a red flag. Also, the course of treatment should correlate with the injury. A person with a broken arm would most likely not need an MRI or scan of the head.
Specialized treatment ordered by a general practice doctor (non-specialist) or the same treatment performed multiple times would also not be considered necessary. Treatment for soft tissue injuries that continues after three weeks would also not be covered.
Under current workers’ compensation law, it is up to the employer to prove that the medical expenses are unnecessary or unreasonable through the utilization review process. Utilization review is performed by a licensed doctor who practices the same specialty as the provider the employee is currently using.
Listen to your doctor and get his or her advice on the preferred course of treatment for your injury. If your doctor advises you against a particular type of medical treatment, it is likely because it will not help your condition and will likely not be paid for by insurance anyway. If you do choose an unreasonable or unnecessary treatment, be prepared to pay for it out of your own pocket.
Get Help With Your Workers’ Compensation Claim
Filing a workers’ compensation claim can be challenging. Once you are approved, there are limitations. If you have been denied proper medical care because the workers’ compensation insurance company considered your medical treatment unreasonable or unnecessary, get legal help right away. You should be able to get the care you need, even if the care is expensive or if you require second opinions in order to get the proper care.
The team of workers’ compensation and work injury attorneys at Krasno Krasno & Onwudinjo will ensure that you get the medical treatment you need for your work injury. We have been serving Philadelphia since 1936. Contact us today at (800) 952-9640 or online to find out how we can help. A free consultation can help ensure that you understand your legal rights.
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