After your workers’ compensation claim has been approved, all of your required medical care should be paid for in full by your employer's insurance carrier. However, what if the insurance company comes back and denies payment for some or all of the treatment your authorized treating physician (ATP) prescribed for your care and ongoing recovery?
At Greg Coleman Law, injured workers may often be surprised when their employer's insurance carrier refuses to pay certain medical bills. How could this happen? Are there legal options to help get payment for the care you need? Read on to get answers to important questions regarding your medical care under workers' compensation.
Was payment for any of your medical care denied by your employer's insurance carrier - even though your claim was approved? Our Knoxville workers’ compensation lawyers are prepared to use our decades of experience to help injured employees get the benefits they need, including payment for the medical care they need.
Free case review - at no risk to you. (865) 247-0080
What Medical Costs Are Covered by Workers' Comp?
Workers’ comp insurance in Tennessee is required to cover 100 percent of reasonable and necessary treatments that are the result of a work-related injury. This means that as an injured worker, you are not even required to pay any co-payments.
Reasonable and necessary costs could include any and all of the following:
- Emergency transportation after the accident
- Surgery to help return you to your original physical state
- Hospital stays
- Diagnostic test, including X-rays, MRIs and more
- Physical rehabilitation and physical therapy
- Mobility assistive devices, such as a wheelchair
- Pain management (such as injections)
- Doctor visits - including follow-up appointments
- Prescription medication
- Specialist referrals
Why Was My Treatment Denied?
If you have followed Tennessee’s requirements for notifying your employer about the accident that caused your injury, filed a workers’ comp claim and then selected an ATP, all care prescribed by that ATP should be covered.
However, there are times when this may not happen, such as if your employer or your employer’s insurance carrier determines:
- The recommended care is deemed neither necessary nor reasonable: Sometimes, this decision may be made because the insurer believes there are other, less costly or less invasive treatments that your doctor should attempt first.
- Your maximum medical improvement has been reached: If established - typically by requesting that you attend an Independent Medical Exam (IM), then your insurer is off the hook for providing further care since no additional treatment is reasonably needed.
- Your injury is preexisting: Your employer may try to establish that your injury already existed and is not the result of a work-related incident
- You have been non-compliant: If it is determined that you failed to keep appointments, undergo physical therapy or adhere to other recommendations made by your ATP, your employer and/or insurance carrier may argue that your injuries are not as bad as you claim.
What if My Workers’ Comp Refuses to Pay for Treatment I Need?
If your employer's insurance carrier refuses to pay for any and/or all of your medical care, you can submit an appeal. However, all appeals must be sent to the Tennessee Bureau's Utilization Review Program for consideration within just 30 calendar days of your denied medical receipt. Failure to do so may risk your ability to appeal.
It is also important to note that utilization appeal requirements apply per treatment. They are not a "one and done" denial. This means you need to submit an appeal for each instance where the medical necessity of an ATP's recommended treatment is denied or disputed. The appeal process includes:
- Completing the Tennessee Bureau of Workers' Compensation form - which should be provided to you when you receive notice of a denied medical receipt.
- Send the completed form, along with a copy of the Utilization Review Board's decision, as well as the Peer Reviewer's report
- Provide a copy of your medical history - related to your workers' comp injury - from the past 12 months. These records should include your office visits, surgical notes, physical therapy, diagnostic reports, hospital visits and any other care you received for your job-related injury.
- Include a copy of the signed medical release for your ATP - or complete and sign Form C-31 - the Medical Waiver and Consent form.
- Submit all of these documents together, either by email to firstname.lastname@example.org within 30 days of receipt of your denial notice.
Failure to submit this information for your denied medical receipt may result in you losing your right to appeal this denied payment. This process can seem daunting, especially because of the amount of paperwork required.
Having an attorney on your side from the beginning of your workers' comp claim can help to protect your legal rights and potentially avoid denied medical receipts while you receive care.
Need Help with a Workers' Comp Claim? Greg Coleman Law is Ready to Help
Whether you are applying for benefits for the first time or you have an active workers' comp claim but were denied payment for medical care that you need, our firm is ready to help.
At Greg Coleman Law, we have decades of experience handling many types of workers' compensation claims, and we are ready to fight to help ensure you receive the full benefits provided under your claim.
Contact our office anytime, night or day, to schedule a free, no-obligation legal consultation. We are familiar with the tactics insurance carriers use that make it harder - or impossible - to receive the medical care you need. We have extensive experience should your case need to go to trial, and we have a long and proven track record.
No upfront costs and you can get started today. Call: (865) 247-0080