I talk to many people who have suffered injuries at work. Many people who call me have had problems getting the workers compensation medical treatment they need.
Often, the workers compensation insurance company has denied some or all of the medical treatment that has been ordered by their doctor. This is very frustrating because these denials delay their recoveries from their injuries.
Medical treatment is one of the primary benefits provided when you suffer an injury at work. Basically, Georgia’s workers compensation law requires the insurance company to pay for the medical treatment and testing that you need for your work injury.
Among other things, the insurance company has to pay for:
- Doctor’s visits
- Medication
- Physical therapy
- Diagnostic testing (x-rays, MRIs, etc.)
- Injections
- Surgery
- Referrals to specialists
Essentially, the insurance company has to pay for any medical treatment and testing you need as a result of your injury at work. That being said, you need to know that Georgia’s workers compensation law has special rules about who can provide that medical treatment. You can learn more about those special rules here.
What does denial of medical treatment mean?
For denial of medical treatment to happen, a medical provider must first recommend some type of treatment. This usually happens when you go in to to see the doctor.
The doctor will discuss what happened to you and examine you. After evaluating you, the doctor will often recommend some treatment and testing.
When most doctors recommend workers compensation medical treatment, they want to know they will get paid for the treatment. So, the doctor’s office calls the workers compensation insurance adjuster to ask for approval for treatment or testing.
At this point, a denial of medical treatment by the insurance company can happen a few different ways:
- The insurance company files a Form WC-3 Notice to Controvert which denies medical treatment.
- The doctor’s office calls or emails the insurance company to ask for approval for a certain medical procedure or test, and the insurance company tells the doctor’s office that the treatment is denied
- The doctor’s office asks for approval, and the insurance company provides absolutely no answer in response. In other words, they “deny” the treatment simply by not giving an answer.
If the doctor’s office does not receive approval, the doctor probably will not perform the recommended treatment or testing. This means that you suffer additional pain while you have to wait for approval of the treatment.
Why does the insurance company deny medical treatment?
It depends. An insurance company may deny medical treatment because they believe it is unnecessary. They may deny treatment on the basis that it is provided by an unauthorized medical provider.
In my opinion, the most common reason insurance companies deny medical treatment is simply because they can. When they deny medical treatment, insurance companies often do not face any consequences.
Many people do not know what to do to get the insurance company to pay for treatment. Some people just give up which means they do not get the treatment they need.
Essentially, the insurance company wins when this happens because they do not have to pay for the treatment. This is not fair because the insurance company’s job is to pay for the medical treatment and testing you need as a result of your injury.
How can I make sure I get the medical treatment I need for my injury?
You have to figure out a way to get the insurance company to approve the treatment with the doctor. Here are a few ways you may succeed in getting the treatment approved:
- Get the insurance adjuster on the phone and then get the adjuster to call the doctor’s office and give approval for the treatment while you are on the phone
- Ask the doctor’s office to send what’s called a Form WC-205. This document gives the insurance company a limited amount of time to provide an answer
- File a Form WC-PMT to schedule a conference call with a workers compensation judge about the medical treatment.
- Request a hearing in front of a workers’ compensation judge to get approval for the treatment you need.
Unfortunately, getting the insurance adjuster on the phone can often be difficult. Even when you get them on the phone, getting them to contact the doctors office and provide approval can be difficult as well.
I solve most of my client’s medical treatment delay issues now with filing a Form WC-PMT. While the WC-PMT process usually works well to get medical treatment approved, there are a number of specialized rules that you have to follow to use that process successfully.
Denial and delay of medical treatment can cause extreme frustration. Unfortunately, Georgia’s workers compensation system often makes it difficult to do if you do not have someone on your side helping you out. You may need to talk to an attorney about the issues you have getting medical treatment.
