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What If My Workers’ Comp Medical Costs Aren’t Fully Covered?

Are you dealing with unpaid workers' comp medical costs? If you are injured at work and file for workers' compensation, the expectation is that medical costs will be covered. However, depending on several circumstances, that is not always the case.

Finding out the reasoning behind the lack of coverage and knowing what to do at that point is imperative if you feel your claim should still stand. It is also imperative to know prevention methods in the future should you ever need to file again. Let's explore what to do if your workers' comp medical costs aren't fully covered.

EMT in an ambulance for the article about what to do if workers' comp medical costs aren't covered.

Getting Your Workers' Comp Medical Costs Covered

In order to receive workers' compensation benefits, you must comply with federal, state, and employer regulations. Understanding how to handle a workers' compensation case is imperative to ensuring that your workers' comp medical costs are accounted for.

From filling out the proper paperwork to submitting proper documentation within an appropriate timeframe, what you do matters. Our workers' compensation lawyers and injury attorneys can help you navigate this process. Learn more about the workers' comp settlement timeline or contact us at  910-295-2525 for a free 30-minute consultation.

Potential Reasons Workers' Comp Medical Costs Are Not Covered

There are a variety of reasons your medical costs may not be covered under your workers' compensation claim. Did you notify your employer ASAP of the situation and injury? Did you file the claim within the statutory time period required? Did your injury occur within your place of employment and was it related to your specific job? Were you completely sober (not under the influence of alcohol or drugs)? If you answered “no” to any of these questions, you may have found a reason your costs are not covered.

Also for consideration is whether or not you had a pre-existing condition prior to the incident or whether or not the injury is actually a serious one. You may want to ask yourself if medical treatment is “reasonable and necessary.”

Unfortunately, in some cases, it is even possible that your employer has disputed your claim and is withholding the truth.

Some of the common reasons that an insurer might deny covering your workers' comp medical costs:

  • You did not include enough information about your work injuries in the original workers' comp claim.
  • You filed your claim too long after the accident or did not promptly pursue medical services.
  • The accident report on file with your employer includes different information about your work-related accident and injuries than you specified in your insurance claim.
  • You went to a healthcare provider who was not on your employer’s approved list of medical service providers.
  • Your employer asserts that your work accident is not work-related.

What To Do When Workers' Comp Won't Pay

As described above, there are instances where workers' comp medical costs won't be covered and your employer does not have to pay. When claims are denied the medical bills do not simply go away. So, what happens to medical bills when workers' comp is denied?

If you've been denied, will receive a letter explaining the reasons for the denial. You will be responsible for either taking action to appeal the decision or, you will need to work out how to cover the remaining expenses. That's where a workers' comp lawyer can make the difference.

If your workers' comp medical costs were not covered, a few options are available to you:

  • Use your own health insurance. Most insurance companies will pay disputed bills provided that you sign an agreement to reimburse them if you win your worker's compensation case.
  • Make sure you are visiting the correct provider. Not all providers are covered under workers comp and switching providers may solve the problem.
  • You may appeal your denial. Be prepared to present medical evidence at the hearing.
  • Talk with an experienced workers' compensation attorney about your claim and which workers' comp medical costs are not being covered.

Prevention Methods

To ensure your workers' comp medical costs are covered, make sure to document all injuries (with pictures if applicable) ASAP. Make note of your injury and pain on ALL intake forms and make sure your doctor is aware to do the same. Be specific and always review paperwork thoroughly.

Filing a Workers' Compensation Appeal

If your workers' comp medical costs are not fully covered, it's important to take proactive steps to address the situation.

Filing a workers' compensation appeal involves challenging a decision made by an employer's insurance company or relevant administrative body regarding a workers' compensation claim. When an initial claim is denied, not fully approved, or disputes arise over benefits, an appeal is a recourse to seek a reconsideration of the decision. The appeal process generally involves several steps.

  1. Review Denied Claim: If your workers' compensation claim is denied or not fully approved, carefully review the denial letter or communication you receive. It will outline the reasons for the denial and provide instructions on how to appeal.
  2. Consult an Attorney: Before proceeding, consider seeking legal advice from a workers' compensation attorney. They can assess the strength of your case, guide you through the legal intricacies, and help you gather the necessary evidence to make sure your workers' comp medical costs are properly assessed.
  3. File the Appeal: Initiate the appeal process by submitting the required forms or documents within the specified timeframe. These forms are typically available from the workers' compensation board or agency in your jurisdiction.
  4. Evidence Gathering: Compile comprehensive documentation to support your appeal. This may include medical records, witness statements, expert opinions, and any other relevant evidence that addresses the reasons for the denial.
  5. Mediation: In some cases, mediation may be required as an initial step. A mediator acts as a neutral party to help both sides reach an agreement without proceeding to a formal hearing.
  6. Formal Hearing: If mediation does not resolve the issue, a formal hearing may be scheduled. During the hearing, you and your legal representation will present your case, including evidence and witnesses. The administrative law judge or panel will review the arguments and make a decision.
  7. Appeal Board Review: If either party disagrees with the judge's decision, they can further appeal to a workers' compensation appeal board. This board conducts a review and may uphold, reverse, or modify the judge's decision.
  8. Appellate Courts: In some cases, if dissatisfaction remains after the appeal board's decision, the case can be taken to higher courts, such as the state's court of appeals. These courts focus on the legality of the process and whether it was fairly conducted.
  9. Enforcement of Decision: Once a final decision is reached, it must be followed by all parties. This may involve providing the approved benefits, arranging medical treatments, or settling any compensation owed.

Starting the Workers' Comp Appeal Process

This stage can feel overwhelming, but if you've received that letter stating that your workers' comp medical costs have been denied, there are three steps that you can take to start the appeal.

Initiate Communication with Your Claims Adjuster

Reach out to your workers' compensation claims adjuster or the designated representative responsible for managing your case. Communicate your concerns about the uncovered workers' comp medical costs and provide them with detailed documentation of the treatments, prescriptions, and any related costs that have not been reimbursed. This communication can help initiate a review of your case and potentially lead to a resolution.

Seek Help from a Workers' Compensation Attorney

Seek legal advice from an experienced workers' compensation attorney. They can provide valuable insights into the intricacies of workers' compensation laws in your jurisdiction and guide you on how to navigate the appeals process. Legal representation can be particularly beneficial when dealing with complex cases involving denied claims or disputes over workers' comp medical costs and coverage.

Document All Communication & Be Persistent

By documenting all communication and medical records related to your case, you can strengthen your position in negotiations and potential legal proceedings. Remember that persistence is key – advocating for your rights and diligently pursuing the proper channels can increase the likelihood of obtaining the coverage you rightfully deserve for your work-related medical expenses.

When to Seek a Workers' Comp Lawyer

Knowing when to seek assistance from a workers' compensation lawyer can significantly impact the outcome of your case - and may help get more of your workers' comp medical costs covered.

If Your Workers' Compensation Claim Gets Denied

One crucial scenario in which you should consider engaging a lawyer is when your workers' compensation claim has been denied. If you believe your claim was wrongfully denied and you're facing challenges in covering workers' comp medical costs, a skilled personal injury attorney can help you gather the necessary evidence, navigate complex legal processes, and effectively present your case in an appeal hearing. Their expertise can prove invaluable in strengthening your position and increasing your chances of overturning the denial.

Resistance from Employer or Insurance

Another circumstance in which it's advisable to consult a workers' compensation lawyer is when you encounter resistance or obstacles from your employer or the insurance company. If you're experiencing delays, inadequate benefits, or hostility due to filing a claim, a workers' compensation attorney can act as a mediator and advocate on your behalf.

An attorney can engage with the relevant parties, negotiate settlements, and ensure that your rights are upheld throughout the process. If your injuries are severe, leading to long-term disability, a personal injury lawyer can help you navigate the complexities of securing appropriate compensation, including future medical expenses and lost wages.

By partnering with a workers' compensation lawyer during these critical junctures, you can navigate the legal landscape with confidence and work towards obtaining the full benefits and protections to which you're entitled.

Contact a Personal Injury Attorney

Our personal injury attorneys know exactly what to do to make sure you get workers' comp medical costs covered. We can also help you establish how much to ask for in a personal injury settlement. In some workers' comp claims, not all fees are eligible to be accounted for, but that's where our injury attorneys can help. If you are still unsure of what to do, contact us to schedule a consultation. We'll be glad to guide you through the process from start to finish.

The North Carolina Industrial Commission was created to administer the North Carolina Workers’ Compensation Act. The Industrial Commission can assist both employees and employers with questions or concerns that you have about workers’ compensation.

Disclaimer: The information seen on this website, including the article above, is not legal advice or legal counsel. If you wish to speak to a workers' comp lawyer or personal injury attorney, contact our North Carolina attorneys directly using our online form or by calling  910-295-2525. While our law firm is located in North Carolina, our attorneys have tried cases and work with clients across the country, from RaleighFayettevillePinehurst, and Sanford, to Virginia, Illinois, Oregon, and California to Florida. Call our experienced attorneys today.

Van Camp Law Firm in Pinehurst, North Carolina

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