Q: What medical benefits are available through workers' comp?
A: When you have a work-related injury or illness, you’re entitled to workers’ comp benefits, including any medical care that’s reasonable, necessary, and recommended by your doctor.
Workers’ comp will generally cover your bills for doctors’ visits, hospital stays, surgery or other medical procedures, medication, medical equipment or devices, and physical therapy—but not treatment that’s considered experimental.
Some states provide coverage for other kinds of treatment like acupuncture and chiropractic services, although there are often limits on the number of those treatments you may receive.
The insurance company must generally authorize or approve treatment that your doctor has recommended. In states that have guidelines for standard treatment of common work injuries, both insurance companies and doctors should follow those guidelines.
Q: How long will it take for my medical benefits to begin?
A: Medical benefits are available once your employer’s insurance company accepts your claim. The insurance company will pay your medical providers directly, so you shouldn’t be billed for your doctors’ visits and other medical appointments.
Depending on where you live, your medical treatment might be covered while the insurance company is deciding whether to accept or deny your claim. In California, for example, the insurance company must pay for up to $10,000 in medical expenses while it’s investigating your claim.
Even if the insurer ultimately denies your claim, you won’t be responsible for any of the medical bills it paid while the claim was pending.
Q: How do I choose a doctor?
A: States have different rules for selecting and changing treating doctors in workers’ comp cases. Depending on where you live and work, you may choose your own doctor or select a physician from a managed care network. Or the insurance company may pick your doctor or give you a list to choose from.
These rules don’t apply to emergency treatment. If you have an urgent medical issue, you may get treatment from the nearest doctor or emergency room.
Q: Does my employer have to honor my work restrictions?
A: If your treating doctor has set limits on the activities you can do at work (such as not lifting heavy objects or not standing for more than a certain period of time), any light-duty work that your employer offers while you’re recovering must take those medical restrictions into account.
Q: Do I have to return to work before I've completely recovered?
A: If your doctor clears you to return to part-time or light-duty work while you’re still recovering, you’ll probably have to accept any offer of work from your employer that meets those restrictions.
If you refuse to accept the offer, your workers’ comp benefits may be reduced or stopped altogether. However, if your pay for part-time or light-duty work is less than your regular earnings, you may still be eligible for temporary disability benefits to make up part of the difference.
Q: Can I refuse treatment recommended by my doctor?
A: You can always refuse to undergo medical treatment, but it could mean the end of your workers’ comp benefits unless you had a good reason. If you feel any treatment is doing more harm than good, or you’re concerned about the risks of invasive surgery, discuss your concerns with your doctor before taking action.
If your doctor isn’t responsive to your concerns, you may want to get a second opinion on whether the recommended treatment will improve your condition. Some states specifically allow injured workers’ to get second opinions, at the insurance company’s expense, when their doctors have recommended certain kinds of treatment.
Q: What if the workers' comp insurance company denies authorization for treatment?
A: States have different procedures for resolving disagreements about workers’ comp medical issues, including medical treatment, your ability to return to work, and the extent of any permanent disability from your injury.
If the insurance company has denied authorization for medical treatment, you have the right to challenge that decision. In most states, your first step is to contest the denial with the insurance company, usually by filling out a form. The notification from the insurance company should have instructions on how to contest the decision, including any forms that you need to file. You usually have only a short time to dispute the denial.
Typically, the insurance company may demand that you attend an independent medical examination (IME) exam with a physician other than your treating doctor. In some states, you may also request an IME if you disagree with the examining physician’s conclusions or your treating doctor’s decisions. It’s not unusual to have competing reports from IME doctors and treating doctors. If you and the insurance company aren’t able to reach a settlement, the dispute may then proceed to mediation or a hearing with a workers’ comp judge, who will weigh the opinions of the different doctors.
Some states have different procedures for disputes about medical treatment. For instance, in a process often referred to as utilization review, outside doctors will review your medical records (without an in-person exam) and decide whether treatment that your doctor has recommended is necessary and reasonable.
The rules for resolving medical disputes in workers’ comp cases are complicated. If you’re having trouble getting proper medical care, or the insurance company is fighting your doctor’s conclusions about your medical condition, it’s probably time to get help from a workers’ comp attorney. (Learn more about when you might need a lawyer for your workers’ comp case.)
Q: Does a nurse case manager have the right to go to my doctor's appointments?
A: In some cases, the insurance company will assign a nurse case manager to your workers' comp case. The nurse’s role is to act as an intermediary between the doctor and the insurance company, reporting on your progress and other issues related to your case.
In some cases—particularly when you have complicated medical problems requiring doctors from different specialties—nurse case managers can help by coordinating your care and streamlining the process of getting approval for treatment.
But you should also be aware of the risks. For one thing, nurse case managers will be reporting to the insurance company about any conversations they’ve had with you and anything they’ve observed, even during medical appointments. And some of them may be biased toward the insurance company’s position.
Usually, you may refuse to allow the nurse to sit in on your medical appointments and may even ask the insurance company to remove the nurse from your case.
Q: What is a functional capacity evaluation (FCE)? How are the results used?
A: A functional capacity evaluation (FCE) is a test that is sometimes used to determine whether you have any physical restrictions that might impact your ability to work in the future.
Your treating doctor or an IME physician may order the test, which is usually performed by a physical or occupational therapist. During the FCE, you will be asked to perform a series of physical exercises that test your ability to do certain tasks, such as gripping, walking, bending, kneeling, and lifting. The doctor who ordered the report will then rely on the results to determine what type of work you can perform in the future.
Q: If I’m out on workers’ comp temporary disability, will that take away from my FMLA leave?
A: If your work injury qualifies as a “serious health condition” under the Family and Medical Leave Act (FMLA), your employer may be able to count your workers’ comp leave (while you’re out on temporary disability) against your 12 weeks of unpaid FMLA leave.
However, your workers’ comp leave typically won’t count against your FMLA leave if your employer didn’t notify you in advance that it would be designated as FMLA.
Contact a Workers' Comp Attorney for Answers
If you still have questions about medical issues related to a workers' comp claim, consult an experienced workers' comp attorney in your area. Most attorneys don't charge a fee unless you win your case, so there's nothing to lose.