What To Do When Workers’ Comp Refuses to Pay for Your Necessary Medical Care?

In Massachusetts, when you are injured on the job and your work injury requires medical care, your employer’s workers’ compensation insurer is responsible for paying for 100% of any reasonable and necessary medical treatment.  You are not responsible for any co-payments and your medical providers are prohibited by law from “balance billing” you. (Balance Billing is an illegal practice where a medical provider attempts to bill a patient for the difference between what the insurance company has paid them, pursuant to their contract with the insurance company, and what they would normally bill a patient who does not have insurance).  Of course, just because Massachusetts workers’ compensation laws mandate that your employers’ workers’ compensation insurer pay for 100% of your work-related medical bills, it does not mean that they will always follow the law.

Often times it comes about that I end up representing an injured worker because the workers’ compensation insurer has refused to pay for work injury-related medical care.  This can be very frustrating for an injured worker because it should be obvious to the workers’ compensation insurer that you cannot return to your job as soon as possible unless you receive the necessary medical treatment to return you to pre-injury levels of function.  This denial of medical treatment puts you in a position where you are forced to contact an attorney so that you can get your treatment paid for so you can return to work as soon as possible and move on with your life.  For those injured workers who have been denied payment of medical bills by their employer and/or their workers’ compensation insurer, there are a few things you can do to accelerate the process of resolving this frustrating issue:

  1. For injured workers who have health insurance, give your health insurance information to your medical provider and instruct them to bill health insurance in the event that the workers’ compensation insurer refuses to authorize necessary treatment.  Although health insurers generally are not required to make payments for any work related injuries, if workers’ compensation has issued a denial, the health insurer shall be required to pay for the treatment.  By doing this, the injured worker can get the necessary treatment as soon as possible; AND
  2. Contact a qualified Massachusetts workers’ compensation attorney as soon as possible so they can advise you on filing a claim for medical benefits.  If medical benefits have been denied by the workers’ compensation insurer, and you retain an attorney to bring a claim on your behalf and your attorney is able to get the workers’ compensation insurer to pay for your medical care, it does not cost you anything — the workers’ compensation insurer has to pay your attorney his attorney’s fees.  If you are forced to use health insurance after a denial by workers’ compensation, you will be forced to pay co-payments pursuant to your health insurance plan. These co-payments costs can add up very quickly, especially for those requiring chiropractic care or physical therapy treatment several times per week for an extended period of time.  For those who have been denied medical treatment by the workers’ compensation insurer and do not have health insurance, you need to contact an attorney immediately because it can take up to 5 months to get your claim in front of a judge in Massachusetts.  Only a judge at the Department of Industrial Accidents can order an employer and/or their workers’ compensation insurer to pay medical benefits to an injured worker.    

It is very important to have your work injury- related medical bills paid for by workers’ compensation.  If the unthinkable happens and you are not able to recover from your work injury sufficiently to return to your previous occupation and earn pre-injury wages, you may be entitled to a considerable amount of future weekly workers compensation wage loss benefits and ultimately a lump sum settlement.  These benefits will be your life line to keep you financially afloat during your extended period of disability.  However, if your medical treatment is paid for by health insurance and you do not pursue payment of medical treatment through workers’ compensation, your entitlement to future wage loss benefits will be complicated by the workers’ compensation insurer’s (and possibly the Department of Industrial Accident’s judge’s) assumption that if the treatment was paid for by health insurance and you did not file a claim to compel the workers’ compensation insurer to pay for the treatment, that it was not work related and therefore you are not entitled to any Massachusetts workers’ compensation benefits.

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