A: While you may have an award for “lifetime medical benefits,” this may not necessarily mean what it sounds like. The insurance carrier is only required to cover reasonable, necessary, and causally related medical treatment. Unfortunately, it is the injured worker’s burden to prove these things. Therefore, the insurance company can, and will, deny treatment when they can. The insurance company can contest each and every doctor visit, treatment, and/or prescription based upon these criteria.
They will often get an opinion from an Independent Medical Exam (IME). An IME is an exam performed by a doctor that the insurance company picks specifically in order to ask the doctor to render an opinion on your medical condition. No treatment is rendered by this doctor, just an opinion. As you can imagine, these doctors will often but not always tell the insurance company what they want to hear; which is, that your medical treatment is not reasonable and necessary, or, in most cases, is not causally related to the work injury.
In some cases, the insurance company will not even need another doctor’s opinion. If the medical treatment recommended is not related to a body part specifically listed on your award, the insurance company is likely to deny treatment. This is why it is very important to be sure that all of your injured body parts are specifically listed on the Award Order and to be under an award.
Additionally, even if the body part is listed on the award, if there has been a gap in treatment, the insurance company will deny the treatment as not being causally related to the work injury. The longer the gap in treatment, the more likely it is that the workers’ compensation insurance carrier will deny the treatment. It is very important that you continue to receive periodic treatment if you continue to experience problems. DO NOT try to “tough it out,” as this only works against you and gives the workers’ compensation insurance carrier a reason to deny any future treatment.
If you are having problems getting your medical treatment covered be sure to contact us to discuss solutions.