Injury Lawyer Explains: What Medical Bills Are Covered by Workers’ Compensation and What Are Not?

If you have been injured at work, you may wonder what medical bills are covered by workers’ compensation and what are not. This is an important question because medical expenses can quickly add up and affect your financial situation. In this blog post, we will explain the basics of workers’ compensation and its benefits in Pennsylvania, the types of medical bills covered and not covered by workers’ compensation, and how to file a claim and seek legal advice from an experienced injury lawyer.

What is workers’ compensation, and what are its benefits in Pennsylvania?

workers’ compensation is a system that benefits workers who suffer work-related injuries or illnesses. The benefits include payment of medical expenses, wage loss benefits, specific loss benefits, and death benefits. The purpose of workers’ compensation is to protect workers from the financial hardships caused by work injuries and to promote the health and safety of the workplace.

Workers’ compensation is regulated by the Pennsylvania Department of Labor and Industry (DLI), which administers the Workers Compensation Act (the Act). The Act sets the rules and procedures for workers’ compensation claims, disputes, and appeals. The Act also establishes the Workers Compensation Appeal Board (WCAB) and the Workers Compensation Office of Adjudication (WCOA), which are the agencies that handle workers’ compensation cases.

Workers’ compensation is a no-fault system, meaning you do not have to prove that your employer was negligent or at fault for your injury.

You only have to prove that your injury was caused by your work or occurred in the course of your employment. However, this also means that you cannot sue your employer for additional damages, such as pain and suffering, unless your employer intentionally harmed you or violated a specific safety law.

What types of medical bills are covered by workers’ compensation?

Workers’ compensation covers all reasonable and necessary medical expenses related to your work injury or illness. This includes:

  • Emergency care
  • Hospitalization
  • Surgery
  • Medication
  • Diagnostic tests
  • Physical therapy
  • Prosthetic devices
  • Assistive equipment
  • Transportation costs

Workers’ compensation pays for these medical expenses directly to the providers, so you do not have to pay any deductibles, copayments, or coinsurance. However, you have to follow certain rules when seeking medical treatment for your work injury or illness.

First, you have to notify your employer of your injury or illness as soon as possible, preferably within 21 days. If you fail to do so, you may lose your right to workers’ compensation benefits.

Second, you have to choose a medical provider from a list of designated providers that your employer must post in a conspicuous place at your workplace. You have to treat with a designated provider for the first 90 days after your injury or illness. If you treat with a non-designated provider during this period, your employer may not pay for your medical bills.

Third, you have to follow the treatment plan prescribed by your designated provider and cooperate with any requests for medical examinations or records. If you refuse or fail to do so, your employer may challenge the reasonableness and necessity of your medical treatment and seek a utilization review.

A utilization review is a process where an independent reviewer evaluates whether your medical treatment is reasonable and necessary according to accepted standards of care. If the reviewer determines that your treatment is not reasonable and necessary, your employer may stop paying for it. You have the right to appeal the utilization review decision to a workers’ compensation judge.

What types of medical bills are not covered by Workers’ compensation?

Workers’ compensation does not cover medical expenses that are not related to your work injury or illness. This includes:

  • Cosmetic procedures
  • Experimental treatments
  • Unauthorized providers
  • Out-of-network providers

Cosmetic procedures are those that are performed for aesthetic reasons rather than for functional or health reasons. For example, workers’ compensation will not pay for plastic surgery, botox injections, or teeth whitening.

Experimental treatments are those that are not approved by the Food and Drug Administration (FDA) or recognized by the medical community as safe and effective. For example, workers’ compensation will not pay for stem cell therapy, gene therapy, or acupuncture.

Out of state providers

 

Pennsylvania workers’ compensation insurance can pay for treatment you seek out of state.  However, the out-of-state provider does not have to accept the reimbursement rate paid by the insurance company, which could leave you with a balance.  In these instances, it is best to confirm with the out of state provider that they will accept Pennsylvania workers’ compensation in full.”

 

If you seek medical treatment from any of these providers without prior approval from your employer or the DLI, you may have to pay for the medical bills yourself. You may also jeopardize your workers’ compensation benefits if you do not follow the rules and procedures for seeking medical treatment.

How to file a claim for workers’ compensation and seek legal advice from an experienced injury lawyer?

If you have been injured at work, you should file a claim for workers’ compensation as soon as possible. To do so, you have to complete and submit a First Report of Injury (FROI) form to your employer within 120 days of your injury or illness. Your employer must then file the FROI with the DLI and its insurance carrier or self-insured program within seven days.

Your employer or its insurance carrier or self-insured program must then accept or deny your claim within 21 days of receiving the FROI. If your claim is accepted, you will receive a Notice of Compensation Payable (NCP) that states the amount and duration of your benefits. If your claim is denied, you will receive a Notice of Compensation Denial (NCD) that states the reason for the denial.

If you disagree with the decision of your employer or its insurance carrier or self-insured program, you have the right to file a petition with the WCOA within three years of your injury or illness. A workers’ compensation judge will then hold a hearing and issue a decision on your petition. You have the right to appeal the judge’s decision to the WCAB within 20 days of receiving it.

Filing a claim for workers’ compensation can be a complex and challenging process. You may encounter disputes or denials from your employer or its insurance carrier or self-insured program regarding the cause, extent, or treatment of your work injury or illness. You may also face difficulties in obtaining the medical care and benefits that you need and deserve.

That is why it is advisable to seek legal advice from an experienced injury lawyer who can help you protect your rights and interests under the Act. An injury lawyer can help you:

  • File a claim for workers’ compensation
  • Gather and present evidence to support your claim
  • Negotiate with your employer or its insurance carrier or self-insured program
  • Represent you at hearings and appeals
  • Obtain a fair settlement or award for your work injury or illness

At RG Injury Law, we have been helping injured workers’ in Pennsylvania for over 20 years. We have the knowledge, skills, and resources to handle all types of workers’ compensation cases, from minor injuries to catastrophic ones. We work on a contingency fee basis, which means that you do not pay us anything unless we win your case.

If you have any questions or concerns about your workers’ compensation claim, please contact us today for a free consultation. We will review your case and advise you on the best course of action. We at Rankin & Gregory will also fight for your rights and interests until you receive the medical care and benefits that you deserve. Contact us today.

 

 

RG Injury Law Resource Center

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