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Medical Benefits and Workers' Compensation
One thing you can practically count on is that your desire for comprehensive, first-rate medical care will eventually come into conflict with your employer's desire to limit costs. You should take time to learn your rights and responsibilities and to consult with competent legal counsel to guide you through the complex laws regarding medical care under the Workers' Compensation Act.
Here is more specific information.
What medical benefits are covered under the law?
Immediate and long-term medical expenses related to the injury or illness are covered. Examples include first aid, emergency care, doctor visits, hospital care, surgery, physical therapy, chiropractic treatment, pharmaceuticals, prosthetic devices, prescribed medical appliances, assistive devices such as a wheelchair and perhaps even modifications to your home to accommodate the wheelchair.
Who pays the medical benefits?
Technically, the employer is responsible for all medical expenses related to the injury or illness. In practice, however, the employer's workers' compensation insurance carrier actually pays (or refuses to pay) all benefits. (For simplicity, we will refer to the workers' compensation carrier as the "employer.") You do not have to pay any deductibles or co-payments.
What if my employer refuses to pay some medical bills?
The Workers' Compensation Act and Rules of the Commission set forth a procedure for holding the employer accountable for medical bills it is legally obligated to pay.
Can my employer refuse to pay for medical treatment?
Yes. Employers often refuse to authorize a particular medical procedure or pay a bill for treatment based on a "utilization review." Employers can submit your requests for payment of your medical treatment to a licensed utilization review organization to obtain an opinion as to whether a particular treatment is reasonable and necessary. Depending on the result of the utilization review, your employer may refuse to pay for the treatment.
If your employer disputes a particular bill, it must promptly give you a written explanation of its refusal. Disputes about medical benefits are ultimately decided by the Workers' Compensation Commission.
Can I choose the treating doctor or hospital?
Yes, but there are limits, so you should choose carefully.
You may initially choose any doctor or hospital, even if the provider is outside your regular insurance network. You may also seek treatment from any doctor who that initial provider refers you to.
You may then start over with a second doctor or hospital, and again go to any doctor who that second provider refers you to.
That's where the line is drawn, however. If you choose a third doctor without your employer's approval, your employer is not required to pay for those services.
Going to a hospital for first aid and emergency care does not count toward your two choices.
As long as I stay within the limits on choice of provider, will my employer then pay for all medical care?
Not necessarily. Past, present, and future medical treatments related to the work injury are subject to a utilization review at any time.
Must I allow employer-hired case managers to manage my care?
No. You may, without penalty, refuse or limit the involvement of nurse case managers hired by your employer. You are obligated to provide medical records that are relevant to your case, but otherwise your medical care is confidential.
Practically speaking, however, it is often beneficial to allow a nurse case manager to have limited involvement in a case. It can facilitate the necessary medical care by eliminating continuous utilization reviews. Also, refusing to allow a nurse case manager to participate can intensify the adversarial relationship with your employer.
Can my employer ask for an evaluation by its own doctor?
Yes. However, your employer must give you adequate notice and cover travel expenses and lost wages. You must submit to an examination, known as an independent medical examination (IME), but you are not required to accept any treatment from the employer-hired doctor.
Who decides how much to pay for medical care?
Most covered treatments provided on or after February 1, 2006, are subject to a schedule of maximum fees established by the Workers' Compensation Commission. Of course, the provider could charge less.
If you or a member of your family has been injured in a work-related accident, we can help. Contact the experienced workers' compensation attorneys at Drake & Collopy, P.C. online or call us at 312.345.0220, or toll free at 1.888.372.5355, for more information or to schedule a free consultation.
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