Your employer or their insurance company is supposed to provide you with all the medical treatment you need to get back on your feet after a work accident. However, there are situations where they simply do not do what is required of them. In some cases, your doctor may recommend surgery, but your insurance company declines to pay for it.
What should you do if that happens? You have options. You may be able to appeal the denial so that you can still continue with the surgery or other medical treatment. You might also be able to get reimbursement if you choose to continue with the treatment anyway.
In most cases, your workers comp benefits should not just stop because of this denial. You can take action!
Who Can Deny Me Surgery or Treatment for a Work Injury?
The insurance company makes decisions about your medical treatment in Pennsylvania. That means that only they can deny your surgery or other medical treatment. However, they often deny claims because of advice from a workers’ compensation doctor or other medical professionals.
In most denials, the facts will usually follow a pattern. You have a treating doctor who makes a recommendation regarding surgery or other medical treatment. The insurance company receives that recommendation, but the claims adjuster decides that he or she does not agree with it.
They will then bring in a third-party medical professional to provide a second opinion. In many cases, that second opinion states that you actually do not need the recommended surgery, which gives the insurance company grounds to deny the request.
In some situations, you will have already gone through an independent medical examination (often referred to as an “IME”) with a third-party doctor. Your IME doctor may state that you do not need any additional treatment at all.
Outright claim denials can occur if you have not received any treatment or gotten any benefits or medical expense reimbursements, too.
WhyWorkers’ Comp Insurance Companies Deny Treatment
Insurance companies may deny claims because:
- They do not believe your injury occurred at all or was not work-related.
- You were under the influence of drugs or alcohol at the time of the injury.
- The employer disputes the workers’ compensation claim in general.
- You missed a filing deadline under Pennsylvania law.
- Your treating doctor or a third-party doctor does not believe further surgery or treatment is necessary.
- You have reached maximum medical improvement, according to an IME doctor.
You Weren’t Actually Injured
In some situations, the employer or their insurance company may not believe that you are actually hurt. They might think you are faking your injury or exaggerating your symptoms.
Unfortunately, some of the most common work injuries, like back injuries and muscle strains, will not show up on an x-ray or MRI. That can mean that the insurance company will not take your work injury seriously. In some cases, an injured worker has to put up with an injury until it gets serious enough to show up on an objective test like an MRI before the insurance company will arrange for medical treatment.
You Were Under the Influence
If you were under the influence of drugs or alcohol when the work injury occurred, then your employer can deny your claim. In many cases, your employer will require that you submit to a drug or alcohol test after your workplace accident. However, tests must be done right away to be valid. That means that if you are not tested immediately, the claim denial may be based on inaccurate or invalid information.
Testing is not the only evidence your employer can use. Instead, if other witnesses state that you exhibited behaviors of someone that might be under the influence before the work accident, then that could be used to deny your claim as well.
Your Employer is Disputing Your Workers’ Comp Claim
If your employer is disputing your claim, one of the most common reasons is that they do not think that you were injured at work. They might suspect that you were injured at home or not while you were performing work duties and deny your workers’ comp claim on that basis.
Keep in mind that even injuries or pre-existing conditions that are aggravated at work, such as flaring up old injuries, can still be considered a work-related injury that would trigger medical benefits.
You Missed a Filing Deadline
The Statute of Limitations for reporting a work injury in PA is 120 days. This means that from the day you get injured, you have 120 to tell your employer about your work injury.
Some injured workers make the mistake of not reporting their injury because they do not think that it is that serious, or they are unsure of what caused it. If you believe it is related to work in any way, it is a good idea to report it. Acting quickly can help you avoid a claim denial.
Next Steps After Having a Workers’ Compensation Claim Denied
- Talk to your employer about why your claim was denied.
- Contact an attorney to discuss your options.
- Get a second (or third) opinion about your medical condition and what further medical care you need.
You need to find out why your workers’ comp claim was denied before you can take action. If, for example, your claim was denied because the employer thought you were intoxicated, then you will need testing evidence and witness statements. If your claim was denied because they think something other than work caused your injury, then you will need an opinion from a medical professional to address causation.
How You Might Be Able to Get Workers’ Compensation Benefits
Most insurance companies expect you to give up after your claim is denied initially. However, you should not stop requesting benefits if you believe that you are entitled to receive them. A workers’ compensation attorney can help you determine what your next steps should be based on the unique facts of your case.
Talk to a Workers’ Comp Lawyer if Your Treatment Has Been Denied
If your workers’ compensation claim has been denied or if your request for further medical treatment has been denied, you have options. Pennsylvania workers’ compensation law gives you the means to fight back against claims or requests for treatment that have been denied, and a workers’ compensation attorney can help.
Contact Krasno, Krasno, & Onwudinjo for legal advice that addresses your unique situation. Schedule a free consultation by calling today: 844-243-4823.