Can Workers Compensation Deny My Medical Treatment?3 minute read

I talk to many people who have suffered injuries at work.  Most people who call me have had difficulty getting the workers compensation medical treatment they need.

Often, the insurance company has denied some or all of their medical treatment.  Medical treatment is one of the primary benefits provided in a workers’ compensation case. Basically, Georgia’s workers compensation law requires the insurance company to pay for the medical treatment 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.)
• Surgery
• Referrals to specialists

Essentially, the insurance company has to pay for any medical treatment and testing you need for your injury.  That being said, you need to understand that Georgia’s workers compensation law has special rules about who can provide that medical treatment.  You can read more about those 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.  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, denial of medical treatment can happen a few different ways:

1. The insurance company files a Form WC-3 Notice to Controvert which denies medical treatment.
2. The doctor’s office asks for approval for a certain medical procedure or test, and the insurance company tells the doctor’s office that the treatment is denied
3. The doctors’s office asks for approval, and the insurance company provides absolutely no answer in response.  In other words, they “deny”it because they do not approve it.

If the doctor’s office does not receive approval, the doctor probably will not perform the recommended treatment.  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 that they can.  When they deny treatment, they often do not face any consequences.  Even if a judge orders them to pay for the medical treatment, they often do not have to pay any extra because of their denial.

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 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.

Denial and delay of medical treatment can cause extreme frustration.  You suffered an injury which causes you pain.  Many people want to get their medical treatment as fast as possible.  You need to get the treatment that you need to get better and back to work.

Unfortunately, Georgia’s workers compensation system often makes it difficult to do if you do not have someone helping you out.You may need to talk to an attorney about the issues you have getting medical treatment.