Terminating Workers' Compensation Medical Benefits Employees who have been injured at work and are receiving workers' compensation benefits have a number of rights related to the medical portion of their claims. Injured persons receiving workers' compensation benefits should realize that those benefits are essentially comprised of two aspects - medical and indemnity. The indemnity portion of workers' compensation benefits are the weekly or biweekly checks which compensate injured workers for their lost wages. The medical portion of benefits pertains to the cost of any medical treatment related to the injury. The precise nature of what is covered under the medical portion of a claim can be quite confusing, but generally all medical treatment which is reasonable, necessary, and related to the accepted injury is the responsibility of the employer's workers' compensation carrier.
First, when benefits are awarded, either by a Workers' Compensation Judge, or by a document issued by an insurance carrier (called a Notice of Compensation Payable or "NCP", or an Agreement for Compensation), there is usually a defined and accepted injury. Examples of an accepted injury would be "low back strain and sprain," or "knee sprain." This "accepted" injury is important because it defines exactly what body part the insurance carrier is responsible for covering. For example, if the accepted injury is "knee sprain" the insurance carrier may balk at paying for treatment related to an ankle injury, even if that injury occurred along with and at the same time as the original injury.
Any discrepancies in the injury description can be corrected (within any applicable statutes of limitation) by having an attorney file a petition to review the description of injury. With this petition the injured worker can ask a Judge to amend the injury description to include additional body parts by proving that those injuries are also related to the original injury. However, until the Judge issues an order officially adding to the description of injury, the insurance carrier will not be responsible for treatment of any injuries but the officially accepted injury. This concept is often troublesome to injured workers because litigation over an injury description can often take well over nine months, and until the description is officially amended by a Judge, additional treatment to any parts of the body that are not officially accepted will be denied.
If an insurance carrier chooses to challenge the reasonableness or necessity of medical treatment it can request a Utilization Review ("UR"). This process challenges past or future treatment by having it reviewed by the same type of provider. For example, if an insurance carrier wishes to challenge chiropractic care, it will be reviewed by a third party chiropractor. During this process (which will usually take 30 days), the insurance carrier will not be responsible for paying any bill submitted by that chiropractor. It is important to note that only the bills of the chiropractor under review are temporarily not paid. All other providers' bills must still be paid. This rule is often not followed by insurance carriers. Workers' compensation carriers will often file a UR request and then believe they can decline to pay any medical bills.
Once the UR reviewer makes a determination about the reasonableness or necessity of treatment, either party can then appeal the outcome to a workers' compensation judge. However, during this process all bills must still be paid if the UR determination is positive for the injured worker.
Having covered some of the basics of the medical portion of a claim, the questions still remains, how can an injured worker's medical benefits be stopped? Generally, there are two ways that medical benefits for an officially accepted injury can be stopped. First, the worker can settle his or her case in exchange for a lump sum of money. If the settlement includes a cessation of medical benefits, they will often stop as of the day a Judge officially approves the settlement. Working out the specific details of settlements is best left to workers' compensation attorneys who can make sure that all aspects of a claim are considered as part of the settlement, including medical benefits, and thus all injured workers contemplating a settlement should contact an experienced Pennsylvania workers' comp attorney.
The other way that medical benefits can be stopped is if the insurance company successfully litigates a termination petition. To win a termination petition, the insurance carrier must prove that the injured worker is fully recovered, and can return to his or her pre-injury job without restrictions. The burden of proof is very high on these petitions; thus, they are rarely successful.
The injured worker will attend an independent medical exam, often called an IME, and if the IME doctor opines that the injured worker's injured has ceased entirely, and that the worker can return to work without restrictions, the carrier can then file the termination petition. The injured worker can defend this petition by presenting testimony of his or her own treating doctor to show that the injury continues and that the worker cannot return to work without restrictions. This litigation typically lasts more than nine months and, as mentioned, is rarely successful. However, with the addition of other evidence, such as surveillance, the insurance carriers, from time to time, can convince a judge that the injured worker is fully recovered. Once the judge rules that the workers' disability has ceased entirely, the insurance carrier is no longer responsible to pay for any medical treatment.
Other than the two possibilities discussed above, once an injury is officially accepted, the insurance carrier is responsible for all related medical treatment. And despite the misconceptions to the contrary, it could potentially be responsible for that treatment for the rest of the injured workers' life. Issues surrounding workers' compensation medical benefits are complicated and this article only touches on the basics. Employers and injured workers with questions about terminating a claimant's medical treatment should speak with an attorney who is well-versed in Pennsylvania workers' compensation law.