Who Will Pay For The Treatment After Your Work-Related Injury?

Picture this: you’re a licensed ER nurse and, one day, while moving the bullet-riddled body of a gunshot victim to a stretcher, you hear a distinct snap.  You take a quick revealing glance at the 320-lb. man you just tried to move and realize a horrifying (and potentially expensive) reality: you’ve just thrown out your back.

It’s a classic case of an employment-related injury and one that loosely describes the experience of a friend of the firm who is a licensed Pennsylvania nurse at a prominent Philadelphia hospital. This is an example of being injured on the job, which can include strains, sprains, broken bones, and work related illness, all of which may qualify for workers’ comp benefits.

WORKERS’ COMP MAY PAY FOR TREATMENT, BUT DOES IT PAY FOR EVERY TREATMENT?

Workers’ compensation laws can be a jungle to leaf through.  In Pennsylvania, under the Pennsylvania Workers’ Compensation Act, nearly every employee is protected unless covered by another compensation law (for example, federal civilian employees).

And the Act covers any illness, injury, or disease that is work-related unless it was intentionally self-inflicted or resulted from intoxication.  This includes incidents such as broken bones, strains, sprains, and work related illness that occur on the job.  It is crucial to promptly report the incident to your employer, as there is a legal requirement to report work injuries to ensure eligibility for benefits.

Your first visit to a medical provider is important, as the employer may have a designated list of providers, and your treating physician will play a key role in your initial treatment and ongoing care.  The employer is responsible for providing medical benefits and is involved in the process, including the selection of medical providers for the first 90 days.

The employer may also be involved in decisions regarding your treatment and coverage, and a utilization review may be used to determine if the treatment is reasonable and necessary.

And it provides several benefits including the following:

• Payment for lost wages: available if you are totally disabled and unable to work or partially disabled and, as a result, receiving wages that are less than what you were making before the injury. This includes total disability benefits, and there is no set time limit for receiving these benefits, though the employer or their insurance carrier may attempt to limit them.
• Death benefits: available to surviving dependents of the deceased employee
• Specific loss benefits: available if there is a permanent loss of use of an appendage or digit or if there is a serious disfigurement to a body part
• Medical care: You are entitled to reasonable medical and surgical services, and time lost from your job for medical appointments may be compensated.

Specifically regarding medical care benefits, you are entitled to reasonable medical and surgical services.  These can include medicine, supplies, prostheses, and orthopedic appliances.  But Pennsylvania courts have ruled only those that are causally related to the injury can be compensated.  Whether the treatment you seek, however, is “causally related to the injury” can admittedly be a confusing question.

If your workers comp benefits are denied or delayed, health insurance may help supplement your medical expenses.  When you reach maximum medical improvement, your treating physician will determine if your condition is stable and if ongoing benefits are needed.  Suffering, both physical and emotional, should be properly documented and treated to support your claim.

After a certain period, you have the right to treat with a medical provider of your choice, and the recommendations of your treating physician are important in determining ongoing care and benefits.  And whether the alternative treatment you sought and ended up being successful – where traditional, Western allopathic medicine has failed – will be one that a court recognizes as compensable is another confusing question.

HOW CAN STAMPONE LAW HELP YOU?

It’s important to understand you have rights despite the type of treatment for the employment-related injury you may have pursued. An attorney at Stampone law can help you understand those rights and fight for them.

Employers and their insurance companies will likely pay out as little as possible, given the increasing costs of workers’ compensation insurance.  And they may have their own lawyers to fight as hard as they can to pay you as little as possible.  The attorneys at Stampone law want to make sure you can have a fair fight.

Insurance Carrier Responsibilities

If you’ve been hurt on the job in Pennsylvania, you’ll find that insurance companies play a huge role in your workers compensation case, acting as the main source of payment for your medical bills and lost wages after a workplace injury.

Under Pennsylvania’s Workers’ Compensation Act, these insurance carriers have a duty to make sure you get the workers compensation benefits you deserve, including coverage for all reasonable and necessary medical treatment related to your work injury.

When you file your workers compensation claim, the insurance company is required by law to respond within 21 days. During this time, they’ll investigate your claim and decide whether to accept or deny responsibility for your injury. If they accept your claim, the carrier will issue a Notice of Compensation Payable or, in some cases, a Notice of Temporary Compensation Payable.

These documents spell out what compensation you’re entitled to, including how much workers compensation pay you’ll receive, how long your benefits will last, and what medical coverage you can expect.

Your insurance carrier is on the hook for paying all medical expenses that are directly related to your work injury. This covers everything from doctor visits and surgeries to hospital stays, prescription medications, medical devices, and even mileage reimbursement for travel to and from your medical appointments.

The insurance company must also cover the costs of getting your medical records and other documentation needed to support your workers compensation claim.

One key thing insurance carriers do is conduct utilization reviews. This process determines whether the medical treatment you’re receiving is reasonable and necessary. If the insurance carrier believes that certain treatments or services aren’t justified, they may deny payment for those specific medical bills.

However, you have the right to challenge these decisions and request a hearing or appeal, often with the help of an experienced workers compensation attorney who knows how to fight for your rights.

In some cases, the terms of a collective bargaining agreement may affect what your insurance carrier is responsible for, particularly when it comes to medical coverage and choosing your medical providers. Regardless of these agreements, the insurance company must always prioritize your right to receive appropriate medical care and compensation.

If an insurance carrier denies your claim or refuses to pay for certain treatments, you’re not without options. You can seek a free consultation with a knowledgeable attorney who can help determine your average weekly wage, calculate the correct amount of workers compensation payments you should be getting, and fight for the full range of benefits available under Pennsylvania workers compensation law.

Having legal representation can be crucial in making sure insurance carriers fulfill their obligations and that you receive the compensation and medical treatment you deserve.

Understanding what insurance carriers are supposed to do—and knowing your rights as an injured worker—can make a huge difference in how your workers compensation claim turns out. If you have questions about your benefits, medical bills, or the claims process, don’t hesitate to contact a qualified attorney for guidance and support.