Getting medical treatment when the claim is denied or controverted.
When the employer and insurer controvert or contest a workers’ compensation claim, they will not pay for your medical treatment or income benefits unless the State Board orders them. Consequently, you will be responsible for finding a physician to treat you and for payment of his or her medical bills.
This determination does not necessarily mean the injured worker’s claim has ended. It is merely the position the employer and insurer have taken. It will be your – the claimant’s – burden to prove that the employer and insurer are wrong. From a practical perspective, employees often do not have health insurance, making it difficult to secure medical treatment resulting from an accident.
When a claim is controverted, you may see a physician of your choice, according to Board Rule 201(b). This Board Rule states that “The employer/insurer cannot restrict treatment of the Employee to the panel of physicians, conformed panel of physicians, or WC/MCO when the claim has been controverted.” You are free to choose your authorized treating physician. However, you must be responsible for the medical expenses until the State Board determines otherwise.
Since the cost of medical treatment may escalate quickly, you must consider alternatives to paying for medical treatment out of pocket or through another insurance carrier. An attractive alternative for employees is to identify a physician who will provide medical treatment on a lien basis. Treating on a lien basis means you will not pay for medical treatment or services when the treatment is rendered but instead will pay for the treatment when your claim settles.
A physician or medical facility that offers medical treatment on a lien basis to workers’ compensation patients will protect their interests by requiring you and your attorney to sign a letter of protection. A letter of protection is a contract between the patient, attorney, and medical provider, which ensures the attorney will pay all medical bills for treatment rendered on a lien basis from your settlement funds.
Seeking treatment on a lien basis is not ideal for most employees and attorneys. Still, it is a workable alternative for the injured employee who cannot afford the immediate out-of-pocket cost. It may be the only way an employee may receive medical care.
If your workers’ compensation claim is controverted, please contact Ramos & Law to discuss seeking treatment for your work injuries.
These case studies are not meant to promise or guarantee a certain or similar result, but rather to demonstrate the legal attention and work ethic our attorneys assert in our cases. Every case is different and is fact sensitive. Certain facts can greatly influence and determine a client’s award, outcome, and recovery.
An employee worked for a manufacturer of outdoor power products in Middle Georgia. His job required him to pull pallets of material across the work area. As a result, he experienced a back strain. The manufacturer denied the claim and contested his need for medical care. Ramos & Law was able to secure helpful diagnostic scans and meaningful medical care for the injured worker. After a few months of litigation, the parties reached a settlement of $65,000 with a complete resolution of all outstanding medical bills.
An employee was stocking heavy merchandise for a large retailer in Columbus, Georgia. During the course of her job duties, a stocking cart of the merchandise fell on her right foot and great toe. The national retailer directed her to its company doctors but she received very little relief. The attorneys at Ramos & Law were able to navigate her medical care to more qualified doctors where she received a better overall results. As she reached maximum medical improvement, the large retailer settled the claim for over $100,000 and paid for all of her past medical treatment.
Failed Back Syndrome
An employee was working part-time for a large automotive parts store. The employee fell off a ladder injuring his teeth, neck, ribs, and low back. After exhausting conservative medical care, physical therapy, injection regimens, and medication, it became clear that this injured employee required the need for spinal surgery. While the insurance company fought the surgery, Ramos & Law was able to force the insurance company into paying for the surgery and associated therapies including the implant of a spinal cord stimulator. Given the severity of the injury, Ramos & Law was able to refer the client to a federal disability benefit specialist who assisted him in securing Social Security. This part-time employee settled his case for $185,000 plus almost $300,000 in future medical care.
Low Back Herniations
A pediatric physician injured his back while assisting a child off an examining room table. As a result, the physician herniated several discs in his spine which also triggered depressive mental episodes. While the insurance company denied medical coverage for his numerous symptoms, Ramos & Law was able to secure quality medical care for the employee including orthopedic care, psychiatric treatment, a spinal cord stimulator, and physical therapy. Additionally, the employee received on-going income benefits at the maximum workers' compensation rate. At the end of the case, the matter settled for a figure close to $250,000 in addition to payment of previous medical bills.
An employee at a beverage maker in Atlanta was stocking heavy cases of merchandise when she felt severe neck and shoulder pain. It was revealed that she suffered a torn rotator cuff. While the beverage maker initially denied her medical care, Ramos & Law was able to convince the employer to approve her treatment plan and accept the case. After months attempting to return to work, it was clear that the employer was not able to accommodate her medical limitations. As a result, the case settled for $115,000, along with all her medical bills being paid.
A part-time grocery employee fell into a tub of “degreaser” that caused severe third degree burns over his torso and buttocks region. The employee required immediate medical care and several weeks in the intensive care unit within the local burn center. The costs of the care reached in the millions of dollars. While the grocery store denied liability for the accident, the attorneys at Ramos & Law were able to secure a settlement of $250,000 in addition to the employer’s acknowledgment to pay for all past medical bills.