Medical Benefits

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Workers Compensation Medical Benefits

Workers Comp Medical Benefits

In California, all employees are protected by the law if they suffer a work-related injury or illness. In order to determine whether your particular situation falls within the scope of a compensable injury, it is best to seek relevant legal advice from our Los Angeles Workers Comp Attorneys.

Nevertheless, Los Angeles Workers Comp law can be largely confusing, we have provided for the benefit of our readers a generalized description on the topics of Workers’ Comp Medical Benefits below. The information found within this article is generalized and simplifies the law in a way that would be most useful to all employees who may be wondering whether they are entitled to workers’ compensation.

The medical benefits that may be received after sustaining a compensable injury vary due to the many different types of injuries which can be sustained. The rest of this article aims to answer some of the main questions with respect to workers’ compensation medical benefits.

What kind of medical treatment am I entitled to after I suffer a compensable injury?

The medical treatment received after sustaining a work injury needs to be evidence-based, and is the duty of the doctors who are treating you. This basically means that they are required to provide treatment that has been medically proven to cure or relieve the specific work-related injury or illness that you have sustained.

There are specific guidelines which give details on proper treatments that are effective for certain injuries, guidelines on frequency i.e. how often the treatment should be given, guidelines as to the extent of the treatment (intensity), and for how long (duration), among other things.

The requirements in respect to the treatment, namely that it must be evidence-based, has led to the adoption of a medical treatment utilization schedule (MTUS) in the State of California in 2003. It includes, amongst others:

  • Practice guidelines
  • Guidelines for acupuncture
  • Guidelines for chronic pain, and
  • Guidelines for therapy after surgery.

New evidence in respect of treatments is constantly being evaluated and updated within the guidelines.

If my case has reached settlement prior to 2003, do the guidelines affect me?

The guidelines themselves are considered to be applicable even in cases which have reached settlements prior to their adoption in 2003. If you have already received treatment for your injury to which you are now accustomed to, you may continue to receive medical benefits for continuing this treatment from your claim’s administrator.

What to do if you need immediate treatment for your injury, but your claims administrator has not responded to your claim?

The claims administrator is required to promptly respond to your claim and provide authorization for necessary medical treatment following you filing your claim with your employer. However, you may still seek necessary medical treatment prior to your claim being fully authorized i.e. during the process of investigation (delay period), but there is a cap on the total amount of medical benefits you may receive during the investigation period, which is $10,000.

What are the limits to the treatment available?

In general, there are established limits for the treatment that you might be entitled to with respect to your work injury.

For example, if your injuries were sustained in 2004 or after, then you are entitled to a total of 24 physical therapy visits, occupational therapy visits, and/or chiropractic visits.

Are these limits always applicable, what if I need more than 24 visits?

No. Your claims administrator may authorize visits that exceed the said limits – the authorization must be in writing. Moreover, for injuries sustained prior to Jan. 1, 2004 this does not apply.

The cap also does not apply with respect to visits related to certain post-surgical medicine and rehabilitation services.

What is the length of time during which I can receive treatment?

You may receive treatment for as long as it is medically necessary to relieve and/or cure your injury. But this does not dispose of the requirement that the medical treatment that you receive must be evidence-based. Also, some treatments are limited by law.

As mentioned above, the MTUS provides guidelines for the treatments which have been proven scientifically to cure or relieve work-related injuries or illnesses.

Sometimes, the treatment that the doctor recommends will be different or will go beyond what has been recommended by the MTUS guidelines. In order for you to receive coverage for that treatment, your doctor must show evidence that proves that the treatment is necessary and will have the needed effect.

Additionally, the claims administrator may appoint a third party to review your doctors’ treatment plan – the process is called utilization review (UR), and all claims administrators utilize this process. More information regarding UR is discussed in the section below.

What is utilization review (UR)?

The State of California has specific rules on how UR should be conducted. What it essentially represents is a program which claims administrators use to make sure the treatment you receive is medically necessary.

All claims administrators are required by law to have a utilization review program, and with this program it is decided whether or not a particular medical treatment which has been recommended by your treating doctor should be approved.

However, there are certain requirements that must be followed by the claim administrator in order for the UR determination to be valid. If there is suspicion on your part that the UR review is not being conducted in compliance with the particular rules enacted, then you may file a complaint with the DWC, or hire a worker’s comp attorney in order to obtain the maximum benefits that you may be entitled to.

Do I have to pay if I have already been treated, but the claims administrator refuses to pay?

It is not necessarily the case that you would have to pay out of pocket. This matter is up to the claims administrator and the doctor to resolve. In some situations, the doctor may treat you on a lien basis. Meaning that they will provide you with the necessary medical treatment without requiring payment from you, and then proceed to collect payment directly from the claims administrator after your claim has been resolved or settled.

Can I be treated by a doctor of my choice?

Yes. While your employer is generally the one who selects your primary treating physician, at least for the first 30 days, you may nevertheless be treated by your predesignated physician or medical group. Moreover, if you need treatment for a period exceeding 30 days, then even if your employer has selected your primary treating physician, you may be able to switch to a doctor of your choice.

Some terms that you would need to be familiar with are the following:

Medical provider network (MPN)– a group of health care providers set up by your employer's insurance company and approved by DWC's administrative director to treat workers injured on the job.

Health care organization (HCO)– an organization certified by the DWC with the aim of providing medical care to workers who have sustained injuries.

Primary treating physician (PTP)– it is the physician who is responsible for the treatment of the injury or the illness, and is generally selected by the employer, but at times can be substituted at the choice of the patient.

It is also important to note that you may predesignate your personal doctor. Doing so involves going through a particular process where you notify your employer that you would like your personal physician to treat your work-related injury. This can only happen if certain conditions are met, which include the following:

  1. A written notice predesignating the employee's personal physician or medical group is given in writing to the employee's employer prior to the date of injury for which treatment is sought and the notice includes the physician's name and business address.
  2. The employee has healthcare coverage for non-occupational injuries or illnesses on the date of injury in a plan, policy or fund; and
  3. The employee's personal physician or medical group agrees to be predesignated prior to the dates of injury.

A form for predesignating a personal physician can be found on the DWC website.

Can I work during my recovery?

Generally, yes. However, your doctor is the one who decides what kind of work you may undertake during your recovery. The doctor must explain in the form of a written report, the following:

  • The kind of work you can and can't do while recovering
  • The changes needed in your work schedule or assignments.

Your employment description must be reviewed and changes must be put in place. Generally, this review is undertaken jointly by you, your employer, your treating doctor and your attorney (if you have one). You, your treating doctor, your employer and your attorney should review your job description and discuss the changes needed in your job.

Conclusions

Navigating and dealing with medical benefits can prove to be very tricky. Serious complications may arise in instances, for example, where the doctor’s report does not reflect your expectations, necessary treatment, or where you feel that your injury has not fully resolved and that you need more treatment.

This is why it is important when faced with such an issue regarding your health, that you make sure you do everything possible to ensure that you receive the maximum benefits that you are entitled to. The best way to do that is to contact one of our Los Angeles Workers Compensation Attorneys, who can give you a comprehensive and detailed explanation and advice for all that you need specifically for your particular situation. You may contact Workers Comp Lawyers Los Angeles by clicking the contact form or calling us directly at (310) 988-0818.

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